A Pilot Study of a Group-Based HIV and STI Prevention Intervention for Lesbian,Bisexual,Queer,and Other Women Who Have Sex with Women in Canada

Abstract

Limited research has evaluated interventions to reduce HIV and sexually transmitted infection (STI) vulnerability among lesbian, bisexual, and queer (LBQ) women, and other women who have sex with women. The Queer Women Conversations (QWC) study examined the effectiveness of a group-based psycho-educational HIV/STI intervention with LBQ women in Toronto and Calgary, Canada. We conducted a nonrandomized cohort pilot study. Participants completed a pre-test, post-test, and 6-week follow-up. The primary outcome was sexual risk practices, while secondary objectives included intrapersonal (self-esteem, STI knowledge, resilient coping, depression), interpersonal (safer sex self-efficacy), community (community connectedness, social support), and structural (sexual stigma, access to healthcare) factors. The study was registered at http://clinicaltrials.gov. Forty-four women (mean age 28.7 years) participated in a weekend retreat consisting of six consecutive sessions tailored for LBQ women. Sessions covered a range of topics addressing behavioral and social-structural determinants of HIV/STI risk, including STI information, safer sex negotiation skills, and addressing sexual stigma. Adjusted for socio-demographic characteristics, sexual risk practices (β2=−2.96, 95% CI −4.43, −1.50), barrier use self-efficacy (β2=1.52, 95% CI 0.51, 2.53), STI knowledge (β2=4.41, 95% CI 3.52, 5.30), and sexual stigma (β2=−2.62, 95% CI −3.48, −1.75) scores showed statistically significant changes 6 weeks post-intervention. Initial increases in safer sex self-efficacy, social support, and community connectedness were not sustained at 6-week follow up, highlighting the need for booster sessions or alternative approaches to address social factors. Study results may inform HIV/STI prevention interventions, sexual health care provision, and support services tailored for LBQ women.

Introduction

Lesbian, bisexual, and queer (LBQ) women and other women who have sex with women (WSW) are vulnerable to sexually transmitted infections (STIs) such as trichomoniasis, human papillomavirus, bacterial vaginosis, herpes simplex virus, and hepatitis B.^{1

–10} Studies in Canada^7,11 and the US¹² report that one-fifth of LBQ women have a lifetime history of STI—similar to STI infection rates among heterosexual women.^2,6,13,14 The limited research examining LBQ women's sexual practices has revealed inconsistent uptake of safer sex strategies.^7,15,16 Perceptions that LBQ women are at low risk for STI acquisition contribute to a scarcity of research on effective strategies to reduce STI vulnerability among this population.^{12,13,15,17
–19}

Despite similar STI infection risks, LBQ women in high income countries access sexual health services, including routine gynecologist appointments¹⁵ and STI testing,¹² at lower rates than heterosexual women. Canadian data indicate that lesbians reported significantly lower rates of Papanicolaou testing than heterosexual or bisexual women, lesbians and bisexual women had higher odds of not having a regular doctor than heterosexual women, and bisexual women had higher reported unmet healthcare needs than lesbian and heterosexual women.²⁰ LBQ women's limited utilization of health services has been associated with perceptions these services do not adequately meet their needs^21
–23 and may not be culturally relevant;²⁴ additionally women may be hesitant to disclose their sexual orientation within a potentially stigmatizing context.²⁵ Yet results from a cross-sectional study with LBQ women in Toronto revealed associations between a lifetime history of STI and receiving Papanicolaou tests in the past 2 years, highlighting the importance of integrating sexual health services into women's generalized medical treatment.¹¹

It is particularly important to account for sexual and ethno-racial differences within populations of LBQ women.^17,25

–28 To illustrate, a recent study reported a prevalence of herpes simplex virus (HSV) type 2 of 26% among African American WSW and 54% among African American women who have sex with women and men (WSWM), indicating significant differences in STI prevalence between sexual orientations.²⁹ A cross-sectional study of WSW in Toronto, Canada, indicated that women identifying as bisexual had higher self-reported lifetime STI history rates than lesbian or queer identified women.¹¹

Social and structural drivers operate as distal influences on individual and group level HIV and STI vulnerability by constraining or enabling individual practices and access to sexual health services.^30,31 For example, sexual stigma is associated with reduced uptake of safer sex practices among men who have sex with men³² and higher rates of STI among LBQ women.⁸ Sexual stigma refers to social processes that devalue lesbian, gay, bisexual, and queer persons and afford less power to same-sex identities, relationships, and communities.³³ Reducing HIV and STI vulnerability among LBQ women requires a multi-level approach that addresses individual (e.g., STI knowledge),^32,34,35 social (e.g., social support), and structural factors (e.g., sexual stigma).^{1,3
–5,7,11} There is a scarcity of interventions that address HIV and STI vulnerability among LBQ women. Marazzo et al.³⁶ used a motivational computer-based self-interview to address perceived susceptibility, severity, benefits of prevention, and perceived barriers to implementing preventative practices to reduce bacterial vaginosis among LBQ women; the intervention was associated with increased glove use during sex. No other studies were found that evaluated STI prevention interventions with LBQ women, including strategies to increase STI knowledge, STI testing, and a range of safer sex practices.

This article describes the pilot testing of Queer Women Conversations (QWC), a group-based psycho-educational HIV and STI prevention intervention for LBQ women and other WSW developed and delivered in collaboration with community-based agencies in Toronto and Calgary, Canada. Our primary objective was to evaluate whether, in comparison with pre-intervention, LBQ women who attended QWC demonstrated decreased sexual risk practices. Our secondary objective was to examine if, in comparison with pre-intervention scores, participants who received the QWC intervention would report the following changes in scores post-intervention: (1) increased self-esteem; (2) increased resilient coping; (3) increased STI knowledge; (4) reduced depression; (5) increased safer sex self-efficacy; (6) increased social support; (7) increased LGBQ community connectedness; (8) reduced sexual stigma; and (9) increased access to healthcare.³⁷

Methods

This was a multicenter, non-randomized pragmatic cohort pilot study using a pre-test/post-test design with a 6-week follow-up conducted in March and April 2014. Purposive venue-based sampling was used to recruit a minimum of 36 participants (to achieve an effect size of 0.50 based on power of 0.90 calculated using G*Power 3³⁸) from community-based organizations in Toronto and Calgary, two large urban Canadian cities. This study is registered at http://clinicaltrials.gov, registration number NCT02067845. The study protocol has been previously published.³⁷ Research participants included self-identified women: aged 18 and over; lesbian, bisexual, queer, a women who has sex with women, or same-sex attracted; able to provide informed consent; and committed to attending a weekend retreat and completing three surveys. We hired LBQ women peer research assistants (n=2) and graduate students (n=3) to assist with recruitment of diverse LBQ women through engagement of local community agencies serving LBQ women and WSW, LBQ events (e.g., list-serves for LBQ women's events and parties) and sexual health centers. This study was approved by the University of Toronto Research Ethics Board (#29291) and the University of Calgary Research Ethics Board (#13-1114).

Intervention

Development of the QWC intervention has been detailed elsewhere.³⁷ QWC was informed by evidence-based group HIV/STI prevention strategies with MSM, including the 3MV intervention.²³ We also conducted key informant interviews to acquire input from stakeholders including WSW health and social service providers in Toronto. The QWC intervention was theoretically informed by the Modified Social Ecological Model (MSEM) framework³⁰ that highlights multi-level factors associated with HIV and STI vulnerability,^{4,30,39

–42} including intrapersonal (self-esteem, STI knowledge, resilient coping, depression, internalized stigma); interpersonal (safer sex self-efficacy); community (social provisions, community connectedness); and structural (sexual stigma, access to healthcare) dimensions. The intervention involved six consecutive 2–3 h sessions conducted at weekend retreats held in Toronto and Calgary. Sessions were facilitated by the research coordinator and community facilitators who identified as LBQ women and were involved in agencies that serve LBQ women and WSW.

Consistent with recommendations from key stakeholders, content was delivered using a variety of techniques including small and large group discussions, role play, and arts-based methods. Session topics covered included:

(1) personal goals and objectives for the intervention;

(2) sex, bodies, pleasure, and safer sex knowledge (HIV, STI, safer sex, negotiating safer sex);

(3) sexual stigma, sexuality, barriers, and facilitators to safer sex, emotional and mental health;

(4) power relations, healthy relationships, communication skills, safer sex self-efficacy, intimacy;

(5) internalized stigma, self-esteem, self-acceptance, resilient coping;

(6) social and health services, community resources and support systems, strategies of building and connecting to LGBT communities.

The group-based intervention offered women an opportunity to learn about STI, safer sex strategies and negotiation skills, to build community, and to combat sexual stigma through open discussions facilitated by trained facilitators. Participants received an honorarium of $100 CAD for attending the weekend retreat and conducting pre/post and 6-week follow-up surveys.

Data collection

We conducted pre-test, post-test, and 6-week follow-up surveys using an online self-administered survey in order to reduce bias in self-report measures of sexual risk practices.⁴³ Computer-assisted surveys enhance the reliability and validity of self-reported sexual risk practices data in HIV research⁴⁴ and have been used in prior LGBT research.²³ Participants provided online informed consent prior to beginning the survey and a separate written informed consent prior to participating in the QWC intervention.

We report measures used and Cronbach's alpha coefficients from pre-intervention for the current analyses. The primary outcome of sexual risk practices was measured using the ‘Safer Sexual Practices among Lesbian Women’ scale,⁴⁵ Cronbach's α=0.67. Given that a lower score on the scale indicates decreased sexual risk practices and/or decreased lack of knowledge of safer sex practices⁴⁵ and increased safer sex and/or increased knowledge of safer sex practices, we renamed the outcome to “sexual risk practices” rather than “safer sex practices” for ease of comprehension. We used this measure to assess frequency of sexual risk practices (e.g., condoms on sex toys, latex gloves, dental dams, saran wrap, not sharing sex toys or razors). Secondary outcomes included: safer sex self-efficacy, STI knowledge, brief resilient coping, social support, community connectedness, sexual stigma (total, internalized, enacted, felt normative), access to sexual healthcare, depression, and self-esteem. Safer sex self-efficacy was assessed using a modified version of (1) the Condom Use Self-Efficacy Scale,⁴⁶ Cronbach's α=0.80, referred to as barrier use self-efficacy to enhance appropriateness for LBQ women, and (2) the Safer Sex Self-Efficacy Scale,⁴⁷ Cronbach's α=0.77, which assesses general safer sex self-efficacy, and thus is referred to as general safer sex self-efficacy. Participants self-reported STI testing history in past 6 weeks. We measured STI knowledge using the Sexually Transmitted Disease Knowledge Questionnaire (STD-KQ),⁴⁸ Cronbach's α=0.70. The Brief Resilient Coping Scale was used to assess resilient coping,⁴⁹ Cronbach's α=0.69.

Social support was measured using the Social Provisions Scale.⁵⁰ We calculated a total social support score, Cronbach's α=0.90 as well as scores for each of the six subscales: (1) attachment, Cronbach's α=0.75; (2) social integration, Cronbach's α=0.68; (3) reassurance of worth, Cronbach's α=0.59; (4) reliable alliance, Cronbach's α=0.77; (5) guidance, Cronbach's α=0.86; and (6) opportunity for nurturance, Cronbach's α=0.61. Connection to LGBQ communities was assessed using the Community Connectedness Scale,⁵¹ Cronbach's α=0.84. Total, enacted, and felt-normative sexual stigma was measured using the Homophobia Scale,⁵² Cronbach's α=0.77, 0.72, 0.56, respectively. Internalized stigma was measured using the Short Internalised Homonegativity Scale,⁵³ Cronbach's α=0.77. Access to healthcare was assessed using items from a survey conducted with lesbian women in the US (e.g., costs related to transportation and medications, belief that healthcare provider is uncomfortable with one's sexual orientation).⁵⁴ Depression was measured using the Patient Health Questionnaire 2,⁵⁵ Cronbach's α=0.89, and self-esteem was measured using the Rosenberg Self-Esteem Scale,⁵⁶ Cronbach's α=0.88.

Data analysis

We conducted descriptive analyses of socio-demographic (e.g., age, income) variables, including means and standard deviations or frequencies and proportions, to provide an overview of participant characteristics. We summarized socio-demographic variables among participants in each location (Toronto, Calgary) and differences between locations were assessed using Student t-tests for continuous variables and χ² analyses or Fisher's exact test for categorical variables.

Items for each outcome scale were summed to calculate total or subscale scores for each measure (e.g., STI knowledge, social support guidance subscale) and we report each with means and standard deviations. Outcome measures were tested for pre-intervention differences by socio-demographic characteristics using Pearson product-moment correlation for continuous variables, Student t-tests for dichotomous variables, and analysis of variance for variables of three or more categories. Socio-demographic characteristics on which the pre-intervention primary outcome measure differed at the p<0.1 level were selected for statistical adjustment in the pre-post analysis longitudinal regression model. For secondary outcomes, we chose for model adjustment the set of socio-demographic variables on which four or more outcomes differed significantly and were not significantly associated with each other.

We used mixed-effects regression to model each continuous outcome measure as a function of two time dummy variables, one for post-intervention interview time point and one for week 6 follow-up. This method accounts for the correlated structure of three repeated measures (pre-intervention, post-intervention, week 6 follow-up)⁵⁷ and uses maximum likelihood estimation for inference that allows inclusion of cases with missing data.⁵⁸ While accounting for within- and between-subject variability, regression-based models also allow the flexibility to adjust for socio-demographic covariates. The model coefficients for the model dummy variables represent the change in outcome score from pre-intervention to post-intervention and from pre-intervention to week 6 follow-up. For the primary outcome, safer sex practices, we adjusted the two modeled change scores for education, ethnicity, and study site. For all secondary outcomes, the modeled change scores were adjusted for age, education, and income security. All statistical analyses were conducted using Stata 11.2.⁵⁹

Results

Forty-four participants consented to complete and completed the intervention and pre-intervention survey (n=24 in Toronto; n=20 in Calgary). Forty-two of 44 women (95%) completed the post-intervention survey, and 38 of 44 women (86%) completed the week 6 follow-up survey. Socio-demographic characteristics across the entire sample and stratified by study site are presented in Table 1. Participants were on average 28.7 years old and had at least a community college education (84.1%). Average yearly income was $30,473 CAD. Participants were mostly white/Caucasian (54.6%) and African Caribbean black (34.1%), self-identified as queer (50.0%), lesbian (29.6%), or bisexual/other (20.4%), and were in a variety of relationship types, and one-third had no current partners (34.1%). Most were employed full- or part-time (88.4%). One-fifth of participants (n=9) reported a history of STI. Slightly more participants were recruited at the Toronto study site (54.6%). Participants from the Toronto site were more likely to identify as queer, and those from Calgary more likely to identify as bisexual/other (Fisher's exact p<0.01). There were more African Caribbean black participants at the Toronto site in comparison with Calgary (Fisher's exact p<0.01). Sexual risk practices scores were higher among those with lower education compared to middle (college and some university) and higher (university or higher) education (28.7 vs. 23.1 and 24.8, F=4.3, p=0.02).

Table 1.

Participant Characteristics, Overall and By Location (n=44)

	Overall N (%) 44 (100)	Toronto N (%) 24 (54.55)	Calgary N (%) 20 (45.45)
Age (years) (n=42)	28.7 (5.7)	28.8 (6.2)	28.6 (5.3)
Education (n=42)
≥High school, some college	7 (15.91)	3 (12.5)	4 (20.0)
College, some university	13 (29.55)	6 (25.0)	7 (35.0)
≥University	24 (54.55)	15 (62.5)	9 (45.0)
Income (annual $CAD) (n=38)	$30 473 (20 834)	$24 850 (18 689)	$36 722 (21 894)
Sexual orientation^a
Bisexual/other	9 (20.45)	1 (4.17)	8 (40.0)
Lesbian	13 (29.55)	6 (25.0)	7 (35.0)
Queer	22 (50.0)	17 (70.83)	5 (25.0)
Ethnicity^a
White/Caucasian	24 (54.55)	8 (33.33)	16 (80.0)
Black (African, Caribbean, Canadian)	15 (34.09)	13 (54.17)	2 (10.0)
Other ethnicities	5 (11.36)	3 (12.5)	2 (10.0)
Employment
Full-time/self-employed	25 (58.14)	10 (41.67)	15 (78.95)
Part-time	13 (30.23)	10 (41.67)	3 (15.79)
Unemployed/other	5 (11.36)	4 (16.67)	1 (5.26)
Current relationship
Married/living together	11 (25.0)	4 (16.67)	7 (35.0)
Dating, not cohabitating	12 (27.27)	7 (29.17)	5 (25.0)
No current partners	15 (34.09)	9 (37.5)	6 (30.0)
Casual dating/multiple partners	6 (13.64)	4 (16.67)	2 (10.0)
History of STI
No history STI	35 (79.55)	20 (83.33)	15 (75.00)
Current or Past STI	9 (20.45)	4 (16.67)	5 (25.00)

Statistically significant difference in sexual orientation between participants in Calgary and Toronto, p<0.01.

Missing data on outcome measures ranged from 0.0–9.1% at pre-intervention, 4.6–20.5% at post-intervention, and 13.6–25.0% at week 6 follow-up. Thirty-eight of 44 participants (86.4%) completed the survey at week 6 follow-up. Those who were missing post-intervention primary outcome data reported significantly higher income than those with valid data (t=2.93, p<0.01), and there were no socio-demographic differences between those with missing and valid primary outcome data at week 6 follow-up. Similarly, participants with missing secondary outcomes data at post-intervention and week 6 follow-up reported higher income than those with valid data.

Table 2 presents results from mixed-effects analyses of pre-intervention scores and subsequent adjusted extent of changes in these scores at post-intervention and week 6 follow-up. The primary outcome, sexual risk practices score, showed significant reduction at post-intervention (β1=−1.63, 95% CI −3.07, −0.19) and at week 6 follow-up (β2=−2.96, 95% CI −4.43, −1.50). Barrier use self-efficacy (β1=1.624, 95% CI 0.648, 2.600; β2=1.521, 95% CI 0.513, 2.529) and STI knowledge (β1=4.40, 95% CI 3.54, 5.26; (β2=4.41 95% CI 3.52, 5.30) scores increased at post-intervention and week 6 follow-up. Total sexual stigma (β1=−1.48, 95% CI −2.32, −0.63; β2=−2.62, 95% CI −3.48, −1.75), enacted sexual stigma (β1=−0.67, 95% CI −1.20, −0.15; β2=−1.04, 95% CI −1.58, −0.50), and perceived sexual stigma (β1=−0.81, 95% CI −1.33, −0.29; β2=−1.58, 95% CI −2.13, −1.05) decreased at pre-intervention and week 6 follow-up. Social support reliable alliance (β1=−1.02, 95% CI −1.87, −0.18) and guidance (β1=−1.02, 95% CI −2.0, −0.03) subscale scores decreased and general safer sex self-efficacy (β1=1.700, 95% CI 0.344, 3.056) community connectedness (β1=1.28, 95% CI 0.36, 2.21) scores increased at post-intervention.

Table 2.

Adjusted Change in Outcome Scores from Pre- to Post-Intervention and Pre- to Week 6 Follow-Up Among LBQ Women Who Participated in a Group-Based HIV/STI Intervention

	Pre to post-intervention				Pre-intervention to week 6 follow-up
	β	95% CI		p	β	95% CI		p
Primary outcome^a
Sexual risk practices total score	−1.627	−3.066	−0.188	0.027^c	−2.963	−4.427	−1.498	<0.001^e
Secondary outcomes^b
Barrier use self-efficacy	1.624	0.648	2.600	<0.001^e	1.521	0.513	2.529	0.003^d
General safer sex self-efficacy	1.700	0.344	3.056	0.014^c	1.339	−0.048	2.726	0.058
STI knowledge	4.399	3.539	5.259	<0.001^e	4.407	3.523	5.291	<0.001^e
Brief resilient coping	−0.022	−0.720	0.676	0.951	0.604	−0.106	1.313	0.095
Total social support	−3.912	−8.293	0.469	0.080	−1.449	−5.836	2.939	0.518
Social support (attachment)	−0.431	−1.183	0.321	0.261	0.317	−0.456	1.091	0.422
Social support (social integration)	−0.771	−1.706	0.163	0.106	−0.368	−1.301	0.564	0.439
Social support (reassurance of worth)	−0.597	−1.336	0.141	0.113	0.134	−0.627	0.895	0.730
Social support (reliable alliance)	−1.024	−1.872	−0.177	0.018^c	−0.302	−1.164	0.561	0.493
Social support (guidance)	−1.017	−1.999	−0.034	0.042^c	−0.463	−1.480	0.554	0.372
Social support (opportunity for nurturance)	−0.552	−1.425	0.321	0.215	−0.198	−1.105	0.709	0.669
Community connectedness	1.283	0.356	2.209	0.007^d	0.271	−0.666	1.207	0.571
Depression	0.134	−0.209	0.478	0.444	−0.292	−0.646	0.061	0.105
Total sexual stigma	−1.476	−2.320	−0.631	0.001^d	−2.615	−3.477	−1.754	<0.001^e
Internalized sexual stigma	−0.019	−2.750	2.712	0.989	1.383	−1.450	4.215	0.339
Enacted sexual stigma	−0.671	−1.197	−0.145	0.012^c	−1.038	−1.575	−0.501	<0.001^e
Perceived sexual stigma	−0.811	−1.332	−0.289	0.002^d	−1.588	−2.125	−1.052	<0.001^e
Self-esteem	0.237	−1.301	0.827	0.662	0.874	−0.257	2.005	0.130

Adjusted for education, ethnicity, and city.

Adjusted for education, income security, and age.

p<0.05; ^d p<0.01; ^e p<0.001.

Discussion

A group-based, psycho-educational HIV and STI prevention intervention was effective in reducing sexual risk practices and sexual stigma, and increasing barrier use self-efficacy and STI knowledge, among LBQ women and other WSW in Toronto and Calgary. Participants included predominantly young, college-educated women who were born in Canada, identified as queer, and one-third had no current sexual partners. This study corroborates previous findings that approximately 20% of LBQ women and other WSW report a lifetime history of STI.^7,11,12

Scant studies have evaluated the effectiveness of HIV and STI prevention interventions among LBQ women. This pilot study aimed to enhance understanding of the feasibility of conducting a future randomized control trial or intervention scale up. While results are promising, not all secondary outcome variable changes were maintained at week 6 follow-up; for example, post-test changes in general safer sex self-efficacy, community connectedness, and social support were not sustained. This suggests that addressing these interpersonal and social level changes may require a different approach. Additionally, that there were no statistically significant changes for several secondary outcomes, including: brief resilient coping, social support (total score and subscale scores: attachment, social integration, reassurance of worth, opportunity for nurturance), depression, internalized sexual stigma, and self-esteem at either post-intervention or week 6 follow-up. These results may indicate that further intervention development is necessary, or that impacting change in cognitive and social factors may require a more in-depth, long-term intervention.

A few methodological limitations should be considered. This was a non-randomized pilot trial of an intervention (QWC) with a small sample size (n=44): the sample size may have limited the ability to assess statistical significance of intervention outcomes. Additionally, the sample was characterized by women who were highly educated, predominantly Caucasian, and cisgender, which may overestimate the appropriateness of the intervention for women with less socio-economic resources and from diverse ethno-racial backgrounds and gender identities. Future intervention studies should purposively sample underserved populations of WSW who experience overrepresentation among STI and HIV prevalence rates.

Additionally, the lack of a comparison group limits our ability to determine if changes observed were due to the intervention itself. Future studies should aim to control for history bias through use of a control group. All measures were self-reported and therefore potentially sensitive questions about sexual practices and HIV/STI history may have been impacted by social desirability bias. While all overall scale measures had adequate reliability for preliminary and pilot research,^60,61 low alpha coefficients for some measures highlight the importance of further validating these scales among LBQ women, and conducting additional studies with larger sample sizes. Using biologic STI outcomes to understand associations between intervention participation and STI and HIV infection rates would strengthen future studies. While sustainable changes at week 6 follow-up are promising, this study could not assess if the intervention effects were long lasting.

Despite these limitations, this study has several strengths. This study is among the first to demonstrate that sexual risk practices among LBQ women and other WSW can be reduced through a brief intervention. QWC is a theory-driven intervention based on the Modified Social Ecological Model (MSEM) framework³⁰ and social and structural drivers of HIV and STI.^11,17 This study provides evidence for future randomized control trials to address multi-level dimensions associated with HIV and STI vulnerability, including individual (safer sex practices, STI knowledge, safer sex self-efficacy) and structural (sexual stigma) factors. Including participants from geographically diverse regions of Canada (Calgary and Toronto) shows promise with regards to translating our study findings other urban Canadian centres.

Scant research has evaluated interventions to reduce STI and HIV vulnerability among WSW. A behavioral intervention by Marazzo et al.³⁶ aimed to address unprotected digital-vaginal contact among lesbian women; their motivational computer-based self-assessment resulted in significantly increased glove use among the intervention group. Our current study builds on these important findings to reveal that an intervention for WSW may increase safer sex practices beyond digital-vaginal contact (e.g., using condoms on sex toys, using dental dams). These studies suggest that sexual health interventions tailored for LBQ women can be administered in multiple ways, including online, individual focused³³ as well as in person, group focused. To our knowledge, QWC is the first study to address and measure multi-level (individual, social, structural) outcomes associated with HIV/STI vulnerability among LBQ women and other WSW.

While our results suggest the QWC intervention was effective in addressing individual (safer sex practices, safer sex self-efficacy, STI knowledge) and structural factors (sexual stigma), future research could evaluate alternative methods to address social (social support, community connectedness) factors. While we saw initial increases in social support and community connectedness, these were not sustained; developing and evaluating booster sessions or other strategies to enhance sustainability of results is warranted. Findings can inform healthcare providers and LBQ women's community and social support services who can counsel women about the importance of, and options for, safer sex practices. Counsellors and LBQ women's services could also consider group-based strategies similar to QWC to address sexual stigma and promote social support. Given findings from the current and prior studies^7,11,12 that approximately 20% of LBQ and WSW report a lifetime history of STI, it is critical to understand how to tailor multi-level strategies that reduce STI vulnerability among this population of women overlooked in most STI prevention research.^17,62

Footnotes

Acknowledgments

Canadian Institutes of Health Research (CIHR) Social Research Centre in HIV Prevention for Funding (Fund 1: 487453; Fund 2: HCP-97106). Community partners, including Griffin Centre, Women's Health in Women's Hands Community Health Centre, Black Coalition for AIDS Prevention, 519 Community Centre, Calgary Women's Centre, and Outlink. Special thank you to Janine Cote and all of the retreat facilitators.

Author Disclosure Statement

No conflicting financial interests exist.

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