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1.  Perceived Everyday Racism, Residential Segregation and HIV Testing in an STD Clinic Sample 
American journal of public health  2009;99(Suppl 1):S137-S143.
More than a quarter of human immunodeficiency virus (HIV)-infected persons are undiagnosed and therefore unaware of their HIV+ status. African Americans are disproportionately infected. Although perceived racism influences their attitudes toward HIV prevention, how racism influences their behaviors is unknown. We sought to determine whether perceiving everyday racism and racial segregation influence African American HIV testing behavior.
This was a clinic-based, multi-level study. Eligibility was limited to African Americans (N=373) seeking sexually transmitted disease diagnoses or screening. We collected survey data, block group characteristics, and lab-confirmed HIV testing behavior. We estimated associations using logistic regression with generalized estimating equations (GEE).
More than 90% of the sample perceived racism, which was associated with higher odds of HIV testing (OR=1.64, 95% CI=1.07, 2.52) controlling for residential segregation and other covariates. Neither patient satisfaction nor mechanisms for coping with stress explained the association.
African Americans are not merely victims of racism but also exercise agency within their social contexts. Those who perceive everyday racism may draw upon health promoting assets relative to their behaviors. How segregation influences testing warrants further research.
PMCID: PMC2724930  PMID: 19218186
2.  Does Motivational Interviewing Counseling Time Influence HIV-Positive Persons’ Self-Efficacy to Practice Safer Sex? 
Patient education and counseling  2011;87(1):101-107.
This study examined the impact of motivational interviewing (MI) counseling time on self-efficacy to practice safer sex for people living with HIV/AIDS (PLWHA).
In 4 month intervals we followed a cohort of 490 PLWHA for 12 months. We conducted hierarchical linear regression models to examine changes in safer sex self-efficacy when participants received zero, low to moderate (5–131 minutes) and high (132–320 minutes) doses of MI time. We conducted a similar analysis using number of counseling sessions as the predictor variable.
Participants with low to moderate doses of MI counseling had 0.26 higher self-efficacy scores than participants with zero MI time (p=0.01). Also, they had 0.26 lower self-efficacy scores than participants with high amounts of MI time (p=0.04). Participants with high doses of MI had a 0.5 higher self-efficacy score than participants with zero amount of MI time (p<0.0001). Participants who received 3–4 counseling sessions had 0.41 greater self-efficacy scores than participants who did not receive any sessions (p<0.0001) but did not differ from participants receiving 1–2 sessions.
MI time is a key to enhancing safer sex self-efficacy among PLWHA.
Practice Implications
Safer sex self-efficacy improves the more MI counseling time and sessions PLWHA receive.
PMCID: PMC3782534  PMID: 21890300
HIV; Motivational Interviewing; Self-efficacy; Safer Sex
3.  Sexual Communication Between Early Adolescents and Their Dating Partners, Parents, and Best Friends 
Journal of sex research  2013;51(7):731-741.
This study assessed early adolescents' sexual communication with dating partners, parents, and best friends about six sexual health topics: condoms, birth control, STDs, HIV/AIDS, pregnancy, and abstinence/waiting. Using a school-based sample of 603 youth (ages = 12–15; 57% female; 46% Caucasian), we examined communication differences across demographic and developmental factors, tested whether communication with parents and best friends was associated with greater communication with partners, and examined associations between communication and condom use. Over half of participants had not discussed any sexual topics with their dating partners (54%), and many had not communicated with parents (29%) or best friends (25%). On average, communication was more frequent among adolescents who were female, African American, older, and sexually active, despite some variation in subgroups across partner, parent, and friend communication. Importantly, communication with parents and friends – and the interaction between parent and friend communication – was associated with increased communication with dating partners. Further, among sexually active youth, increased sexual communication with partners was associated with more frequent condom use. Results highlight the importance of understanding the broader family and peer context surrounding adolescent sexual decision-making and suggest a possible need to tailor sexual communication interventions.
PMCID: PMC4063897  PMID: 24354655
adolescent sexual communication; parent-child communication; peer influence; HIV; condom use
4.  A 2-Arm, Randomized, Controlled Trial of a Motivational Interviewing–Based Intervention to Improve Adherence to Antiretroviral Therapy (ART) Among Patients Failing or Initiating ART 
Rationale and Purpose
Motivational interviewing (MI) is a counseling technique that has been used effectively to change a number of health-related behaviors. We sought to assess the impact on patients’ antiretroviral therapy (ART) adherence of a multicomponent, MI-based ART adherence intervention compared with that of an HIV informational control program.
Study Design
Two-arm, randomized, controlled trial.
One hundred forty adult HIV-infected patients attending a large, academic center infectious diseases clinic who were either failing or newly initiating an ART regimen.
Study Endpoints
(1) Mean adherence level (% of prescribed doses take in the prior month) at the week 12 visit, (2) change in mean adherence, (3) percentage of patients achieving >95% adherence in the third 4-week block, and (4) change in viral load.
Main Findings
The MI group’s mean adherence improved by 4.5% compared with a decrease in the control group’s adherence by 3.83% (P = 0.10). In the treatment group, 29% achieved >95% adherence compared with only 17% in the control group (P = 0.13). When we controlled for ethnicity, the intervention group had 2.75 times higher odds of achieving more than 95% adherence than did the controls (P = 0.045; 95% confidence interval: 1.023, 7.398). Although a number of mediating variables (beliefs about ART, coping style, social support, and goals set) had statistically significant changes in the expected direction in the MI group compared with controls, in the intent-to-treat analysis, the mean adherence at study exit for the intervention group was 76% (SD = 27%) and 71% (SD = 27%) for the control group (P = 0.62).
Although not definitive, this study provides some evidence that MI offers an effective approach to improving adherence. Future studies able to build MI into the intervention for longer than 3 months may have a greater impact.
PMCID: PMC3670099  PMID: 16763491
antiretroviral adherence; motivational interviewing; medication compliance
5.  The Association between Poor Antiretroviral Adherence and Unsafe Sex: Differences by Gender and Sexual Orientation and Implications for Scale-Up of Treatment as Prevention 
AIDS and behavior  2014;18(8):1541-1547.
Non-adherence to safer sex and non-adherence to ART can each have adverse health consequences for HIV-infected individuals and their sex partners, but little is known about the association of these behaviors with each other. This “dual risk” has potential negative public health consequences since non-adherence can lead to the development of resistant virus that can then be transmitted to sex partners.
Among participants in the Multi-site Adherence Collaboration in HIV (MACH14) we examined, at study baseline, the association between the frequency of unprotected sex (assessed by self-report) and ART adherence (assessed by Medication Event Monitoring System, Aardex) among the sexually active participants in the five studies (N=459) that collected sexual risk behavior. The bivariate association between sexual risk behaviors and ART adherence was assessed by Pearson correlations; subsequently ANOVAs were used to evaluate the role of demographic characteristics, depression and substance use in explaining the “dual risk” outcome (sexual risk and non-adherence).
Among participants who had been sexually active, more unprotected anal/vaginal sex was weakly associated with poorer ART adherence (r = −.12, p=0.01 for the overall sample). Further analysis showed this association was driven by the heterosexual men in the sample (r = −.29, p<0.001), and was significant only for this group, and not for gay/bisexual men or for women (heterosexual and homosexual). Neither substance use nor depression accounted for the association between sexual risk and ART adherence.
HIV-infected heterosexual men who are having difficulty adhering to ART are also more likely to engage in risky sexual behaviors and therefore may benefit from counseling about these risk behaviors. We must identify procedures to screen for these risk behaviors and develop interventions, appropriately tailored to specific populations and identified risk factors, that can be integrated into routine clinical care for people living with HIV. This will become increasingly important in the context of wider access to treatment globally, including new recommendations for ART initiation earlier in a patients’ disease course (e.g., “Test and Treat” paradigms).
PMCID: PMC4016192  PMID: 24213215
ART adherence; sexual risk behavior; test-and-treat; depression; substance use
6.  Assessing Usual Care in Clinical Trials 
Researchers designing clinical trials often specify usual care received by participants as the control condition expecting that all participants receive usual care regardless of group assignment. The assumption is that the groups in the study are affected similarly. We describe the assessment of usual care within the 16 studies in MACH 14, a multi-site collaboration on adherence to antiretroviral therapy. Only five of the studies in MACH 14 assessed usual care. Assessment protocols varied as did the timing and frequency of assessments. All usual care assessments addressed patient education focused on HIV, HIV medications, and medication adherence. Our findings support earlier work that calls for systematic assessments of usual care within the study design, inclusion of descriptions of usual care in reports of the study, and the influence of usual care on the experimental condition in clinical trials.
PMCID: PMC4493893  PMID: 24622154
Usual care; Intervention; Control condition; HIV; Adherence
7.  Substance Use Patterns and Factors Associated with Changes Over Time in a Cohort of Heterosexual Women At Risk for HIV Acquisition in the United States 
Drug and alcohol dependence  2014;139:93-99.
Substance use is associated with HIV sexual risk behaviors, yet few studies have examined substance use patterns longitudinally. We evaluated the types and frequency of substances used over a six-month period among U.S. women at risk for HIV acquisition.
Women reporting unprotected sex with a man in the previous six months and at least one other personal or partner HIV risk characteristic enrolled in a multisite cohort study and completed interviews about substance use at study visits. Prevalence and frequency of substance use at the baseline and six-month visits were compared and correlates of decreased substance use at the six-month visit were assessed.
Of 2,099 women enrolled, 1,882 had substance use data at baseline and six-months. Of these, 76.1% reported using at least one drug or binge drinking in the previous six months; 37.5% were frequent and 38.6% non-frequent substance users. Binge drinking was most frequently reported (63.3%), followed by cocaine (25.0%) and opioids (16.5%). Fifty-five percent of opiate users and 30% of cocaine users reported daily/almost daily use. At the six-month visit, 40.5% reported a decrease in frequency of use. Adjusting for income and type of drug used, poly-substance users were less likely to decrease frequency of use compared to those who only used one substance.
A substantial decrease in frequency of substance use over time was observed in this cohort. Poly-substance users were less likely to reduce frequency of use over time, suggesting that specific substance use interventions targeting these users are warranted.
PMCID: PMC4104540  PMID: 24698079
women; substance use; opiate use; cocaine use; binge drinking; HIV
8.  Underuse of Surveillance Colonoscopy in Patients at Increased Risk of Colorectal Cancer 
Colorectal cancer incidence and mortality have declined over the past two decades, and much of this improvement is attributed to increased use of screening. Approximately 25% of patients who undergo screening colonoscopy have premalignant adenomas that require removal and follow-up colonoscopy. However, there are few studies of the use of surveillance colonoscopy in increased risk patients with previous adenomas.
We conducted a cross-sectional study to examine factors associated with underuse of surveillance colonoscopy among patients who are at increased risk for colorectal cancer. The study population consisted of patients with previously identified adenomatous polyps and who were due for follow-up colonoscopy. Patients were categorized as attenders (n=100) or non-attenders (n=104) on the basis of completion of follow-up colonoscopy. Telephone surveys assessed the use of surveillance colonoscopy across domains of predisposing patient characteristics, enabling factors, and patient need. Mutlivariable logistic regression was used to identify factors associated with screening completion.
Perceived barriers, perceived benefits, social deprivation, and cancer worry were associated with attendance at colonoscopy. Higher benefits (odds ratio (OR) 2.37, 95% confidence interval (CI) 1.04–5.41) and cancer worry (OR 1.73, 95% CI 1.07–2.79) increased the odds of attendance at follow-up colonoscopy, whereas greater barriers (OR 0.49, 95% CI 0.28–0.88) and high social deprivation (≥2; OR 0.09, 95% CI 0.01–0.76) were associated with lower odds.
Our results suggest that multilevel factors contribute to the use of surveillance colonoscopy in higher risk populations, many of which are amenable to intervention. Interventions, such as patient navigation, may help facilitate appropriate use of surveillance colonoscopy.
PMCID: PMC4422764  PMID: 25384901
9.  The Role of Self-Efficacy and Motivation to Explain the Effect of Motivational Interviewing Time on Changes in Risky Sexual Behavior among People Living with HIV: A Mediation Analysis 
AIDS and behavior  2013;17(2):813-823.
Little is known about the amount of Motivational Interviewing (MI) needed to reduce risky sexual behavior among People Living with HIV/AIDS (PLWHA) or the roles self-efficacy and motivation to practice safer sex play. Among 183 PLWHA who received safer sex MI and were surveyed every 4 months over a 12 month period, we used hierarchical negative binomial regression models to examine the association between amount of counseling time and sexual risk behavior. We performed mediation analysis to evaluate whether changes in self-efficacy and motivation explained this association. This study found that as MI time and number of provided sessions increased, participants’ sexual risk behavior decreased. The effect of MI time and number of sessions on sexual behavior was mediated by self-efficacy but not by motivation to practice safer sex.
PMCID: PMC4400728  PMID: 22228069
HIV; Motivational interviewing; Self-efficacy; Motivation; Sexual behavior
10.  SafeTalk, a Multicomponent, Motivational Interviewing-Based, Safer Sex Counseling Program for People Living with HIV/AIDS: A Qualitative Assessment of Patients' Views 
AIDS Patient Care and STDs  2010;24(4):237-245.
With the continued transmission of HIV each year, novel approaches to HIV prevention are needed. Since 2003, the U.S. HIV prevention focus has shifted from primarily targeting HIV-negative at-risk persons to including safer sex programs for people already infected with HIV. At least 20–30% of people infected with HIV engage in risky sexual practices. Based on these data, policymakers have recommended that interventionists develop strategies to help HIV-infected people reduce their risky sexual behaviors. In the past, the few safer sex interventions that targeted HIV-infected people met with limited success because they basically adapted strategies previously used with HIV-uninfected individuals. In addition, often these adaptations did not address issues of serostatus disclosure, HIV stigma, or motivation to protect others from HIV. We had previously tested, in a demonstration project named the Start Talking About Risks (STAR) Program, a monthly three-session motivational interviewing (MI)-based intervention to help people living with HIV practice safer sex. In this study, we refined that program by enhancing its frequency and intensity and adding written and audio components to support the counseling. We theorized that an intervention such as MI, which is tailored to each individual's circumstances more than standardized prevention messages, would be more successful when supplemented with other components. We qualitatively assessed participants' perceptions, reactions, and preferences to the refined prevention with positives counseling program we called SafeTalk and learned that participants found the SafeTalk MI counseling and educational materials appealing, understandable, and relevant to their lives.
PMCID: PMC2864060  PMID: 20377435
11.  Retention Strategies and Factors Associated with Missed Visits Among Low Income Women at Increased Risk of HIV Acquisition in the US (HPTN 064) 
AIDS Patient Care and STDs  2014;28(4):206-217.
Women at high-risk for HIV acquisition often face challenges that hinder their retention in HIV prevention trials. These same challenges may contribute to missed clinical care visits among HIV-infected women. This article, informed by the Gelberg-Andersen Behavioral Model for Vulnerable Populations, identifies factors associated with missed study visits and describes the multifaceted retention strategies used by study sites. HPTN 064 was a multisite, longitudinal HIV seroincidence study in 10 US communities. Eligible women were aged 18–44 years, resided in a census tract/zipcode with high poverty and HIV prevalence, and self-reported ≥1 personal or sex partner behavior related to HIV acquisition. Multivariate analyses of predisposing (e.g., substance use) and enabling (e.g., unmet health care needs) characteristics, and study attributes (i.e., recruitment venue, time of enrollment) identified factors associated with missed study visits. Retention strategies included: community engagement; interpersonal relationship building; reduction of external barriers; staff capacity building; and external tracing. Visit completion was 93% and 94% at 6 and 12 months. Unstable housing and later date of enrollment were associated with increased likelihood of missed study visits. Black race, recruitment from an outdoor venue, and financial responsibility for children were associated with greater likelihood of attendance. Multifaceted retention strategies may reduce missed study visits. Knowledge of factors associated with missed visits may help to focus efforts.
PMCID: PMC3985524  PMID: 24697160
12.  Incarceration and Unstable Housing Interact to Predict Sexual Risk Behaviors among African American STD Clinic Patients 
Given dramatic racial disparities in rates of HIV/STDs among African Americans, understanding broader structural factors that increase the risk for HIV/STDs is crucial. This study investigated incarceration history and unstable housing as two structural predictors of HIV risk behavior among 293 African Americans (159 men/134 women, Mage=27). Participants were recruited from an urban STD clinic in the southeastern U.S. Approximately half the sample had been incarcerated in their lifetime (54%), and 43% had been unstably housed in the past 6 months. Incarceration was independently associated with number of sex partners and the frequency of unprotected sex. Unstable housing was independently associated with the frequency of unprotected sex. However, these main effects were qualified by significant interactions: individuals with a history of incarceration and more unstable housing had more sex partners and more unprotected sex in the past three months than individuals without these structural barriers. Implications for structural-level interventions are discussed.
PMCID: PMC4037926  PMID: 24060677
HIV/AIDS; sexual risk behavior; structural factors; housing; incarceration; racial disparities
13.  Characteristics and Behaviors Associated With HIV Infection Among Inmates in the North Carolina Prison System 
American journal of public health  2009;99(6):1123-1130.
We identified factors associated with testing HIV positive in a prison system performing voluntary HIV testing on inmates and estimated the number of undetected HIV cases to evaluate the efficacy of risk-factor–based HIV testing.
We used logistic regression to estimate associations between HIV serostatus and HIV risk behaviors, mental health, coinfection status, and socio-demographic characteristics for prisoners entering the North Carolina Department of Correction from January 2004 through May 2006. We estimated the number of undetected HIV cases on the basis of age-, gender-, and race-specific HIV prevalences among prisoners and in the state.
Nearly 3.4% (718/21419) of tested prisoners were HIV positive. The strongest risk factors for infection among men were having sex with men (odds ratio [OR]=8.0), Black race (OR=6.2), other non-White race (OR=7.4), and being aged 35 to 44 years (OR=4.1). The strongest risk factor among women was Black race (OR=3.8). Among HIV-positive prisoners, 65% were coinfected with HCV. We estimated that between 24% (223) and 61% (1101) of HIV cases remained undetected.
The associations between HIV serostatus and a variety of factors highlight the potential limitations of risk-factor–based HIV testing in prisons, as do the high number of potential undetected HIV cases.
PMCID: PMC2679772  PMID: 19372527
14.  An Evaluation of HIV Testing Among Inmates in the North Carolina Prison System 
American journal of public health  2009;99(Suppl 2):S452-S459.
We examined the use of voluntary HIV testing among state prisoners in the North Carolina prison system.
We calculated system-wide and facility-specific proportions and rates of adult inmates tested for HIV and estimated associations between testing status and inmate characteristics for prisoners in North Carolina.
Of the 54016 inmates who entered prison between January 2004 and May 2006, 20820 (38%) were tested for HIV; of those tested, 18574 (89%) were tested at admission. Across the 8 intake prisons, more than 80% of inmates in both female facilities but less than 15% of inmates in 4 of 6 male facilities were tested. Prisoners with a documented history of heroin use, crack or cocaine use, conventional HIV risk behavior, or tuberculosis were at least 10% more likely to be tested than were inmates without these characteristics. However, more than 60% of men reporting conventional risk behaviors were not tested. Before covariate adjustment, Black men were 30% less likely than White men to be tested; in the multivariable regression model, this difference was attenuated to 13%.
Rates of HIV testing varied widely across intake prisons, and many male inmates with documented risk of infection were never tested.
PMCID: PMC2760001  PMID: 19797758
We examined parameters of sexual partnerships, including respondents’ participation in concurrency, belief that their partner had concurrent partnerships (partners’ concurrency), and partnership intervals, among the 2,099 women in HIV Prevention Trials Network 064, a study of women at high risk for HIV infection, in ten US communities.
We analyzed baseline survey responses about partnership dates to determine prevalence of participants’ and partners’ concurrency, intervals between partnerships, knowledge of whether recent partner(s) had undergone HIV testing, and intercourse frequency during the preceding 6 months.
Prevalence of participants’ and partners’ concurrency was 40% and 36% respectively; 24% of respondents had both concurrent partnerships and non-monogamous partners. Among women with >1 partner and no concurrent partnerships themselves, the median gap between partners was one month. Multiple episodes of unprotected vaginal intercourse with >2 of their most recent partners was reported by 60% of women who had both concurrent partnerships and non-monogamous partners, 50% with only concurrent partners and no partners’ concurrency, and 33% with only partners’ concurrency versus 14% of women with neither type of concurrency (p<.0001). Women who had any involvement with concurrency were also more likely than women with no concurrency involvement to report lack of awareness of whether recent partners had undergone HIV testing (participants’ concurrency 41%, partners’ concurrency 40%, both participants’ and partners’ concurrency 48%, neither 17%; p<.0001).
These network patterns and short gaps between partnerships may create substantial opportunities for HIV transmission in this sample of women at high risk for HIV infection.
PMCID: PMC4172374  PMID: 24056163
16.  Multilevel challenges to engagement in HIV care after prison release: a theory-informed qualitative study comparing prisoners’ perspectives before and after community reentry 
BMC Public Health  2014;14:1253.
Although prison provides the opportunity for HIV diagnosis and access to in-prison care, following release, many HIV-infected inmates experience clinical setbacks, including nonadherence to antiretrovirals, elevations in viral load, and HIV disease progression. HIV-infected former inmates face numerous barriers to successful community reentry and to accessing healthcare. However, little is known about the outcome expectations of HIV-infected inmates for release, how their post-release lives align with pre-release expectations, and how these processes influence engagement in HIV care following release from prison.
We conducted semi-structured interviews (24 pre- and 13 post-release) with HIV-infected inmates enrolled in a randomized controlled trial of a case management intervention to enhance post-release linkage to care. Two researchers independently coded data using a common codebook. Intercoder reliability was strong (kappa = 0.86). We analyzed data using Grounded Theory methodology and Applied Thematic Analysis. We collected and compared baseline sociodemographic and behavioral characteristics of all cohort participants who did and did not participate in the qualitative interviews using Fisher’s Exact Tests for categorical measures and Wilcoxon rank-sum tests for continuous measures.
Most participants were heterosexual, middle-aged, single, African American men and women with histories of substance use. Substudy participants were more likely to anticipate living with family/friends and needing income assistance post-release. Most were taking antiretrovirals prior to release and anticipated needing help securing health benefits and medications post-release. Before release, most participants felt confident they would be able to manage their HIV. However, upon release, many experienced intermittent or prolonged periods of antiretroviral nonadherence, largely due to substance use relapse or delays in care initiation. Substance use was precipitated by stressful life experiences, including stigma, and contact with drug-using social networks. As informed by the Social Cognitive Theory and HIV Stigma Framework, findings illustrate the reciprocal relationships among substance use, experiences of stigma, pre- and post-release environments, and skills needed to engage in HIV care.
These findings underscore the need for comprehensive evidence-based interventions to prepare inmates to transition from incarceration to freedom, particularly those that strengthen linkage to HIV care and focus on realities of reentry, including stigma, meeting basic needs, preventing substance abuse, and identifying community resources.
PMCID: PMC4295310  PMID: 25491946
HIV/AIDS; Incarceration; Social cognitive theory; Stigma; Qualitative research; Substance misuse
17.  Sexuality, Sexual Practices, and HIV Risk among Incarcerated African-American Women in North Carolina 
Women who have been in prison carry a greater lifetime risk of HIV for reasons that are not well understood. This effect is amplified in the Southeastern United States, where HIV incidence and prevalence is especially high among African American (AA) women. The role of consensual sexual partnerships in the context of HIV risk, especially same-sex partnerships, merits further exploration.
We conducted digitally recorded qualitative interviews with 29 AA women (15 HIV-positive, 14 HIV-negative) within three months after entry into the state prison system. We explored potential pre-incarceration HIV risk factors, including personal sexual practices. Two researchers thematically coded interview transcripts and a consensus committee reviewed coding.
Women reported complex sexual risk profiles during the six months prior to incarceration, including sex with women as well as prior sexual partnerships with both men and women. Condom use with primary male partners was low and a history of transactional sex work was prevalent. These behaviors were linked to substance use, particularly among HIV-positive women.
Although women may not formally identify as bisexual or lesbian, sex with women was an important component of this cohort’s sexuality. Addressing condom use, heterogeneity of sexual practices, and partner concurrency among at-risk women should be considered for reducing HIV acquisition and preventing forward transmission in women with a history of incarceration.
PMCID: PMC3891845  PMID: 24183410
18.  How New Subscribers Use Cancer-Related Online Mailing Lists 
Online cancer-related support is an under-studied resource that may serve an important function in the information seeking, care, and support of cancer patients and their families. With over 9.8 million cancer survivors (defined as anyone living with cancer) in the United States alone and the number growing worldwide, it is important to understand how they seek and use online resources to obtain the information they need, when they need it, and in a form and manner appropriate to them. These are stated cancer communication goals of the US National Cancer Institute.
Our purposes are to (1) present background information about online mailing lists and electronic support groups, (2) describe the rationale and methodology for the Health eCommunities (HeC) study, and (3) present preliminary baseline data on new subscribers to cancer-related mailing lists. In particular, we describe subscribers' use of mailing lists, their reasons for using them, and their reactions to participating shortly after joining the lists.
From April to August 2004, we invited all new subscribers to 10 Association of Cancer Online Resources mailing lists to complete Web-based surveys. We analyzed baseline data from the respondents to examine their perceptions about cancer-related mailing lists and to describe how cancer patients and survivors used these lists in the period shortly after joining them.
Cumulative email invitations were sent to 1368 new mailing list subscribers; 293 Web surveys were completed within the allotted time frame (21.4% response rate). Most respondents were over age 50 (n = 203, 72%), white (n = 286, 98%), college graduates (n = 161, 55%), and had health insurance (n = 283, 97%). About 41% (n = 116) of new subscribers reported spending 1 to 3 hours per day reading and responding to list messages. They used the mailing lists for several reasons. Among the most frequently reported, 62% (n = 179) strongly agreed they used mailing lists to obtain information on how to deal with cancer, 42% (n = 121) strongly agreed they used mailing lists for support, and 37% (n = 109) strongly agreed that they were on the mailing lists to help others. Smaller proportions of new subscribers strongly agreed that others on the mailing lists had similar cancer experiences (n = 23, 9%), that they could relate to the experiences of others on the lists (n = 66, 27%), and that others on the list gave them good ideas about how to cope with cancer (n = 66, 27%).
Cancer-related online mailing lists appear to be an important resource, especially for information seeking but also for support of cancer survivors. These were the primary motivators most members reported for joining mailing lists. The modest proportion of subscribers who strongly agreed that they could relate to others' cancer experiences (as well as similar responses to other process questions) is undoubtedly due at least in part to the short duration that these subscribers were involved with the mailing lists. Emerging data, including our own, suggest that mailing lists are perhaps under-used by minority patients/survivors. These preliminary data add to a growing body of research on health-related online communities, of which online mailing lists are one variant.
PMCID: PMC1550655  PMID: 15998623
Internet; cancer; patients; survivors; online communities; mailing lists; online support groups, listservs
19.  Adherence to PEG/Ribavirin Treatment for Chronic Hepatitis C: Prevalence, Patterns, and Predictors of Missed Doses and Nonpersistence 
Journal of viral hepatitis  2013;20(8):536-549.
Adherence to treatment for hepatitis C virus (HCV) maximizes treatment efficacy. Missed doses and failing to persist on treatment are two patient-level processes that are rarely defined or analyzed separately from other factors affecting treatment adherence. We evaluated the prevalence and patterns of missed doses and nonpersistence, and identified patient characteristics associated with these outcomes. Missed doses of ribavirin (RBV) and peginterferon (PEG), measured prospectively in Virahep-C using electronic monitoring technology, were analyzed using generalized estimating equations. Cox proportional hazards models analyzed time to nonpersistence from baseline to week 24 (N=401) and from week 24–48 in Responders (N=242). Average proportion of PEG and RBV missed doses increased over time from 5 to 15% and 7 to 27%, respectively. Patients who were younger, African American, unemployed, or unmarried were at greater risk of missing PEG from week 0–24; higher baseline depression predicted missing PEG from weeks 24–48. Patients who were younger or African American were more likely to miss daily RBV from weeks 0–24; and those without private insurance or employment were more likely to miss RBV from weeks 24–48. Fifty-two patients failed to persist on treatment for patient-driven deviations. Predictors of nonpersistence from weeks 0–24 included younger age, lower education, public or no insurance, or worse baseline headaches. In conclusion electronic monitoring and the prospective Virahep-C design afforded a unique opportunity to evaluate missing doses and nonpersistence separately, and identify patients at risk for nonadherence. These processes will be important to investigate as the dosing schedules of antiviral regimens become increasingly complex.
PMCID: PMC3703869  PMID: 23808992
compliance; dose; interferon; liver; medication adherence
20.  Disease Prevalence and Use of Health Care among a National Sample of Black and White Male State Prisoners 
U.S. prisons have a court-affirmed mandate to provide health care to prisoners. Given this mandate, we sought to determine whether use of prison health care was equitable across race using a nationally-representative sample of Black and White male state prisoners. We first examined the prevalence of health conditions by race. Then, across all health conditions and for each of 15 conditions, we compared the proportion of Black and White male prisoners with the condition who received health care. For most conditions including cancer, heart disease, and liver-related disorders, the age-adjusted prevalence of disease among Blacks was lower than among Whites (p<.05). Blacks were also modestly more likely than Whites to use health care for existing conditions (p<.05), particularly hypertension, cerebral vascular accident/brain injury, cirrhosis, flu-like illness, and injury. The observed racial disparities in health and health care use are different from those among non-incarcerated populations.
PMCID: PMC4047705  PMID: 22643475
Prisoners; health disparities; access to health care; health care systems
21.  Do Safer Sex Self-Efficacy, Attitudes toward Condoms, and HIV Transmission Risk Beliefs Differ among Men who have Sex with Men, Heterosexual Men, and Women Living with HIV? 
AIDS and behavior  2013;17(5):1873-1882.
To understand sexual decision-making processes among people living with HIV, we compared safer sex self-efficacy, condom attitudes, sexual beliefs, and rates of unprotected anal or vaginal intercourse with at-risk partners (UAVI-AR) in the past 3 months among 476 people living with HIV: 185 men who have sex with men (MSM), 130 heterosexual men, and 161 heterosexual women. Participants were enrolled in SafeTalk, a randomized, controlled trial of a safer sex intervention. We found 15% of MSM, 9% of heterosexual men, and 12% of heterosexual women engaged in UAVI-AR. Groups did not differ in self-efficacy or sexual attitudes/beliefs. However, the associations between these variables and UAVI-AR varied within groups: greater self-efficacy predicted less UAVI-AR for MSM and women, whereas more positive condom attitudes – but not self-efficacy – predicted less UAVI-AR for heterosexual men. These results suggest HIV prevention programs should tailor materials to different subgroups.
PMCID: PMC3657340  PMID: 22252475
HIV transmission risk behavior; self-efficacy; safer sex attitudes; condom attitudes; sexual behavior
22.  HIV Acquisition Among Women From Selected Areas of the United States 
Annals of internal medicine  2013;158(1):10-18.
Women account for 23% of newly diagnosed HIV infections in the United States, but there are few recent, well-characterized cohorts of U.S. women in whom behavior characteristics and HIV acquisition have been well-described.
To evaluate HIV incidence and describe behaviors among U.S. women residing in areas of high HIV prevalence.
Multisite, longitudinal cohort of women who had HIV rapid testing and audio computer-assisted self-interviews at baseline and every 6 months for up to 12 months. ( NCT00995176)
10 urban and periurban communities with high HIV prevalence and poverty rates, located in the northeastern and southeastern United States.
Venue-based sampling was used to recruit women aged 18 to 44 years who recently had unprotected sex and had 1 or more additional personal or partner risk factors and no self-reported previous HIV diagnosis.
HIV prevalence and incidence, frequency of HIV risk behaviors, and health status perceptions.
Among 2099 high-risk women (85.9% black and 11.7% of Hispanic ethnicity), 32 (1.5%) were diagnosed with HIV infection at enrollment. Annual HIV incidence was 0.32% (95% CI, 0.14% to 0.74%). Older age, substance use, and knowing a partner had HIV were associated with HIV prevalence. Ten women died during the study (0.61% per year).
Longitudinal assessment of risk behaviors was limited to a maximum of 12 months. There were few incident HIV infections, precluding identification of characteristics predictive of HIV acquisition.
This study enrolled a cohort of women with HIV incidence substantially higher than the Centers for Disease Control and Prevention national estimate in the general population of U.S. black women. Concerted efforts to improve preventive health care strategies for HIV and overall health status are needed for similar populations.
PMCID: PMC4033695  PMID: 23277896
23.  Serostatus Disclosure to Sexual Partners among People Living with HIV: Examining the Roles of Partner Characteristics and Stigma 
AIDS care  2012;25(5):566-572.
HIV serostatus disclosure among people living with HIV/AIDS (PLWHA) is an important component of preventing HIV transmission to sexual partners. Due to barriers like stigma, however, many PLWHA do not disclose their serostatus to all sexual partners. This study explored differences in HIV serostatus disclosure based on sexual behavior subgroup [men who have sex with men (MSM), heterosexual men, and women], characteristics of the sexual relationship (relationship type and HIV serostatus of partner), and perceived stigma. We examined disclosure in a sample of 341 PLWHA: 138 MSM, 87 heterosexual men, and 116 heterosexual women who were enrolled in SafeTalk, a randomized, controlled trial of a safer sex intervention. We found that, overall, 79% of participants disclosed their HIV status to all sexual partners in the past 3 months. However, we found important differences in disclosure by subgroup and relationship characteristics. Heterosexual men and women were more likely to disclose their HIV status than MSM (86%, 85%, and 69%, respectively). Additionally, disclosure was more likely among participants with only primary partners than those with only casual or both casual and primary partners (92%, 54%, and 62%, respectively). Participants with only HIV-positive partners were also more likely to disclose than those with only HIV-negative partners, unknown serostatus partners, or partners of mixed serostatus (96%, 85%, 40%, and 60%, respectively). Finally, people who perceived more HIV-related stigma were less likely to disclose their HIV serostatus to partners, regardless of subgroup or relationship characteristics. These findings suggest that interventions to help PLWHA disclose, particularly to serodiscordant casual partners, are needed and will likely benefit from inclusion of stigma reduction components.
PMCID: PMC3622199  PMID: 23020136
HIV serostatus disclosure; stigma; gender differences; sexual partners
24.  Chronic Hepatitis C and Antiviral Treatment Regimens: Where Can Psychology Contribute? 
To evaluate the existing literature on psychological, social, and behavioral aspects of chronic hepatitis C viral (HCV) infection and antiviral treatment; provide the state of the behavioral science in areas that currently hinder HCV-related health outcomes; and make recommendations for areas in which clinical psychology can make significant contributions.
The extant literature on HCV and antiviral therapy was reviewed as related to biopsychosocial factors such as mental health, substance/alcohol use, quality of life, coping, stigma, racial disparities, side effects, treatment adherence, integrated care, and psychological interventions.
For reasons that have not been well elucidated, individuals infected with HCV experience psychological and somatic problems and report poor health-related quality of life. Preexisting conditions, including poor mental health and alcohol/substance use, can interfere with access to and successful completion of HCV treatment. Perceived stigma is highly prevalent and associated with psychological distress. Racial disparities exist for HCV prevalence, treatment uptake, and treatment success. During HCV treatment, patients experience exacerbation of symptoms, treatment side effects, and poorer quality of life, making it difficult to complete treatment. Despite pharmacological advances in HCV treatment, improvements in clinical and public health outcomes have not been realized. The reasons for this lack of impact are multifactorial, but include suboptimal referral and access to care for many patients, treatment-related side effects, treatment nonadherence, and lack of empirically-based approaches.
Biomedical advances in HCV and antiviral treatment have created a fertile field in which psychologists are uniquely positioned to make important contributions to HCV management and treatment.
PMCID: PMC3504622  PMID: 22730952
Interferon; Psychosocial; Coping; Adherence; Multidisciplinary
25.  When do condom use intentions lead to actions? Examining the role of sexual communication on safer sexual behavior among people living with HIV 
Journal of health psychology  2012;18(4):507-517.
This study investigated the moderating role of sexual communication in the association between intentions to use condoms and unprotected sex in a sample of 358 individuals living with HIV (233 men, 125 women, M age = 43). Longitudinal analyses revealed a significant interaction between condom intentions and sexual communication: individuals who were high in both condom intentions and safer sex communication engaged in less unprotected sex with all partners and with partners of HIV negative or unknown serostatus over 6 months of follow-up. Among individuals low in communication, intentions were not associated with unprotected sex. Implications for interventions are discussed.
PMCID: PMC3612384  PMID: 22689591
Safer sex; HIV/AIDS; condom intentions; sexual communication

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