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1.  Delineating Interpersonal Communication Networks: A Study of the Diffusion of an Intervention Among Female Entertainment Workers in Shanghai, China 
AIDS and behavior  2012;16(7):2004-2014.
Diffusion of innovation (DOI) is widely cited in the HIV behavior change literature; however there is a dearth of research on the application of DOI in interventions for sex workers. Following a randomized-controlled trial of HIV risk reduction among female entertainment workers (FEWs) in Shanghai, China, we used qualitative approaches to delineate potential interpersonal communication networks and contributing factors that promote diffusion of information in entertainment venues. Results showed that top-down communication networks from the venue owners to the FEWs were efficient for diffusion of information. Mammies/madams, who act as intermediaries between FEWs and clients form an essential part of FEWs’ social networks but do not function as information disseminators due to a conflict of interest between safer sex and maximizing profits. Diffusion of information in large venues tended to rely more on aspects of the physical environment to create intimacy and on pressure from managers to stimulate communication. In small venues, communication and conversations occurred more spontaneously among FEWs. Information about safer sex appeared to be more easily disseminated when the message and the approach used to convey information could be tailored to people working at different levels in the venues. Results suggest that safer sex messages should be provided consistently following an intervention to further promote intervention diffusion, and health-related employer liability systems in entertainment venues should be established, in which employers are responsible for the health of their employees. Our study suggests that existing personal networks can be used to disseminate information in entertainment venues and one should be mindful about the context-specific interactions between FEWs and others in their social networks to better achieve diffusion of interventions.
PMCID: PMC4273942  PMID: 22638867
Diffusion of innovation; HIV behavior intervention; Female entertainment workers; Social networks; China
2.  GB Virus C (GBV-C) Infection in Hepatitis C Virus (HCV) Seropositive Women with or at Risk for HIV Infection 
PLoS ONE  2014;9(12):e114467.
GB virus C (GBV-C) may have a beneficial impact on HIV disease progression; however, the epidemiologic characteristics of this virus are not well characterized. Behavioral factors and gender may lead to differential rates of GBV-C infection; yet, studies have rarely addressed GBV-C infections in women or racial/ethnic minorities. Therefore, we evaluated GBV-C RNA prevalence and genotype distribution in a large prospective study of high-risk women in the US.
438 hepatitis C virus (HCV) seropositive women, including 306 HIV-infected and 132 HIV-uninfected women, from the HIV Epidemiologic Research Study were evaluated for GBV-C RNA. 347 (79.2%) women were GBV-C RNA negative, while 91 (20.8%) were GBV-C RNA positive. GBV-C positive women were younger than GBV-C negative women. Among 306 HIV-infected women, 70 (22.9%) women were HIV/GBV-C co-infected. Among HIV-infected women, the only significant difference between GBV-negative and GBV-positive women was age (mean 38.4 vs. 35.1 years; p<0.001). Median baseline CD4 cell counts and plasma HIV RNA levels were similar. The GBV-C genotypes were 1 (n = 31; 44.3%), 2 (n = 36; 51.4%), and 3 (n = 3; 4.3%). The distribution of GBV-C genotypes in co-infected women differed significantly by race/ethnicity. However, median CD4 cell counts and log10 HIV RNA levels did not differ by GBV-C genotype. GBV-C incidence was 2.7% over a median follow-up of 2.9 (IQR: 1.5, 4.9) years, while GBV-C clearance was 35.7% over a median follow-up of 2.44 (1.4, 3.5) years. 4 women switched genotypes.
Age, injection drug use, a history of sex for money or drugs, and number of recent male sex partners were associated with GBV-C infection among all women in this analysis. However, CD4 cell count and HIV viral load of HIV/HCV/GBV-C co-infected women were not different although race was associated with GBV-C genotype.
PMCID: PMC4262414  PMID: 25493916
3.  Prevalence of Sexually Transmitted Diseases and Risk Behaviors from the NIMH Collaborative HIV/STD Prevention Trial 
This cross-sectional study describes the baseline prevalence and correlates of common bacterial and viral sexually transmitted diseases (STDs) and risk behaviors among individuals at high risk for HIV recruited in five low- and middle-income countries. Correlations of risk behaviors and demographic factors with prevalent STDs and the association of STDs with HIV prevalence are examined. Between 2,212 and 5,543 participants were recruited in each of five countries (China, India, Peru, Russia, and Zimbabwe). Standard protocols were used to collect behavioral risk information and biological samples for STD testing. Risk factors for HIV/STD prevalence were evaluated using logistic regression models. STD prevalence was significantly higher for women than men in all countries, and the most prevalent STD was Herpes simplex virus-type 2 (HSV-2). HIV prevalence was generally low (below 5%) except in Zimbabwe (30% among women, 11.7% among men). Prevalence of bacterial STDs was generally low (below 5% for gonorrhea and under 7% for syphilis in all sites), with the exception of syphilis among female sex workers in India. Behavioral and demographic risks for STDs varied widely across the five study sites. Common risks for STDs included female gender, increasing number of recent sex partners, and in some sites, older age, particularly for chronic STDs (i.e., HSV-2 and HIV). Prevalence of HIV was not associated with STDs except in Zimbabwe, which showed a modest correlation between HIV and HSV-2 prevalence (Pearson coefficient = .55). These findings underscore the heterogeneity of global STD and HIV epidemics and suggest that local, focused interventions are needed to achieve significant declines in these infections.
PMCID: PMC4230575  PMID: 25400718
HIV prevention; sexually transmitted diseases; behavioral risk factors; international
4.  “Everything that looks good ain’t good!”: Perspectives on Urban Redevelopment among Persons with a History of Injection Drug Use in Baltimore, Maryland 
While urban redevelopment is intended to ameliorate urban decay, some studies demonstrate that it can negatively impact some residents. Few studies have considered its impact on persons with a history of drug use.
A convenience sample of 25 current or former injection drug users from Baltimore, Maryland, enrolled in the AIDS Linked to the Intravenous Experience study, and reporting residence in or bordering a redeveloping neighborhood participated in 1-2 semi-structured in-depth interviews from July, 2011-February, 2012. Interviews explored personal experiences with redevelopment and perceptions of community-wide impact. Data were analyzed using the constant comparison method.
Respondents rarely described urban redevelopment as solely negative or positive. Revitalization and increased security in the redeveloping area were reported as positive consequences. Negative consequences included the lack of redevelopment-related employment opportunities, disruption of social ties, and housing instability among relocated residents. Respondents also said that urban redevelopment led to the displacement of drug markets to adjacent neighborhoods and outlying counties. Residential relocation and displacement of drug markets were reported as beneficial for persons in contemplative and later stages of recovery.
These findings support a holistic approach to urban redevelopment that increases access to employment opportunities and affordable housing and ensures equitable coverage of public services such as law enforcement.
PMCID: PMC3896568  PMID: 23647924
urban planning; urban redevelopment; substance use; drug markets
5.  The longitudinal association between homelessness, injection drug use, and injection-related risk behavior among persons with a history of injection drug use in Baltimore, MD 
Drug and alcohol dependence  2013;132(3):457-465.
Few studies have assessed the temporal association between homelessness and injection drug use, and injection-related risk behavior.
Among a cohort of 1,405 current and former injection drug users in follow-up from 2005–2009, we used random intercept models to assess the temporal association between homelessness and subsequent injection drug use, and to determine whether the association between homelessness and sustained injection drug use among active injectors differed from the association between homelessness and relapse among those who stopped injecting. We also assessed the association between homelessness and subsequent injection-related risk behavior among participants who injected drugs consecutively across two visits. Homelessness was categorized by duration: none, <1 month, and ≥1 month.
Homelessness was reported on at least one occasion by 532 (38%) participants. The relationship between homelessness and subsequent injection drug use was different for active injectors and those who stopped injecting. Among those who stopped injecting, homelessness was associated with relapse [<1 month: AOR=1.67, 95% CI (1.01, 2.74); ≥1 month: AOR=1.34 95% CI (0.77, 2.33)]. Among active injectors, homelessness was not associated with sustained injection drug use [<1 month: AOR=1.03, 95% CI (0.71, 1.49); ≥1 month: AOR=0.81 95% CI (0.56, 1.17)]. Among those injecting drugs across two consecutive visits, homelessness ≥1 month was associated with subsequent injection-related risk behavior [AOR=1.61, 95% CI (1.06, 2.45)].
Homelessness appears to be associated with relapse and injection-related risk behavior. Strengthening policies and interventions that prevent homelessness may reduce injection drug use and injection-related risk behaviors.
PMCID: PMC3926693  PMID: 23578590
unstable housing; homelessness; relapse; injection drug use; injection-related risk behavior; random intercept models
6.  Effect of community-based voluntary counselling and testing on HIV incidence and social and behavioural outcomes (NIMH Project Accept; HPTN 043): a cluster-randomised trial 
The lancet global health  2014;2(5):e267-e277.
NIMH Project Accept (HPTN 043) was a cluster-randomized trial that tested whether a multicomponent, multi-level prevention strategy (community-based voluntary counselling and testing [CBVCT]) reduced HIV incidence compared to standard voluntary counselling and testing (SVCT).
Forty-eight communities were enrolled at five sites in South Africa, Tanzania, Zimbabwe, and Thailand. CBVCT was designed to make testing more accessible in communities, engage communities through outreach, and provide post-test support services. SVCT comprised standard VCT services established at existing facilities. Communities were randomized in matched pairs to 36 months of CBVCT or SVCT. Data were collected at baseline (n=14,567) and post-intervention (n=56,683) by cross-sectional random surveys of 18–32 year-old community residents. HIV incidence was estimated using a cross-sectional multi-assay algorithm. Thailand was excluded from incidence analyses due to low HIV prevalence.
The estimated incidence in the CBVCT was 1.52% vs. 1.81% in the SVCT with an estimated reduction in HIV incidence of 13·9% (relative risk [RR]=0·86; 95% confidence interval [CI]=0·725–1·023; p=0·08). Women older than 24 years had RR=0·70 (95% CI=0·54–0·90; p=0·009). CBVCT increased testing rates by 25% overall (95% CI=12%–39%; p=0·0003), by 45% among men and 15% among women. No overall effect on sexual risk behaviour was observed. However, among HIV-infected participants, CBVCT reduced the number of sexual partners by 8% (95% CI=1%–15%; p=0.03) and the proportion of multiple partnerships by 30% (95% CI=8%-46%; p=0.01). Social norms regarding HIV testing were improved in CBVCT communities.
The intervention was effective in increasing HIV testing, particularly among men, promoted positive social norms regarding testing, and reduced behavioural risk among HIV-infected participants. A modest reduction in HIV incidence was observed. This intervention focused primarily on HIV detection. Current and future studies that include strategies for HIV treatment and viral suppression should demonstrate further incidence reductions.
PMCID: PMC4131207  PMID: 25103167
HIV; incidence; Project Accept; Africa; HPTN 043
7.  Beyond Surveillance: A Role for Respondent-driven Sampling in Implementation Science 
American Journal of Epidemiology  2013;178(2):260-267.
We are now in the fourth decade of the human immunodeficiency virus (HIV) pandemic. Several novel prevention tools have been identified, and prevalence and incidence have declined in many settings. A remaining challenge is the delivery of preventive interventions to hard-to-reach populations, including men who have sex with men and injection drug users. Leaders in the field of HIV have called for a new focus on implementation science, which requires a shift in thinking from individual randomized controlled trials to cluster-randomized trials. Multiple challenges need to be addressed in the conduct of cluster-randomized trials, including: 1) generalizability of the study population to the target population, 2) potential contamination through overlap/exchange of members of control and intervention clusters, and 3) evaluation of effectiveness at multiple levels of influence. To address these key challenges, we propose a novel application of respondent-driven sampling—a chain-referral strategy commonly used for surveillance—in the recruitment of participants for the evaluation of a cluster-randomized trial of a community intervention. We illustrate this application with an empirical example of a cluster-randomized trial that is currently under way to assess the effectiveness of men's wellness centers in improving utilization of HIV counseling and testing among men who have sex with men in India.
PMCID: PMC3712656  PMID: 23801014
HIV; implementation science; men who have sex with men; randomized controlled trial; respondent-driven sampling
8.  In Peru, reporting male sex partners imparts significant risk of incident HIV/STI infection: all men engaging in same-sex behavior need prevention services 
Sexually transmitted diseases  2013;40(7):569-574.
Detailed information on the sexual behavior of bisexual, non-gay identified men and the relationship between same-sex behavior and HIV/STI incidence are limited. This study provides information on the sexual behavior with male partners of non-gay identified men in urban, coastal Peru and the relationship of this behavior with HIV/STI incidence.
We analyzed data from 2146 non-gay identified men with a baseline and then two years of annual follow-up, including detailed information on sexual behavior with up to 5 sex partners, to determine characteristics associated with bisexual behavior. Discrete time proportional hazards models were used to determine the effect of self-reported sex with men on subsequent HIV/STI incidence.
Over the three study visits, sex with a man was reported by 18.9% of men, 90% of whom also reported sex with a female partner. At baseline, reported bisexual behavior was associated with other sexual risk behaviors such as exchanging sex for money and increased risk of HIV, HSV-2, and gonorrhea. The number of study visits in which recent sex with men was reported was positively correlated with risk of other sexual risk behaviors and incident HIV, HSV-2, and gonorrhea. Recent sex with a man was associated with increased HIV/STI incidence, HR 1.79 (95% CI 1.19 – 2.70), after adjusting for socio-demographics and other sexual risk behaviors.
Given the prevalence of recent sex with men and the relationship of this behavior with HIV/STI incidence, interventions with non-gay identified men who have sex with men and their partners are warranted.
PMCID: PMC3752699  PMID: 23965772
Bisexual men; Men who have sex with men; sexual risk behavior; HIV/STI prevention; Peru
9.  A comparison of HIV/AIDS-related stigma in four countries: Negative attitudes and perceived acts of discrimination towards people living with HIV/AIDS☆ 
Social science & medicine (1982)  2009;68(12):2279-2287.
HIV/AIDS-related stigma and discrimination have a substantial impact on people living with HIV/AIDS (PLHA). The objectives of this study were: (1) to determine the associations of two constructs of HIV/AIDS-related stigma and discrimination (negative attitudes towards PLHA and perceived acts of discrimination towards PLHA) with previous history of HIV testing, knowledge of antiretroviral therapies (ARVs) and communication regarding HIV/AIDS and (2) to compare these two constructs across the five research sites with respect to differing levels of HIV prevalence and ARV coverage, using data presented from the baseline survey of U.S. National Institute of Mental Health (NIMH) Project Accept, a four-country HIV prevention trial in Sub-Saharan Africa (Tanzania, Zimbabwe and South Africa) and northern Thailand. A household probability sample of 14,203 participants completed a survey including a scale measuring HIV/AIDS-related stigma and discrimination. Logistic regression models determined the associations between negative attitudes and perceived discrimination with individual history of HIV testing, knowledge of ARVs and communication regarding HIV/AIDS. Spearman's correlation coefficients determined the relationships between negative attitudes and perceived discrimination and HIV prevalence and ARV coverage at the site-level. Negative attitudes were related to never having tested for HIV, lacking knowledge of ARVs, and never having discussed HIV/AIDS. More negative attitudes were found in sites with the lowest HIV prevalence (i.e., Tanzania and Thailand) and more perceived discrimination against PLHA was found in sites with the lowest ARV coverage (i.e., Tanzania and Zimbabwe). Programs that promote widespread HIV testing and discussion of HIV/AIDS, as well as education regarding and universal access to ARVs, may reduce HIV/AIDS-related stigma and discrimination.
PMCID: PMC4029331  PMID: 19427086
Sub-Saharan Africa; Thailand; HIV/AIDS; Stigma; Discrimination; Tanzania; Zimbabwe; South Africa
10.  Prevalence and Seroincidence of Hepatitis B and Hepatitis C Infection in High Risk People Who Inject Drugs in China and Thailand 
We determined the prevalence and incidence of HBV and HCV infection in people who inject drugs (PWIDs) at high risk for HIV in China and Thailand and determined the association of HBV and HCV incidence with urine opiate test results and with short-term versus long-term buprenorphine-naloxone (B-N) treatment use in a randomized clinical trial (HPTN 058). 13.8% of 1049 PWIDs in China and 13.9% of 201 PWIDs in Thailand were HBsAg positive at baseline. Among HBsAg negative participants, the HBsAg incidence rate was 2.7/100 person years in China and 0/100 person years in Thailand. 81.9% of 1049 PWIDs in China and 59.7% of 201 in Thailand were HCV antibody positive at baseline. The HCV confirmed seroincidence rate among HCV antibody negative PWIDs was 22/100 person years in China and 4.6/100 person years in Thailand. Incident HBsAg was not significantly different in the short-term versus long-term B-N arm in China or Thailand. Participants with positive opiate results in at least 75% of their urines during the time period were at increased risk of incident HBsAg (HR = 5.22; 95% CI, 1.08 to 25.22; P = 0.04) in China, but not incident HCV conversion in China or Thailand.
PMCID: PMC3985324  PMID: 24860664
11.  Incidence of HIV and Sexually Transmitted Infections and Risk Factors for Acquisition among Young Methamphetamine Users in Northern Thailand 
Sexually transmitted diseases  2009;36(5):284-289.
Southeast Asia is experiencing an epidemic of methamphetamine use, a drug associated with risky sexual behaviors, putting a large segment of the population at increased risk for STI and HIV and in need of prevention efforts. Incidence estimates of sexually transmitted infections (STIs) are rare in Southeast Asia, especially among newer risk groups.
Study Design
We enrolled methamphetamine users aged 18 to 25 years in a 12-month randomized behavioral intervention trial in Chiang Mai, Thailand in 2005. Behavioral questionnaires were administered at visits every three months and biological specimens were collected at baseline and 12 months to test for common STIs (chlamydia, gonorrhea, HSV-2, and HIV). Poisson regression with robust variance was used to determine risk factors for incident STIs.
Overall, 12.7% of 519 participants acquired at least one STI. Chlamydia was the most common (10.6%), followed by HSV-2 (4.0%), gonorrhea (2.9%), and HIV (0.6%). Risk factors for both men and women included self-reported incarceration and having a casual sex partner during follow-up, and having a prevalent STI at baseline. Additionally, among women, having 2 or more heterosexual partners, and among men, having a greater frequency of drunkenness were risk factors for STI acquisition.
While HIV incidence is low in this population, incidence of other STIs is high compared to previous studies of young Thai adults. Risk factors for acquisition emphasize the need for new prevention strategies targeted towards current populations at risk.
PMCID: PMC3682416  PMID: 19295472
Thailand; HIV; STI; methamphetamine; young adults
12.  Changes in sexual and drug-related risk behavior following antiretroviral therapy initiation among HIV-infected injection drug users 
AIDS (London, England)  2012;26(18):2383-2391.
To evaluate whether HAART is associated with subsequent sexual and drug-related risk behavior compensation among injection drug users (IDUs).
A community-based cohort study of 362 HIV-infected IDUs initiating HAART in Baltimore, Maryland.
HAART use and risk behavior was assessed at 8316 biannual study visits (median 23). Using logistic regression with generalized estimating equations (GEE), we examined the effect of HAART initiation on changes in risk behavior while adjusting for sociodemographics, alcohol use, CD4+ cell count, year of initiation and consistency of HAART use.
At HAART initiation, participants were a median of 44.4 years old, 71.3% men and 95.3% African–American. In multivariable analysis, HAART initiation was associated with a 75% reduction in the likelihood of unprotected sex [adjusted odds ratio (aOR) 0.25; 95% confidence interval (CI), 0.19–0.32] despite no change in overall sexual activity (aOR 0.95; 0.80–1.12). Odds of any injecting decreased by 38% (aOR 0.62; 0.51–0.75) after HAART initiation. Among the subset of persistent injectors, needle-sharing increased nearly two-fold (aOR 1.99; 1.57–2.52). Behavioral changes were sustained for more than 5 years after HAART initiation and did not differ by consistency of HAART use. Reporting specific high-risk behaviors in the year prior to initiation was a robust predictor of engaging in those behaviors subsequent to HAART.
Overall, substantial declines in sexual risk-taking and active injecting argue against significant behavioral compensation among IDUs following HAART initiation. These data also provide evidence to support identifying persons with risky pre-HAART behavior for targeted behavioral intervention.
PMCID: PMC3678983  PMID: 23079804
antiretroviral therapy; HIV prevention; injecting; injection drug users; risk compensation; sexual behavior
13.  Sexually transmitted infection risk behaviors in rural Thai adolescents and young adults: Support for gender- and age-specific interventions 
Sexually transmitted diseases  2013;40(3):216-220.
STI prevalence and risks in a sample of rural Thai adolescents and young adults (14–29 years old) were examined. Unprotected sex with a casual partner conferred the greatest risk for prevalent STIs, particularly for younger adolescents and alcohol use increased the STI risk for women but not for men.
PMCID: PMC3572507  PMID: 23403603
Thailand; adolescents; sexually transmitted infections; gender; social norms
14.  Effects of an HIV peer prevention intervention on sexual and injecting risk behaviors among injecting drug users and their risk partners in Thai Nguyen, Vietnam: A randomized controlled trial 
Globally, 30% of new HIV infections outside sub-Saharan Africa involve injecting drug users (IDU) and in many countries, including Vietnam, HIV epidemics are concentrated among IDU. We conducted a randomized controlled trial in Thai Nguyen, Vietnam, to evaluate whether a peer oriented behavioral intervention could reduce injecting and sexual HIV risk behaviors among IDU and their network members. 419 HIV-negative index IDU aged 18 years or older and 516 injecting and sexual network members were enrolled. Each index participant was randomly assigned to receive a series of six small group peer educator-training sessions and three booster sessions in addition to HIV testing and counseling (HTC) (intervention; n = 210) or HTC only (control; n = 209). Follow-up, including HTC, was conducted at 3, 6, 9 and 12 months post-intervention. The proportion of unprotected sex dropped significantly from 49% to 27% (SE (difference) = 3%, p < 0.01) between baseline and the 3-month visit among all index-network member pairs. However, at 12 months, post-intervention, intervention participants had a 14% greater decline in unprotected sex relative to control participants (Wald test = 10.8, df = 4, p = 0.03). This intervention effect is explained by trial participants assigned to the control arm who missed at least one standardized HTC session during follow-up and subsequently reported increased unprotected sex. The proportion of observed needle/syringe sharing dropped significantly between baseline and the 3-month visit (14% vs. 3%, SE (difference) = 2%, p < 0.01) and persisted until 12 months, but there was no difference across trial arms (Wald test = 3.74, df = 3, p = 0.44).
PMCID: PMC3938286  PMID: 24034963
Vietnam; Injecting drug use; HIV; Randomized controlled trial; Peer network; Intervention; Evaluation
15.  Elevated alcohol and sexual risk behaviors among young Thai lesbian/bisexual women 
Drug and alcohol dependence  2012;127(1-3):53-58.
Little empirical data have been published about drinking or sexual behaviors among Thai lesbians. We examine the association of sexual identity with established indicators of alcohol- and sexual-related health behaviors among female bar patrons.
We conducted a cross-sectional study among women (N=121) aged 18–24 who frequented popular drinking establishments in Chiang Mai, Thailand. We used general linear modeling techniques to estimate associations between sexual identity and positive alcohol expectancy, harmful drinking, age at sexual debut, and number of lifetime sexual partners.
Nearly one-third of women aged 18–24 recruited from Chiang Mai drinking venues identified as lesbian/bisexual. As compared to their heterosexual counterparts, lesbian/bisexuals reported higher positive alcohol expectancy scores, more harmful drinking, earlier age at sexual debut, and higher number of lifetime sexual partners. In adjusted models, lesbian/bisexual identity was associated with higher positive alcohol expectancy (β=1.94 points; 95% CI: 0.75,3.13), earlier age at sexual debut (β = −0.85 years; 95% CI:−1.46,−0.23), and higher number of lifetime sexual partners (Rate Ratio=1.7; 95% CI:1.22, 2.37).
Lesbian/bisexual women in this study engaged in multiple behaviors that are potentially harmful to health, which may in turn place this group at heightened risk for alcohol abuse and sexually transmitted infections in Thailand. The clustering of alcohol- and sexual-related risk behaviors, and its consequences for health outcomes in this population, should be explored in future research and may be an important point of intervention.
PMCID: PMC3486947  PMID: 22770462
Lesbian health; Adolescent women; Alcohol use; Sexual health risk; Thailand
16.  The association between cervical HPV infection and HIV acquisition among women in Zimbabwe 
AIDS (London, England)  2010;24(7):1035-1042.
The prevalence of HPV is higher among HIV+ women, but the prevalence of HPV prior to HIV acquisition has not been carefully evaluated.
This study evaluated whether HPV infection is independently associated with heterosexual HIV acquisition in a cohort of Zimbabwean women.
Case-control study nested within a large multi-center cohort study (HC-HIV).
Cases consisted of Zimbabwean women with incident HIV infection observed during follow-up (n=145). HIV-uninfected controls were selected and matched to cases (n=446). The prevalence of cervical HPV infections was compared at the visit prior to HIV infection in the cases and at the same follow-up visit in the matched controls.
The odds of acquiring HIV were 2.4 times higher in women with prior cervical HPV infection after adjustment for behavioral and biologic risk factors. There was no statistically significant difference in the risk of HIV acquisition between women infected with high versus low risk HPV types. Loss of detection of at least one HPV DNA type was significantly associated with HIV acquisition (OR =5.4 [95%CI, 2.9–9.9] (p<.0001).
Cervical HPV infection is associated with HIV acquisition among women residing in a region with a high prevalence of both infections. Further studies are required to evaluate whether the observed association is causal.
PMCID: PMC3831602  PMID: 20397287
HPV; heterosexual HIV transmission; HIV prevention; cervical HPV; STI
17.  HIV Risk Behaviors in Sub-Saharan Africa and Northern Thailand: Baseline Behavioral Data from Project Accept 
Of 2.5 million new HIV infections worldwide in 2007, most occurred in Sub-Saharan Africa and Southeast Asia. We present the baseline data on HIV risk behaviors and HIV testing in Sub-Saharan Africa and northern Thailand from Project Accept, a community-randomized controlled trial of community mobilization, mobile voluntary counseling and testing (VCT), and post-test support services.
A random household probability sample of individuals aged 18–32 years yielded a sample of 14,657 with response rates ranging from 84–94% across the five sites (Thailand, Zimbabwe, Tanzania and two in South Africa). Individuals completed an interviewer-administered survey on demographic characteristics, HIV risk behaviors and history of VCT.
In multivariate analysis, females, married individuals, less educated with one sexual partner in the past 6 months were more likely to have had unprotected intercourse in the previous 6 months. Rates of lifetime HIV testing ranged from 5.4% among males in Zimbabwe to 52.6% among females in Soweto.
Significant risk of HIV acquisition in Project Accept communities exists despite two decades of prevention efforts. Low levels of recent HIV testing suggest that increasing awareness of HIV status through accessible VCT services may reduce HIV transmission.
PMCID: PMC2643066  PMID: 18845954
18.  Estimation of HIV Incidence in a Large, Community-Based, Randomized Clinical Trial: NIMH Project Accept (HIV Prevention Trials Network 043) 
PLoS ONE  2013;8(7):e68349.
National Institute of Mental Health Project Accept (HIV Prevention Trials Network [HPTN] 043) is a large, Phase III, community-randomized, HIV prevention trial conducted in 48 matched communities in Africa and Thailand. The study intervention included enhanced community-based voluntary counseling and testing. The primary endpoint was HIV incidence, assessed in a single, cross-sectional, post-intervention survey of >50,000 participants.
HIV rapid tests were performed in-country. HIV status was confirmed at a central laboratory in the United States. HIV incidence was estimated using a multi-assay algorithm (MAA) that included the BED capture immunoassay, an avidity assay, CD4 cell count, and HIV viral load.
Data from Thailand was not used in the endpoint analysis because HIV prevalence was low. Overall, 7,361 HIV infections were identified (4 acute, 3 early, and 7,354 established infections). Samples from established infections were analyzed using the MAA; 467 MAA positive samples were identified; 29 of those samples were excluded because they contained antiretroviral drugs. HIV prevalence was 16.5% (range at study sites: 5.93% to 30.8%). HIV incidence was 1.60% (range at study sites: 0.78% to 3.90%).
In this community-randomized trial, a MAA was used to estimate HIV incidence in a single, cross-sectional post-intervention survey. Results from this analysis were subsequently used to compare HIV incidence in the control and intervention communities.
Trial Registration NCT00203749
PMCID: PMC3708944  PMID: 23874597
19.  Temporal trends in HAART initiation among injection drug users in Baltimore, MD, 1996–2008 
We characterized temporal trends in HAART initiation (1996–2008) among treatment eligible persons in a community-based cohort of current and former injection drug users (IDUs) in Baltimore.
The AIDS Linked to the IntraVenous Experience (ALIVE) cohort has been following HIV positive IDUs since 1988. HAART eligibility was defined as the first visit after January 1, 1996 where CD4 was <350 cells/µl. Temporal trends and predictors of HAART initiation were examined using chi-square tests for trend and lognormal survival models.
The median age of 582 HAART-eligible IDUs was 41; 75% were male, 97% African American and 60% active injectors. 345 initiated HAART over 1803 person-years (19.2 per 100 person-years, 95% CI, 17.2–21.3); there was no significant temporal trend in HAART initiation. Independent predictors of delayed initiation included heavy injection and higher CD4 count; prior AIDS diagnosis, usual source of care and health insurance were predictors of more rapid initiation. The delay between eligibility and initiation decreased among those becoming eligible most recently (2003–07) compared with those in earlier calendar periods (1996–2003); however, a substantial number initiated HAART in recent calendar years either after substantial delay or not at all.
We failed to observe substantial improvement in HAART initiation among current and former IDUs over 12 years; heavy drug injection remains the major barrier to HAART initiation and consistent HIV care. The fact that many IDUs initiate HAART after significant delay or not at all raises concern that disparities in HIV care for IDUs remain at a time of simplified antiretroviral regimens and increasing adoption of earlier treatment.
PMCID: PMC2874101  PMID: 20450418
HIV/AIDS; injection drug users; highly active antiretroviral therapy; temporal trends
20.  Short-term safety of buprenorphine/naloxone in HIV-seronegative opioid-dependent Chinese and Thai drug injectors enrolled in HIV Prevention Trials Network 058 
Buprenorphine/naloxone (BUP/NX) is not licensed for use in China or Thailand and there was little clinical experience with this drug combination in these countries at the inception of HIV Prevention Trial Network (HPTN) 058, a randomized trial comparing risk reduction counseling combined with either short-term or long-term medication assisted treatment with BUP/NX to prevent HIV infection and death among opioid-dependent injectors.
We conducted a safety phase that included the first 50 subjects enrolled at each of the three initial study sites (N=150). Clinical and laboratory assessments were conducted at baseline and weekly for the first 4 weeks. Changes in laboratory parameters were estimated with random effects models.
BUP/NX was well tolerated by study subjects and opioid withdrawal scores decreased substantially during the 3-day induction. Two participants experienced grade 3 clinical adverse events, which were categorized as probably not related to the study drug. Grade 2 or 3 increases in alanine aminotransferase (ALT) occurred in 25 (17%) subjects. The magnitude of ALT increase over 4-week follow-up was strongly associated with baseline ALT elevation.
In Chinese and Thai opioid-dependent injectors, we found BUP/NX to be effective in reducing opioid withdrawal symptoms and safe during short-term use. ALT increases were observed over 4-week-follow-up, which are consistent with reports from Western populations. Long-term safety and efficacy evaluations are indicated.
PMCID: PMC3236277  PMID: 21852093
buprenorphine/naloxone; injection drug use; opioid dependence; HIV prevention; risk reduction counseling; safety; hepatic toxicity
21.  Quality of Life Among Individuals with HIV Starting Antiretroviral Therapy in Diverse Resource-Limited Areas of the World 
AIDS and Behavior  2012;16(2):266-277.
As Antiretroviral Therapy (ART) is scaled up in low- and middle-income countries, it is important to understand Quality of Life (QOL) correlates including disease severity and person characteristics and to determine the extent of between-country differences among those with HIV. QOL and medical data were collected from 1,563 of the 1,571 participants at entry into a randomized clinical trial of ART conducted in the U.S. (n = 203) and 8 resource-limited countries (n = 1,360) in the Caribbean, South America, Asia, and Africa. Participants were interviewed prior to initiation of ART using a modified version of the ACTG SF-21, a health-related QOL measure including 8 subscales: general health perception, physical functioning, role functioning, social functioning, cognitive functioning, pain, mental health, and energy/fatigue. Other measures included demographics, CD4+ lymphocyte count, plasma HIV-1 RNA viral load. Higher quality of life in each of the 8 QOL subscales was associated with higher CD4+ lymphocyte category. General health perception, physical functioning, role functioning, and energy/fatigue varied by plasma HIV-1 RNA viral load categories. Each QOL subscale included significant variation by country. Only the social functioning subscale varied by sex, with men having greater impairments than women, and only the physical functioning subscale varied by age category. This was the first large-scale international ART trial to conduct a standardized assessment of QOL in diverse international settings, thus demonstrating that implementation of the behavioral assessment was feasible. QOL indicators at study entry varied with disease severity, demographics, and country. The relationship of these measures to treatment outcomes can and should be examined in clinical trials of ART in resource-limited settings using similar methodologies.
PMCID: PMC3182285  PMID: 21499794
Quality of life (QOL); Highly active antiretroviral therapy (HAART); HIV
22.  Factors associated with injection cessation, relapse and initiation in a community-based cohort of injection drug users in Chennai, India 
Addiction (Abingdon, England)  2011;107(2):349-358.
To characterize factors associated with injection cessation, relapse and initiation.
MIDACS is a prospective cohort of injection drug users (IDUs) recruited in 2005–06 with semi-annual follow-up through 2009. Discrete-time survival models were used to characterize predictors of time to first injection cessation and relapse.
Chennai, India
855 IDUs who reported injecting in the six months prior to baseline and had > 1 follow-up visit.
Cessation was defined as the first visit where no injection drug use was reported (prior six months) and relapse as the first visit where drug injection (prior six months) was reported after first cessation.
All participants were male; median age was 35. Over three years, 92.7% reported cessation (incidence rate [IR]: 117 per 100 person-years). Factors positively associated with cessation included daily injection and incarceration and factors negatively associated with cessation included marriage, alcohol and homelessness. Of those who reported cessation, 24% relapsed (IR: 19.7 per 100 person-years). Factors positively associated with relapse included any education, injection in the month prior to baseline, sex with a casual partner, non-injection drug use, incarceration and homelessness. Alcohol was negatively associated with relapse. The primary reasons for cessation were medical conditions (36%) and family pressure (22%). The majority initiated with non-injection drugs, transitioning to injection after a median 4 years.
Injection drug users in Southern India demonstrate a high rate of injection cessation over three years, but relapse is not uncommon. Compensatory increases in alcohol use indicate that cessation of injection does not mean cessation of all substance use. Family pressure, concerns about general health, fear of HIV infection, and a history of non-injection drug use are important correlates of cessation.
PMCID: PMC3222716  PMID: 21815960
natural history; drug use; India; injection drug users; cohort
23.  Combined Oral Contraceptive Use Increases HPV Persistence but Not New HPV Detection in a Cohort of Women From Thailand 
The Journal of Infectious Diseases  2011;204(10):1505-1513.
Background. Women diagnosed with cervical cancer report longer duration and more recent use of combined oral contraceptives (COCs). It is unclear how COC use impacts risk of cervical carcinogenesis.
Methods. We estimated the risk of new human papillomavirus (HPV) DNA detection and persistence among 1135 human immunodeficiency virus (HIV)–negative women aged 20–37 years from Thailand who were followed for 18 months at 6-month intervals. Type-specific HPV DNA, demographic information, hormonal contraceptive use, sexual behavior, genital tract coinfection, and Papanicolaou test results were assessed at baseline and each follow-up.
Results. Women who reported current COC use during follow-up were less likely to clear HPV infection compared with nonusers, independent of sexual behavior, and Papanicolaou test diagnosis (AHR: 0.67 [95% CI: .49–.93]). Similar associations were not observed among women reporting current use of depomedroxyprogesterone acetate (DMPA). Neither COC nor DMPA use was significantly associated with new HPV DNA detection.
Conclusions. These data do not support the hypothesis that contraceptive use is associated with cervical cancer risk via increased risk of HPV acquisition. The increased risk of HPV persistence observed among current COC users suggests a possible influence of female sex hormones on host response to HPV infection.
PMCID: PMC3222104  PMID: 21964399
24.  The Effect of Neighborhood Deprivation and Residential Relocation on Long-term Injection Cessation among Injection Drug Users (IDUs) in Baltimore, Maryland 
Addiction (Abingdon, England)  2011;106(11):1966-1974.
To determine the incidence of long-term injection cessation and its association with residential relocation and neighborhood deprivation.
ALIVE (AIDS Linked to the Intravenous Experience) is a prospective cohort with semi-annual follow-up since 1988. Multi-level discrete time-to-event models were constructed to investigate individual and neighborhood-level predictors of long-term injection cessation.
Baltimore, USA
1,697 active injectors from ALIVE with at least 8 semi-annual study visits.
Long-term injection cessation was defined as three consecutive years without self-reported injection drug use.
706 (42%) injectors achieved long-term cessation (incidence = 7.6 per 100 person-years). After adjusting for individual-level factors, long-term injection cessation was 29% less likely in neighborhoods in the third quartile of deprivation (Hazard Ratio [HR] =0.71, 95% CI:0.53–0.95) and 43% less likely in the highest quartile of deprivation (HR=0.57, 95% CI:0.43, 0.76) as compared to the first quartile. Residential relocation was associated with increased likelihood of long-term injection cessation (HR=1.55, 95% CI:1.31, 1.82); however the impact of relocation varied depending on the deprivation in the destination neighborhood. Compared to those who stayed in less deprived neighborhoods, relocation from highly deprived to less deprived neighborhoods had the strongest positive impact on long-term injection cessation (HR=1.96, 95% CI:1.50, 2.57), while staying in the most deprived neighborhoods was detrimental (HR=0.76, 95% CI:0.63, 0.93).
Long-term cessation of injection of opiates and cocaine occurred frequently following a median of 9 years of injection and contextual factors appear to be important. Our findings suggest that improvements in the socio-economic environment may improve the effectiveness of cessation programs.
PMCID: PMC3189272  PMID: 21592251
25.  Variations in sexual risks in drug users: Emerging themes in a behavioral context 
Current HIV/AIDS reports  2008;5(4):212-218.
Drug users are an especially complex population among those studied in HIV-risk behavior research. While injection drug use accounts for over one-third of cumulative HIV transmission in the U.S., the scope of the direct and indirect impact of all drug use is difficult to quantify, especially in relation to attributing HIV to either drug use directly via parenteral exposures or indirectly, through unsafe sex. Important behavioral issues such as social and drug network overlaps, partner selection and the combinations of illicit drugs with erectile dysfunction medications have added complexity to the studying of sexual behavior in drug users. This review covers recent substantive research in the U.S. and Canada on current themes in sexual risk behavior in injection drug and non-injection drug users. We address gender, situational and sexual preference factors that may influence sexual behaviors affecting HIV risk by class of drug and route of administration. Special attention is paid to minority populations, both sexual and race/ethnicity, as their marginalized role in contemporary society places special barriers for risk reduction.
PMCID: PMC2801160  PMID: 18838061

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