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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.  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
4.  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
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
6.  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
7.  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
8.  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
9.  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
10.  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
11.  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
12.  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
13.  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
14.  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
15.  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
16.  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
17.  MACH14: A Multi-Site Collaboration on ART Adherence Among 14 Institutions 
AIDS and behavior  2013;17(1):127-141.
The integration of original data from multiple antiretroviral (ARV) adherence studies offers a promising, but little used method to generate evidence to advance the field. This paper provides an overview of the design and implementation of MACH14, a collaborative, multi-site study in which a large data system has been created for integrated analyses by pooling original data from 16 longitudinal ARV adherence studies. Studies selected met specific criteria including similar research design and data domains such as adherence measured with medication event monitoring system, psychosocial factors related to adherence behavior, and virologic and clinical outcomes. The data system created contains individual data (collected between 1997 and 2009) from 2,860 HIV patients. Collaboration helped resolve the challenges inherent in pooling data across multiple studies, yet produced a data system with strong statistical power and potentially greater capacity to address key scientific questions than possible with single-sample studies or even meta-analytic designs.
PMCID: PMC3769091  PMID: 22864921
HIV/AIDS; Adherence; MEMS Multi-site Antiretroviral medication; Individual participant data
18.  Modeling the impact of Trichomonas vaginalis infection on HIV transmission in HIV-infected individuals in medical care 
Sexually transmitted diseases  2012;39(9):671-677.
To assess factors associated with having a Trichomonas vaginalis (TV) infection among persons receiving care for HIV and estimate the number of transmitted HIV infections attributable to TV.
HIV clinic patients were recruited from two secondary prevention studies, screened by urine nucleic-acid amplification tests for sexually transmitted infections (STIs) and interviewed about risk factors (baseline, 6 and 12 months). We conducted mathematical modeling of the results to estimate the number of transmitted HIV infections attributable to TV among a cohort of HIV-infected patients receiving medical care in North Carolina.
TV was prevalent in 7.4%, and incident in 2% – 3% of subjects at follow-up. Individuals with HIV RNA less than 400 copies/ml (OR 0.32, 95% CI: 0.14 – 0.73) and at least 13 years of education (OR 0.24, 95% CI: 0.08 –0.70) were less likely to have TV. Mathematical modeling predicted that 0.062 HIV transmission events occur per 100 HIV infected women in the absence of TV infection and 0.076 HIV infections per 100 HIV and TV-infected women (estimate range: 0.070 – 0.079), indicating that 23% of the HIV transmission events from HIV-infected women may be attributable to TV infection when 22% of women are co-infected with TV.
The data suggest the need for improved diagnosis of TV infection and suggest that HIV-infected women in medical care may be appropriate targets for enhanced testing and treatment.
PMCID: PMC3424483  PMID: 22902662
HIV; Secondary prevention; Trichomonas infections; Sexually transmitted diseases
19.  Longitudinal Effects of SafeTalk, a Motivational Interviewing-Based Program to Improve Safer Sex Practices Among People Living with HIV/AIDS 
AIDS and behavior  2012;16(5):1182-1191.
Programs to help people living with HIV/AIDS practice safer sex are needed to prevent transmission of HIV and other sexually transmitted infections. We sought to assess the impact of SafeTalk, a multicomponent motivational interviewing-based safer sex program, on HIV-infected patients’ risky sexual behavior. We enrolled sexually active adult HIV-infected patients from one of three clinical sites in North Carolina and randomized them to receive the 4-session SafeTalk intervention versus a hearthealthy attention-control. There was no significant difference in the proportion of people having unprotected sex between the two arms at enrollment. SafeTalk significantly reduced the number of unprotected sex acts with at-risk partners from baseline, while in controls the number of unprotected sex acts increased. Motivational interviewing can provide an effective, flexible prevention intervention for a heterogeneous group of people living with HIV.
PMCID: PMC3670095  PMID: 21964975
AIDS; HIV; Motivational interviewing; Safer sex; SafeTalk
20.  Start Talking About Risks: Development of a Motivational Interviewing-Based Safer Sex Program for People Living with HIV 
AIDS and behavior  2007;11(5 0):S72-S83.
The epidemiology of HIV infection in the US in general, and in the southeast, in particular, has shifted dramatically over the past two decades, increasingly affecting women and minorities. The site for our intervention was an infectious diseases clinic based at a university hospital serving over 1,300 HIV-infected patients in North Carolina. Our patient population is diverse and reflects the trends seen more broadly in the epidemic in the southeast and in North Carolina. Practicing safer sex is a complex behavior with multiple determinants that vary by individual and social context. A comprehensive intervention that is client-centered and can be tailored to each individual’s circumstances is more likely to be effective at reducing risky behaviors among clients such as ours than are more confrontational or standardized prevention messages. One potential approach to improving safer sex practices among people living with HIV/AIDS (PLWHA) is Motivational Interviewing (MI), a non-judgmental, client-centered but directive counseling style. Below, we describe: (1) the development of the Start Talking About Risks (STAR) MI-based safer sex counseling program for PLWHA at our clinic site; (2) the intervention itself; and (3) lessons learned from implementing the intervention.
PMCID: PMC3670096  PMID: 17701337
HIV prevention; Motivational interviewing; Sexual behavior
21.  Challenges of a Hidden Epidemic: HIV Prevention among Women in the United States 
HIV/AIDS trends in the United States depict a concentrated epidemic with hot spots that vary by location, poverty, race/ethnicity, and transmission mode. HIV/AIDS is a leading cause of death among US women of color; two thirds of new infections among women occur in black women, despite the fact that black women account for just 14% of the US female population. The gravity of the HIV epidemic among US women is often not appreciated by those at risk as well as by the broader scientific community. We summarize the current epidemiology of HIV/AIDS among US women and discuss clinical, research, and public health intervention components that must be brought together in a cohesive plan to reduce new HIV infections in US women. Only by accelerating research and programmatic efforts will the hidden epidemic of HIV among US women emerge into the light and come under control.
PMCID: PMC3551266  PMID: 21406990
HIV in women; HIV prevention science; racial disparity
22.  Factors associated with self-reported adherence to antiretroviral therapy in a Tanzanian setting 
AIDS care  2010;22(3):381-389.
This study aimed to determine the level of antiretroviral (ART) adherence and factors associated with adherence among patients receiving free ART at one clinic in Tanzania. Adult patients were recruited into the cross-sectional study and completed a survey that included self-reported adherence over four days and over one month. Less than 95% adherence on either measure was considered “poor”. Factors associated with adherence in unadjusted analyses (α=0.10) were included in a logistic regression model. 340 patients participated in the study, and 5.9% (20/340) reported poor adherence. The final model found poor adherence associated with: being young (OR=4.03) or old (OR=6.68); having lower perceived quality of patient-provider interaction (OR=2.75); and ever missing a clinic appointment (OR=3.13). Results highlight good adherence, but suggest the importance of addressing: 1) age-specific challenges of adherence through counseling and support; 2) client-focused care and quality of patient-provider interaction; and 3) clinic appointment reminder systems.
PMCID: PMC3534771  PMID: 20390519
HIV; adherence; antiretroviral therapy; Tanzania
23.  Intensive Case Management Before and After Prison Release is No More Effective Than Comprehensive Pre-Release Discharge Planning in Linking HIV-Infected Prisoners to Care: A Randomized Trial 
AIDS and behavior  2011;15(2):356-364.
Imprisonment provides opportunities for the diagnosis and successful treatment of HIV, however, the benefits of antiretroviral therapy are frequently lost following release due to suboptimal access and utilization of health care and services. In response, some have advocated for development of intensive case-management interventions spanning incarceration and release to support treatment adherence and community re-entry for HIV-infected releasees. We conducted a randomized controlled trial of a motivational Strengths Model bridging case management intervention (BCM) beginning approximately 3 months prior to and continuing 6 months after release versus a standard of care prison-administered discharge planning program (SOC) for HIV-infected state prison inmates. The primary outcome variable was self-reported access to post-release medical care. Of the 104 inmates enrolled, 89 had at least 1 post-release study visit. Of these, 65.1% of BCM and 54.4% of SOC assigned participants attended a routine medical appointment within 4 weeks of release (P >0.3). By week 12 post-release, 88.4% of the BCM arm and 78.3% of the SOC arm had at attended at least one medical appointment (P = 0.2), increasing in both arms at week 24–90.7% with BCM and 89.1% with SOC (P >0.5). No participant without a routine medical visit by week 24 attended an appointment from weeks 24 to 48. The mean number of clinic visits during the 48 weeks post release was 5.23 (SD = 3.14) for BCM and 4.07 (SD = 3.20) for SOC (P >0.5). There were no significant differences between arms in social service utilization and re-incarceration rates were also similar. We found that a case management intervention bridging incarceration and release was no more effective than a less intensive pre-release discharge planning program in supporting health and social service utilization for HIV-infected individuals released from prison.
PMCID: PMC3532052  PMID: 21042930
Prisoners; Access to care; Case management
24.  “It’s all the time in my mind”: Facilitators of adherence to antiretroviral therapy in a Tanzanian setting 
Social science & medicine (1982)  2009;68(10):1793-1800.
Although HIV-positive patients’ adherence to antiretroviral therapy (ART) is relatively high in African nations, as compared with industrialized nations, few studies have explored why. In the research presented here we aimed to understand the dynamics of good adherence to ART among patients receiving free ART and HIV-related services from a clinic in Arusha, Tanzania. We conducted individual semi-structured interviews with 6 health care providers and 36 patients at the study site. Interviews were conducted in Swahili using interview guides informed by social cognitive theory. All interviews were audio-recorded, transcribed in Kiswahili, translated into English and coded for themes and patterns with Atlas t.i. Of the 36 patients interviewed (mean time on ART 9.8 months; range 1–23 months), 32 reported perfect adherence in the previous month. Self-reported adherence was high despite economic hardship, depression, low rates of HIV disclosure and high perceived HIV-associated stigma. Five factors emerged to explain excellent adherence in the face of such barriers. First, all respondents experienced substantial improvements in their health after starting ART; this supported their confidence in the medication and motivated them to adhere. Second, their perceived need to be able to meet their family responsibilities motivated respondents to stay healthy. Third, respondents developed specific strategies to remember to take pills, particularly routinizing pill-taking by linking it with daily activities or events. Fourth, material and emotional support received from others facilitated adherence. Finally, respondents trusted the advice and instructions of their health care providers, who regularly emphasized adherence. The facilitating factors identified were consistent with the constructs of social cognitive theory and highlighted the importance of interventions that address multiple levels of influence on adherence.
PMCID: PMC3530387  PMID: 19328609
25.  ART adherence changes among patients in community substance use treatment: a preliminary analysis from MACH14 
Opiate substitution treatment has been associated with better adherence to lifesaving antiretroviral medications, but the impact of other substance abuse treatment on adherence is unknown.
In this study, 215 patients who had been in adherence-focused research studies provided electronically-measured adherence data and a measure of whether the patient had recently been in substance abuse treatment. Recent engagement in substance abuse treatment was independently associated with significantly higher adherence, after covarying for recent substance use and other factors potentially affecting adherence.
The findings suggest that substance abuse treatment is associated with better adherence. Potential mechanisms by which substance abuse treatment improves adherence, such as more stability or more future-orientation, require further study.
PMCID: PMC3485617  PMID: 23057423
Medication adherence; AIDS; Substance abuse; Treatment

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