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1.  A reanalysis of a behavioral intervention to prevent incident HIV infections: Including indirect effects in modeling outcomes of Project EXPLORE 
AIDS care  2012;25(7):805-811.
Background
Project EXPLORE -- a large-scale, behavioral intervention tested among men who have sex with men (MSM) at-risk for HIV infection --was generally deemed as ineffective in reducing HIV incidence. Using novel and more precise data analytic techniques we reanalyzed Project EXPLORE by including both direct and indirect paths of intervention effects.
Methods
Data from 4,296 HIV negative MSM who participated in Project EXPLORE, which included ten sessions of behavioral risk reduction counseling completed from 1999-2005, were included in the analysis. We reanalyzed the data to include parameters that estimate the overtime effects of the intervention on unprotected anal sex and the over-time effects of the intervention on HIV status mediated by unprotected anal sex simultaneously in a single model.
Results
We found the indirect effect of intervention on HIV infection through unprotected anal sex to be statistically significant up through 12 months post-intervention, OR=.83, 95% CI=.72-.95. Furthermore, the intervention significantly reduced unprotected anal sex up through 18 months post-intervention, OR=.79, 95% CI=.63-.99.
Discussion
Our results reveal effects not tested in the original model that offer new insight into the effectiveness of a behavioral intervention for reducing HIV incidence. Project EXPLORE demonstrated that when tested against an evidence-based, effective control condition can result in reductions in rates of HIV acquisition at one year follow-up. Findings highlight the critical role of addressing behavioral risk reduction counseling in HIV prevention.
doi:10.1080/09540121.2012.748870
PMCID: PMC3761806  PMID: 23245226
2.  Co-Occurring Psychosocial Problems and HIV Risk Among Women Attending Drinking Venues in a South African Township: A Syndemic Approach 
Background
In South Africa, women comprise the majority of HIV infections. Syndemics, or co-occurring epidemics and risk factors, have been applied to understanding HIV risk among marginalized groups.
Purpose
To apply the syndemic framework to examine psychosocial problems that co-occur among women attending drinking venues in South Africa, and to test how the co-occurrence of these problems may exacerbate risk for HIV infection.
Method
560 women from a Cape Town township provided data on multiple psychosocial problems, including food insufficiency, depression, abuse experiences, problem drinking, and sexual behaviors.
Results
Bivariate associations among the syndemic factors showed a high degree of co-occurrence and regression analyses showed an additive effect of psychosocial problems on HIV risk behaviors.
Conclusions
These results demonstrate the utility of a syndemic framework to understand co-occurring psychosocial problems among women in South Africa. HIV prevention interventions should consider the compounding effects of psychosocial problems among women.
doi:10.1007/s12160-012-9420-3
PMCID: PMC3578969  PMID: 23054944
HIV risk; sexual risk behavior; syndemics; mental health; abuse; alcohol
3.  Drinking before and after pregnancy recognition among South African women: the moderating role of traumatic experiences 
Background
South Africa has one of the world’s highest rates of fetal alcohol spectrum disorder (FASD) and interpersonal trauma. These co-occurring public health problems raise the need to understand alcohol consumption among trauma-exposed pregnant women in this setting. Since a known predictor of drinking during pregnancy is drinking behavior before pregnancy, this study explored the relationship between women’s drinking levels before and after pregnancy recognition, and whether traumatic experiences – childhood abuse or recent intimate partner violence (IPV) – moderated this relationship.
Methods
Women with incident pregnancies (N = 66) were identified from a longitudinal cohort of 560 female drinkers in a township of Cape Town, South Africa. Participants were included if they reported no pregnancy at one assessment and then reported pregnancy four months later at the next assessment. Alcohol use was measured by the Alcohol Use Disorders Identification Test (AUDIT), and traumatic experiences of childhood abuse and recent IPV were also assessed. Hierarchical linear regressions controlling for race and age examined childhood abuse and recent IPV as moderators of the effect of pre-pregnancy recognition drinking on post-pregnancy recognition AUDIT scores.
Results
Following pregnancy recognition, 73% of women reported drinking at hazardous levels (AUDIT ≥ 8). Sixty-four percent reported early and/or recent exposure to trauma. While drinking levels before pregnancy significantly predicted drinking levels after pregnancy recognition, t(64) = 3.50, p < .01, this relationship was moderated by experiences of childhood abuse, B = -.577, t(60) = -2.58, p = .01, and recent IPV, B = -.477, t(60) = -2.16, p = .04. Pregnant women without traumatic experiences reported drinking at levels consistent with levels before pregnancy recognition. However, women with traumatic experiences tended to report elevated AUDIT scores following pregnancy recognition, even if low-risk drinkers previously.
Conclusion
This study explored how female drinkers in South Africa may differentially modulate their drinking patterns upon pregnancy recognition, depending on trauma history. Our results suggest that women with traumatic experiences are more likely to exhibit risky alcohol consumption when they become pregnant, regardless of prior risk. These findings illuminate the relevance of trauma-informed efforts to reduce FASD in South Africa.
doi:10.1186/1471-2393-14-97
PMCID: PMC3975846  PMID: 24593175
South Africa; Pregnancy; Fetal alcohol spectrum disorder; Drinking; Trauma; Childhood abuse; Intimate partner violence
4.  HIV/STI risk among venue-based female sex workers across the globe: A look back and the way forward 
Current HIV/AIDS reports  2013;10(1):65-78.
Female sex workers (FSWs) continue to represent a high-risk population in need of targeted HIV prevention interventions. Targeting environmental risk factors should result in more sustainable behavior change than individual-level interventions alone. There are many types of FSWs who operate in and through a variety of micro- (e.g., brothels) and macro-level (e.g., being sex-trafficked) contexts. Efforts to characterize FSWs and inform HIV prevention programs have often relied on sex work typologies or categorizations of FSWs by venue or type. We conducted a systematic search and qualitatively reviewed 37 published studies on venue-based FSWs to examine the appropriateness of sex work typologies, and the extent to which this research has systematically examined characteristics of different risk environments. We extracted information on study characteristics like venue comparisons, HIV/STI prevalence, and sampling strategies. We found mixed results with regards to the reliability of typologies in predicting HIV/STI infection; relying solely on categorization of FSWs by venue or type did not predict seroprevalence in a consistent manner. Only 65% of the studies that allowed for venue comparisons on HIV/STI prevalence provided data on venue characteristics. The factors that were assessed were largely individual-level FSW factors (e.g. demographics, number of clients per day), rather than social and structural characteristics of the risk environment. We outline a strategy for future research on venue-based FSWs that ultimately aims to inform structural-level HIV interventions for FSWs.
doi:10.1007/s11904-012-0142-8
PMCID: PMC3567216  PMID: 23160840
female sex work; HIV; risk environments; social factors; structural interventions; HIV prevention
5.  Intersecting Epidemics Among Pregnant Women: Alcohol Use, Interpersonal Violence, and HIV Infection in South Africa 
Current HIV/AIDS reports  2013;10(1):103-110.
A critical factor for understanding negative health outcomes is acknowledging the synergistic quality that clusters of health problems create. An important step in addressing clusters of health problems involves gaining an awareness of the contextual factors that connect them. This paper considers the intersection of three mutually reinforcing health problems: alcohol use, interpersonal violence (IPV), and HIV infection among pregnant women residing in South Africa. We explore how SAVA (substance abuse, violence and AIDS)- a syndemics related theory- underscores the dire need to intervene in various areas of psycho-social health and general well-being. Based on World Health Organization data, we highlight the remarkably high rates of alcohol use, IPV, and HIV infection among South African women compared to women residing in other countries around the world. We conclude by highlighting the need for improved recognition of the intersection of these epidemics and for improved surveillance of the prevalence of alcohol use among pregnant women. Finally, based on the literature reviewed, we provide recommendations for future interventions.
doi:10.1007/s11904-012-0145-5
PMCID: PMC3572769  PMID: 23233038
6.  Intentional Non-Adherence to Medications among HIV Positive Alcohol Drinkers: Prospective Study of Interactive Toxicity Beliefs 
ABSTRACT
BACKGROUND
Antiretroviral therapy (ART) adherence is key to successful treatment of HIV infection and alcohol is a known barrier to adherence. Beyond intoxication, ART adherence is impacted by beliefs that mixing alcohol and medications is toxic.
PURPOSE
To examine prospective relationships of factors contributing to intentional medication non-adherence when drinking.
METHODS
People who both receive ART and drink alcohol (N = 178) were enrolled in a 12-month prospective cohort study that monitored beliefs about the hazards of mixing ART with alcohol (interactive toxicity beliefs), alcohol consumption using electronic daily diaries, ART adherence assessed by both unannounced pill counts and self-report, and chart-abstracted HIV viral load.
RESULTS
Participants who reported skipping or stopping their ART when drinking (N = 90, 51 %) demonstrated significantly poorer ART adherence, were less likely to be viral suppressed, and more likely to have CD4 counts under 200/cc3. Day-level analyses showed that participants who endorsed interactive toxicity beliefs were significantly more likely to miss medications on drinking days.
CONCLUSIONS
Confirming earlier cross-sectional studies, the current findings from a prospective cohort show that a substantial number of people intentionally skip or stop their medications when drinking. Interventions are needed to correct alcohol-related interactive toxicity misinformation and promote adherence among alcohol drinkers.
doi:10.1007/s11606-012-2231-1
PMCID: PMC3579979  PMID: 23065532
medication adherence; alcohol use; HIV treatment beliefs
7.  Gender-based Violence, Alcohol use, and Sexual Risk Among Female Patrons of Drinking Venues in Cape Town, South Africa 
Journal of behavioral medicine  2012;36(3):295-304.
Gender-based violence is a well-recognized risk factor for HIV infection among women. Alcohol use is associated with both gender-based violence and sexual risk behavior, but has not been examined as a correlate of both in a context of both high HIV risk and hazardous drinking. The purpose of this paper is to examine the association between recent abuse by a sex partner with alcohol and sexual risk behavior among female patrons of alcohol serving venues in South Africa. Specifically, the aim of this study is to determine whether sexual risk behaviors are associated with gender-based violence after controlling for levels of alcohol use. We surveyed 1,388 women attending informal drinking establishments in Cape Town, South Africa to assess recent history of gender-based violence, drinking, and sexual risk behaviors. Gender-based violence was associated with both drinking and sexual risk behaviors after controlling for demographics among the women. A hierarchical logistic regression analysis showed that after controlling for alcohol use sexual risk behavior remained significantly associated with gender-based violence, particularly with meeting a new sex partner at the bar, recent STI diagnosis, and engaging in transactional sex, but not protected intercourse or number of partners. In South Africa where heavy drinking is prevalent women may be at particular risk of physical abuse from intimate partners as well as higher sexual risk. Interventions that aim to reduce gender-based violence and sexual risk behaviors must directly work to reduce drinking behavior.
doi:10.1007/s10865-012-9423-3
PMCID: PMC3646073  PMID: 22526526
gender-based violence; intimate partner violence; alcohol; sexual risk; HIV risk
8.  Systematic Review and Meta-Analysis of Single-Session Behavioral Interventions to Prevent Sexually Transmitted Infections: Implications for Bundling Multiple STI/HIV Prevention Packages 
American journal of public health  2012;102(11):e34-e44.
Context
Evidence based, single-session, behavioral interventions that can be used in public health settings are urgently needed for preventing the spread of HIV and other sexually transmitted infections (STI). Brief interventions are particularly promising given the relatively low burden they place on financially limited service providers.
Objective
To estimate the efficacy of single-session, behavioral interventions for STI prevention.
Data Sources
MEDLINE (PubMed), PsycINFO, CINAHL, ERIC, Proquest, all international sub-databases in the WHO's Global Health Library were searched through May 2011.
Study Selection
Data from 29 single-session interventions (20 studies; N = 52,465) with an STI outcome were coded and analyzed.
Findings
The odds of participants being infected with an STI in the intervention group were reduced by 35% (OR = .65, 95% CI=.55–.77) relative to control group participants. Interventions were compared to active controls and follow-up periods averaged 58 weeks. As such, single-session interventions lead to considerable benefit in terms of disease prevention and create minimal burden for both the patient and the provider.
Conclusions
Single-session interventions were most often implemented during routine health care services by clinic staff. Use of these procedures make these interventions a reasonable option for currently existing health care infrastructure. Brief and effective STI prevention interventions are a valuable tool for disease prevention and can be readily adapted to bolster the benefits of partially effective biomedical STI/HIV prevention technologies.
doi:10.2105/AJPH.2012.300968
PMCID: PMC3477958  PMID: 22994247
9.  Gender-based Violence and HIV Sexual Risk Behavior: Alcohol Use and Mental Health Problems as Mediators among Women in Drinking Venues, Cape Town 
Social science & medicine (1982)  2012;75(8):1417-1425.
Gender-based violence is a key determinant of HIV infection among women in South Africa as elsewhere. However, research has not examined potential mediating processes to explain the link between experiencing abuse and engaging in HIV sexual risk behavior. Previous studies suggest that alcohol use and mental health problems may explain how gender-based violence predicts sexual risk. In a prospective study, we examined whether lifetime history of gender-based violence indirectly affects future sexual risk behavior through alcohol use, depression and post-traumatic stress disorder (PTSD) in a high-risk socio-environmental context. We recruited a cohort of 560 women from alcohol drinking venues in a Cape Town, South African township. Participants completed computerized interviews at baseline and 4 months later. We tested prospective mediating associations between gender-based violence, alcohol use, depression, PTSD, and sexual risk behavior. There was a significant indirect effect of gender-based violence on sexual risk behavior through alcohol use, but not mental health problems. Women who were physically and sexually abused drank more, which in turn predicted more unprotected sex. We did not find a mediated relationship between alcohol use and sexual risk behavior through the experience of recent abuse or mental health problems. Alcohol use explains the link between gender-based violence and sexual risk behavior among women attending drinking venues in Cape Town, South Africa. Efforts to reduce HIV risk in South Africa by addressing gender-based violence must also address alcohol use.
doi:10.1016/j.socscimed.2012.06.020
PMCID: PMC3425436  PMID: 22832324
South Africa; gender-based violence; HIV; HIV risk; sexual risk; alcohol use; mental health; mediation; women
10.  The relationship between pornography use and sexual behaviors among at-risk HIV negative men who have sex with men 
Sexual health  2012;9(2):166-170.
Objectives
Although pornography is widely available and frequently used among many adults in the US, little is known about the relationship between pornography and risk factors for HIV transmission among men who have sex with men.
Methods
Baseline assessments from a behavioral intervention trial for at-risk men who have sex with men were conducted in Atlanta, GA in 2009. Univariate and multivariate generalized linear models were used to assess the relationships between known risk factors for HIV infection, time spent viewing pornography, and sex behaviors.
Results
One hundred forty nine men reporting HIV-negative status and two or more unprotected anal sex partners in the past six months were enrolled in an intervention trial and completed survey assessments. Time spent viewing pornography was significantly associated with having more male sexual partners (B=.45, SE=.04, p<.001) and unprotected insertive anal sex acts (B=.28, SE=.04, p<.001). Moreover, increased substance use (drug use, B=.61, SE=.14, p<.001; alcohol use, B=.03, SE=.01, p<.01) and decreased perception of risk for HIV infection (B=-.09, SE=.04, p<.05) were found to be significantly associated with greater time spent viewing pornography.
Conclusions
This exploratory study is novel in that it sheds light on the associations between viewing pornography and sexual risk taking for HIV infection. Future studies in this area should focus on understanding how the content of pornography, in particular the viewing of unprotected and protected sex acts, may affect sexual risk taking behavior.
doi:10.1071/SH10092
PMCID: PMC3560402  PMID: 22498161
11.  AIDS-related Stigma, HIV Testing, and Transmission Risk Among Patrons of Informal Drinking Places in Cape Town, South Africa 
Background
AIDS-related stigma as a barrier to HIV testing has not been examined within the context of high at-risk environments such as drinking venues. Of particular importance is whether AIDS-related stigma is associated with HIV transmission risks among people who have never been tested for HIV.
Purpose
We examined: 1) AIDS-related stigma as a barrier to testing, controlling for other potential barriers, and 2) whether stigma is associated with HIV risks among HIV-untested individuals.
Methods
We surveyed 2,572 individuals attending informal drinking establishments in Cape Town, South Africa to assess HIV testing status, AIDS-related stigma endorsement, and HIV transmission sexual risk behavior.
Results
Endorsement of AIDS-related stigma was negatively associated with HIV lifetime testing. In addition, stigma endorsement was associated with higher HIV transmission risks.
Conclusions
AIDS-related stigma must be addressed in HIV prevention campaigns across South Africa. Anti-stigma messages should be integrated with risk reduction counseling and testing.
doi:10.1007/s12160-012-9346-9
PMCID: PMC3565536  PMID: 22367752
HIV/AIDS-related stigma; HIV testing; HIV risk behavior; alcohol; substance use
12.  Pregnancy, Alcohol Intake, and Intimate Partner Violence among Men and Women Attending Drinking Establishments in a Cape Town, South Africa Township 
Journal of Community Health  2012;37(1):208-216.
Background
The highest rates of fetal alcohol syndrome worldwide can be found in South Africa. Particularly in impoverished townships in the Western Cape, pregnant women live in environments where alcohol intake during pregnancy has become normalized and interpersonal violence (IPV) is reported at high rates. For the current study we sought to examine how pregnancy, for both men and women, is related to alcohol use behaviors and IPV.
Methods
We surveyed 2,120 men and women attending drinking establishments in a township located in the Western Cape of South Africa.
Results
Among women 13% reported being pregnant, and among men 12.2% reported their partner pregnant. For pregnant women, 61% reported attending the bar that evening to drink alcohol and 26% reported both alcohol use and currently experiencing IPV. Daily or almost daily binge drinking was reported twice as often among pregnant women than non-pregnant women (8.4% vs. 4.2%). Men with pregnant partners reported the highest rates of hitting sex partners, forcing a partner to have sex, and being forced to have sex. High rates of alcohol frequency, consumption, binge drinking, and problematic drinking were reported across the entire sample. In general, experiencing and perpetrating IPV were associated with alcohol use among all participants except for men with pregnant partners.
Conclusions
Alcohol use among pregnant women attending shebeens is alarmingly high. Moreover, alcohol use appears to be an important factor in understanding the relationship between IPV and pregnancy. Intensive, targeted, and effective interventions for both men and women are urgently needed to address high rates of drinking alcohol among pregnant women who attend drinking establishments.
doi:10.1007/s10900-011-9438-7
PMCID: PMC3286872  PMID: 21744297
13.  Changes in Transmission Risk Behaviors Across Stages of HIV Disease among People Living with HIV/AIDS 
Advances in HIV treatment and opportunistic illness prophylaxis have significantly extended the life expectancy of people living with HIV/AIDS. Increased HIV/AIDS longevity is also marked by changes in HIV transmission risk behaviors. Here we review the literature on HIV transmission risk behaviors as they change in relation to stages of HIV disease among persons who are infected with HIV/AIDS. Studies confirm that the time period immediately preceding testing HIV positive is characterized by high risk behaviors indicating the potential for rapid spread of HIV during acute infection. For many people, reductions in risk behavior are seen immediately following HIV diagnosis. However, these changes in risk taking are not universal and great variability exists in terms of how HIV diagnosis influences risk behaviors. Chronic periods of asymptomatic HIV infection are generally associated with some degree of reverting to high risk behaviors. Also, a CD4 count below 200 cells/mm3 resulting in a formal diagnosis of AIDS, is associated with decreased sexual and drug-related risk behaviors. HIV risk reduction interventions that target men and women living with HIV/AIDS therefore require tailoring to stages of HIV disease. Additional research on risk behaviors of long term HIV positive persons is needed.
doi:10.1016/j.jana.2008.10.005
PMCID: PMC3560412  PMID: 19118770
14.  Condom Negotiation, HIV Testing, and HIV Risks among Women from Alcohol Serving Venues in Cape Town, South Africa 
PLoS ONE  2012;7(10):e45631.
Background
Women in South Africa are at particularly high-risk for HIV infection and are dependent on their male partners' use of condoms for sexual risk reduction. However, many women are afraid to discuss condoms with male partners, placing them at higher risk of HIV infection.
Purpose
To examine the association between fear of condom negotiation with HIV testing and transmission risk behaviors, including alcohol use and sexual risks among South African women.
Method
Women (N = 1333) residing in a primarily Xhosa-speaking African township in Cape Town and attending informal alcohol-serving venues (shebeens) completed anonymous surveys. Logistic regression was used to test the hypothesis that fear of condom negotiation would be associated with increased risk for HIV.
Results
Compared to women who did not fear condom negotiation, those who did were significantly less likely to have been tested for HIV, were more likely to have experienced relationship abuse, and to report more alcohol use and more unprotected sex.
Conclusions
For women in South Africa, fear of condom negotiation is related to higher risk of HIV. HIV prevention efforts, including targeted HIV counseling and testing, must directly address gender issues.
doi:10.1371/journal.pone.0045631
PMCID: PMC3462794  PMID: 23056211
15.  Brief Behavioral Self-Regulation Counseling for HIV Treatment Adherence Delivered by Cell Phone: An Initial Test of Concept Trial 
AIDS Patient Care and STDs  2011;25(5):303-310.
Abstract
Affordable and effective antiretroviral therapy (ART) adherence interventions are needed for many patients to promote positive treatment outcomes and prevent viral resistance. We conducted a two-arm randomized trial (n = 40 men and women receiving and less than 95% adherent to ART) to test a single office session followed by four biweekly cell phone counseling sessions that were grounded in behavioral self-management model of medication adherence using data from phone-based unannounced pill counts to provide feedback-guided adherence strategies. The control condition received usual care and matched office and cell phone/pill count contacts. Participants were baseline assessed and followed with biweekly unannounced pill counts and 4-month from baseline computerized interviews (39/40 retained). Results showed that the self-regulation counseling delivered by cell phone demonstrated significant improvements in adherence compared to the control condition; adherence improved from 87% of pills taken at baseline to 94% adherence 4 months after baseline, p < 0.01. The observed effect sizes ranged from moderate (d = 0.45) to large (d = 0.80). Gains in adherence were paralleled with increased self-efficacy (p < 0.05) and use of behavioral strategies for ART adherence (p < 0.05). We conclude that the outcomes from this test of concept trial warrant further research on cell phone-delivered self-regulation counseling in a larger and more rigorous trial.
doi:10.1089/apc.2010.0367
PMCID: PMC3085946  PMID: 21457056
16.  Sexually transmitted infections and infectiousness beliefs among people living with HIV/AIDS: implications for HIV treatment as prevention 
HIV medicine  2010;11(8):502-509.
Objectives
Sexually transmitted infections (STI) significantly impact the health of people living with HIV/AIDS, increasing HIV infectiousness and therefore transmissibility. The current study examined STI in a community sample of 490 HIV positive men and women.
Methods
Confidential computerized interviews were collected in a community research setting.
Results
14% of the people living with HIV/AIDS in this study had been diagnosed with a new STI in a six month period. Individuals with a new STI had significantly more sex partners in that time period, including non-HIV positive partners. Participants who had contracted an STI were significantly more likely to have detectable viral loads and were less likely to know their viral load than participants who did not contract an STI. Multivariate analysis showed that believing an undetectable viral load leads to lower infectiousness was associated with contracting a new STI.
Conclusions
Individuals who believe having an undetectable viral load reduces HIV transmission risks were more likely infectious because of STI co-infection. Programs that aim to use HIV treatment for HIV prevention must address infectiousness beliefs and aggressively control STI among people living with HIV/AIDS.
doi:10.1111/j.1468-1293.2009.00818.x
PMCID: PMC2937207  PMID: 20201976
HIV/AIDS prevention; HIV/AIDS treatment; Sexually Transmitted Infections
17.  Serosorting Sexual Partners and Continued Risk for HIV Transmission among Men who have Sex with Men 
Objective
The purpose of the current study was to assess whether or not men who have sex with men who limit their unprotected anal sexual partners to those who are of the same HIV status (serosort) differ in their risk for HIV transmission than MSM who do not serosort.
Methods
Cross-sectional surveys administered at a large gay pride festival (80% response rate) were collected from MSM. Univariate and multivariate logistic regressions were used to identify predictors of serosorting.
Results
Participants were self-identified as HIV negative MSM (N=628), about one third of whom engaged in serosorting (n=229). Men who serosort were more likely to believe that serosorting offered protection against HIV transmission, perceived themselves as being at no relatively higher risk for HIV transmission, and had more unprotected anal intercourse partners. Over half the sample reported their frequency of HIV testing as yearly or less frequently; this finding did not differ between serosorters and non-serosorters.
Conclusions
Men who identify as HIV negative and serosort are no more likely to know their HIV status than men who do not serosort and are at higher risk for exposure to HIV. Interventions targeting MSM must address the limitations of serosorting.
doi:10.1016/j.amepre.2007.08.004
PMCID: PMC3151147  PMID: 18022064
18.  Adherence to Antiretroviral Therapy and HIV Transmission Risks: Implications for Test-and-Treat Approaches to HIV Prevention 
AIDS Patient Care and STDs  2010;24(5):271-277.
Abstract
HIV transmission may be prevented by effectively suppressing viral replication with antiretroviral therapy (ART). However, adherence is essential to the success of ART, including for reducing HIV transmission risk behaviors. This study examined the association of nonadherence versus adherence with HIV transmission risks. Men (n = 226) living with HIV/AIDS and receiving ART completed confidential computerized interviews and telephone-based unannounced pill counts for ART adherence monitoring. Data were collected between January 2008 and June 2009. Results showed that nonadherence to ART was associated with greater number of sex partners and engaging in unprotected and protected anal intercourse. These associations were not moderated by substance use. The belief that having an undetectable viral load leads to lower infectiousness was associated with greater number of partners, including nonpositive partners, and less condom use. Men who had an undetectable viral load and believed that having an undetectable viral load reduces their infectiousness, were significantly more likely to have contracted a recent STI. Programs aimed at testing and treating people living with HIV/AIDS for prevention require attention to adherence and sexual behaviors.
doi:10.1089/apc.2009.0309
PMCID: PMC2875951  PMID: 20438373
19.  A novel approach to prevention for at-risk HIV negative men who have sex with men: Creating a teachable moment to promote informed sexual decision making 
American journal of public health  2011;101(3):539-545.
Objectives
HIV continues to disproportionately affect men who have sex with men (MSM). As a result of the impact of HIV among MSM, multiple strategies for reducing HIV risks have emerged from within the gay community. One common HIV risk reduction strategy is to limit unprotected sex partners to those who are of the same HIV status, or to serosort. Although serosorting is commonly practiced for risk reduction, it is closely linked to HIV transmission because of infrequent HIV testing, lack of HIV status disclosure, sexually transmitted infections, and acute HIV infection.
Methods
The current study tested a novel, brief, one-on-one, peer counselor-delivered intervention based on informed decision making, to address the limitations of serosorting. One hundred forty nine at-risk men were recruited and randomly assigned to an intervention condition addressing serosorting or a standard-of-care control.
Results
Men in the serosorting intervention reported fewer sexual partners (Wald X2=8.79,p=<.01) at study follow-ups.
Discussion
Addressing risks associated with serosorting in a feasible, low -cost intervention has the potential to significantly impact the HIV epidemic.
doi:10.2105/AJPH.2010.191791
PMCID: PMC3036682  PMID: 21233441
20.  HIV Super-infection Beliefs and Sexual Practices of People Living with HIV/AIDS 
Sexual health  2010;7(4):420-424.
Background
People living with HIV can be reinfected with a new viral strain resulting in potential treatment resistant recombinant virus known as HIV super-infection. Individual’s beliefs about the risks for HIV super-infection may have significant effects on the sexual behaviors of people living with HIV/AIDS.
Purpose
To examine HIV super-infection beliefs and sexual behaviors among people living with HIV/AIDS.
Methods
Three hundred and twenty men, 137 women, and 33 transgender persons completed confidential surveys in a community research setting.
Results
A majority of participants were aware of HIV super-infection and most believed it was harmful to their health. Hierarchical multiple regressions predicting protected anal/vaginal intercourse with same HIV status (seroconcordant) partners showed that older age and less alcohol use were associated with greater protected sex. In addition, HIV super-infection beliefs predicted protected sexual behavior over and above participant age and alcohol use.
Conclusions
Beliefs about HIV super-infection exert significant influence on sexual behaviors of people living with HIV/AIDS and should be targeted in HIV prevention messages for HIV infected persons.
doi:10.1071/SH09121
PMCID: PMC3058929  PMID: 21062581
21.  “There is no Proof that HIV Causes AIDS”: AIDS Denialism Beliefs among People Living with HIV/AIDS 
Journal of behavioral medicine  2010;33(6):432-440.
AIDS denialists offer false hope to people living with HIV/AIDS by claiming that HIV is harmless and that AIDS can be cured with natural remedies. The current study examined the prevalence of AIDS denialism beliefs and their association to health-related outcomes among people living with HIV/AIDS. Confidential surveys and unannounced pill counts were collected from a predominantly middle aged and African American convenience sample of 266 men and 77 women living with HIV/AIDS. One in five participants stated that there is no proof that HIV causes AIDS and that HIV treatments do more harm than good. AIDS denialism beliefs were more often endorsed by people who more frequently used the internet after controlling for confounds. Believing that there is a debate among scientists about whether HIV causes AIDS was related to refusing HIV treatments and poorer health outcomes. AIDS denialism beliefs may be common among people living with HIV/AIDS and such beliefs are associated with poor health outcomes.
doi:10.1007/s10865-010-9275-7
PMCID: PMC3015095  PMID: 20571892
22.  HIV Transmission Risk among HIV Seroconcordant and Serodiscordant Couples: Dyadic Processes of Partner Selection 
AIDS and behavior  2008;13(2):185-195.
Selecting sex partners of the same HIV status or serosorting is a sexual risk reduction strategy used by many men who have sex with men. However, the effectiveness of serosorting for protection against HIV is potentially limited. We sought to examine how men perceive the protective benefits of factors related to serosorting including beliefs about engaging in serosorting, sexual communication, and perceptions of risk for HIV. Participants were 94 HIV negative seroconcordant (same HIV status) couples, 20 HIV serodiscordant (discrepant HIV status) couples, and 13 HIV positive seroconcordant (same HIV status) couples recruited from a large gay pride festival in the southeastern US. To account for nonindependence found in the couple-level data, we used multilevel modeling which includes dyad in the analysis. Findings demonstrated that participants in seroconcordant relationships were more likely to believe that serosorting reduces concerns for condom use. HIV negative participants in seroconcordant relationships viewed themselves at relatively low risk for HIV transmission even though monogamy within relationships and HIV testing were infrequent. Dyadic analyses demonstrated that partners have a substantial effect on an individual’s beliefs and number of unprotected sex partners. We conclude that relationship partners are an important source of influence and, thus, intervening with partners is necessary to reduce HIV transmission risks.
doi:10.1007/s10461-008-9480-3
PMCID: PMC2937197  PMID: 18953645
HIV; serosorting; MSM; dyad; multilevel modeling
23.  A strategy for selecting sexual partners believed to pose little/no risks for HIV: Serosorting and its implications for HIV transmission 
AIDS care  2009;21(10):1279-1288.
A common HIV/AIDS risk reduction strategy among men who have sex with men (MSM) is to limit their unprotected sex partners to those who are of the same HIV status, a practice referred to as serosorting. Decisions to serosort for HIV risk reduction are based on personal impressions and beliefs, and there is limited guidance offered on this community derived strategy from public health services. This paper reviews research on serosorting for HIV risk reduction and offers an evidence-based approach to serosorting guidance. Following a comprehensive electronic and manual literature search, we reviewed 51 studies relating to the implications of serosorting. Studies showed that HIV negative MSM who select partners based on HIV status are inadvertently placing themselves at risk for HIV. Infrequent HIV testing, lack of HIV status disclosure, co-occurring STIs, and acute HIV infection impede the potential protective benefits of serosorting. Public health messages should continue to encourage reductions in numbers of sexual partners and increases in condom use. Risk reduction messages should also highlight the limitations of relying on one’s own and partner’s HIV status in making sexual risk decisions.
doi:10.1080/09540120902803208
PMCID: PMC2937200  PMID: 20024704
serosorting; acute infection; HIV testing; prevention messages
24.  Risk Compensation in HIV Prevention: Implications for Vaccines, Microbicides, and Other Biomedical HIV Prevention Technologies 
Current HIV/AIDS reports  2007;4(4):165-172.
Studies investigating the effects of biological HIV prevention technologies have been reported with promising results for slowing the spread of HIV. Although prevention technologies can reduce the rate of HIV transmission at varying levels of efficaciousness, it is vital to anticipate the impact of HIV prevention technologies on subsequent sexual behaviors. Risk homeostasis theory posits that decreases in perceived risk, which will occur with access to HIV prevention technologies, will correspond with increases in risk taking behavior. Here we review the literature on risk compensation in response to HIV vaccines, topical microbicides, antiretroviral medications, and male circumcision. Behavioral risk compensation is evident in response to prevention technologies that are used in advance of HIV exposure and at minimal personal cost. We conclude that behavioral risk compensation be addressed by implementing adjunct behavioral risk reduction interventions to avoid negating the preventive benefits of biomedical HIV prevention technologies.
PMCID: PMC2937204  PMID: 18366947
25.  Sexual Partner Selection and HIV Risk Reduction Among Black and White Men Who Have Sex with Men 
American journal of public health  2010;100(3):503-509.
Objectives
In the US, black men who have sex with men (BMSM) are diagnosed with HIV at a rate far exceeding other men. However, many studies report no substantial increase in risk behavior among BMSM. Here we examine a partner selection strategy as a potential risk factor for HIV among BMSM and white MSM (WMSM).
Methods
Cross-sectional surveys were collected from self-reported HIV negative BMSM and WMSM attending a gay pride festival in Atlanta, GA.
Results
HIV negative WMSM were more likely to report having unprotected anal intercourse with HIV negative men, and HIV negative BMSM were more likely to report unprotected anal intercourse with HIV status unknown partners. Furthermore, WMSM were more likely to endorse serosorting (limiting unprotected partners to those who have the same HIV status) beliefs and favorable HIV disclosure beliefs than BMSM.
Conclusions
WMSM appear to be using risk reduction strategies to reduce the likelihood of HIV infection more so than BMSM. Partner selection strategies have serious limitations; however they may explain in part the disproportionate number of HIV infections among BMSM.
doi:10.2105/AJPH.2008.155903
PMCID: PMC2820059  PMID: 20075328
ethnicity; men who have sex with men; risk behavior; perceptions of risk

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