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1.  A Mixed-Methods Study on the Acceptability of Using eHealth for HIV Prevention and Sexual Health Care Among Men Who Have Sex With Men in China 
Human immunodeficiency virus (HIV) infection disproportionately affects men who have sex with men (MSM). Over half of all HIV-positive MSM in China may not know their HIV status. Mobile phones and Web interventions (eHealth) are underutilized resources that show promise for supporting HIV education, testing, and linkage to care.
This mixed-methods study among MSM in China assessed technology utilization and eHealth acceptability for sexual health care.
We conducted in-depth interviews and an online survey. Qualitative analyses informed the development of the Internet survey, which was administered through two popular MSM websites. Bivariate and multivariate analysis assessed characteristics of MSM interested in eHealth for sexual health care.
The qualitative sample included MSM across a range of ages, education, marital status, sexuality, and HIV testing experience. Qualitative findings included the importance of the Internet as the primary source of information about sexual health, HIV and other sexually transmitted diseases (STDs), use of the Internet to enable HIV testing opportunities by facilitating connections with both the gay community and health care providers, and mixed perceptions regarding the confidentiality of eHealth tools for sexual health. Among the Internet sample (N=1342), the average age was 30.6 years old, 82.81% (1098/1342) were single, and 53.42% (711/1331) had completed college. In the past 3 months, 38.66% (382/988) had condomless sex and 60.53% (805/1330) self-reported having ever tested for HIV. The majority of men owned computers (94.14%, 1220/1296) and mobile phones (92.32%, 1239/1342), which many had used to search for HIV/STD information and testing sites. In multivariate analysis, interest in using computers or mobile phones to support their sexual health care was associated with being a student, prior use of computers or mobile phones to search for general health information, prior use of computers or mobile phones to search for HIV/STD information, and confidentiality concerns.
MSM in this sample had high utilization of technology and interest in eHealth despite confidentiality concerns. Future eHealth interventions can thoughtfully and creatively address these concerns as a priority for successful implementation.
PMCID: PMC4420841  PMID: 25900881
Internet; HIV; AIDS; China; men who have sex with men; mixed method; sexually transmitted diseases
2.  Mobile Phone Applications for the Care and Prevention of HIV and Other Sexually Transmitted Diseases: A Review 
Mobile phone applications (apps) provide a new platform for delivering tailored human immunodeficiency virus (HIV) and sexually transmitted disease (STD) prevention and care.
To identify and evaluate currently available mobile phone apps related to the prevention and care of HIV and other STDs.
We searched the Apple iTunes and Android Google Play stores for HIV/STD-related apps, excluding apps that exclusively targeted industry, providers, and researchers. Each eligible app was downloaded, tested, and assessed for user ratings and functionality as well as 6 broad content areas of HIV prevention and care: HIV/STD disease knowledge, risk reduction/safer sex, condom promotion, HIV/STD testing information, resources for HIV-positive persons, and focus on key populations.
Search queries up to May 2012 identified 1937 apps. Of these, 55 unique apps met the inclusion criteria (12 for Android, 29 for iPhone, and 14 for both platforms). Among these apps, 71% provided disease information about HIV/STDs, 36% provided HIV/STD testing information or resources, 29% included information about condom use or assistance locating condoms, and 24% promoted safer sex. Only 6 apps (11%) covered all 4 of these prevention areas. Eight apps (15%) provided tools or resources specifically for HIV/STD positive persons. Ten apps included information for a range of sexual orientations, 9 apps appeared to be designed for racially/ethnically diverse audiences, and 15 apps featured interactive components. Apps were infrequently downloaded (median 100-500 downloads) and not highly rated (average customer rating 3.7 out of 5 stars).
Most available HIV/STD apps have failed to attract user attention and positive reviews. Public health practitioners should work with app developers to incorporate elements of evidence-based interventions for risk reduction and improve app inclusiveness and interactivity.
PMCID: PMC3636069  PMID: 23291245
HIV; technology; mobile phone applications
3.  Migration and HIV risk: Life histories of Mexican-born men living with HIV in North Carolina 
Culture, health & sexuality  2014;16(7):820-834.
Latino men in the Southeastern USA are disproportionately affected by HIV, but little is known about how the migration process influences HIV-related risk. In North Carolina (NC), a relatively new immigrant destination, Latino men are predominantly young and from Mexico. We conducted 31 iterative life history interviews with 15 Mexican-born men living with HIV. We used holistic content narrative analysis methods to examine HIV vulnerability in the context of migration and to identify important turning points. Major themes included the prominence of traumatic early life experiences, migration as an ongoing process rather than a finite event, and HIV diagnosis as a final turning point in migration trajectories. Findings provide a nuanced understanding of HIV vulnerability throughout the migration process and have implications including the need for bi-national HIV prevention approaches, improved outreach around early testing and linkage to care, and attention to mental health.
PMCID: PMC4313377  PMID: 24866206
HIV prevention; migrant men; life history; narrative analysis; USA
4.  Keeping Them in “STYLE”: Finding, Linking, and Retaining Young HIV-Positive Black and Latino Men Who Have Sex with Men in Care 
AIDS Patient Care and STDs  2011;25(1):37-45.
Young men who have sex with men (YMSM) of color are at particularly increased risk for HIV infection compared to white MSM. National data highlight the need to link YMSM of color to care to improve their overall health and stem further infections, yet, there is limited data on interventions and clinical outcomes focused on engaging and retaining youth, specifically HIV-infected YMSM of color in care. To address the medical care needs of this underserved population, in 2005, the Health Research and Services Administration (HRSA) created the YMSM of Color Initiative. Utilizing a social marketing campaign targeting youth and members of their sexual and social networks, testing and outreach on college campuses and within the broader community, and a tightly linked medical–social support network, we created STYLE (Strength Through Youth Livin’ Empowered), a novel intervention that sought to diagnose, engage, and retain HIV-positive black and Latino YMSM in HIV primary care services. Over a 3-year period, 81 men were either newly diagnosed or reengaged in care. Overall, 63% of the cohort was retained in clinical care; defined as attending at least one medical visit every 4 months. Compared to the 3 years prior to STYLE, the odds ratio for whether or not someone attended a clinic visit was 2.58 (95% confidence interval [CI] 1.34–4.98) if enrolled in STYLE. We conclude that compared to a pre-STYLE cohort, STYLE was an effective intervention that increased HIV diagnoses, provided efficient and timely engagement in care for both those newly diagnosed and those who had fallen out of care and improved overall retention.
PMCID: PMC3030910  PMID: 21162690
5.  Incident sexually transmitted infection as a biomarker for high risk sexual behavior following diagnosis with acute HIV 
Sexually transmitted diseases  2014;41(7):447-452.
Sexually transmitted infection (STI) diagnosis following diagnosis of acute HIV infection (AHI) indicates ongoing high-risk sexual behavior and possible risk of HIV transmission. We assessed predictors of STI acquisition and the effect of time since care entry on STI incidence in AHI patients in care and receiving consistent risk-reduction messaging.
Data on incident gonorrhea, chlamydia, trichomoniasis, primary/secondary syphilis, demographic, and clinical risk factors were abstracted from medical charts for patients diagnosed with AHI and engaged in care. Poisson regression models using generalized estimating equations were fit to estimate incidence rates (IR), incidence rate ratios (IRR), and robust 95% confidence intervals (CI).
Among 185 AHI patients, 26 (14%) were diagnosed with ≥1 incident STI over 709.4 person-years; 46 STIs were diagnosed during follow-up (IR=6.8/100 person-years). The median time from HIV care entry to first STI diagnosis was 609 days (range=168–1681). Men who have sex with men (MSM) (p=0.03), a shorter time between presentation to medical care and AHI diagnosis (p=0.06), and STI diagnosis prior to AHI diagnosis (p=0.0003) were predictors of incident STI. STI IR >1 year after entering care was double that of patients in care ≤1 year (IRR=2.0 95% CI 0.8–4.9). HIV viral load was above the limits of detection within 1 month of 11 STI diagnoses in 6 patients (23.1%) (median=15,898 copies/mL, range=244–152,000 copies/mL).
Despite regular HIV care, STI incidence was high among this primarily young, MSM AHI cohort. Early antiretroviral initiation may decrease HIV transmission given ongoing risk behaviors despite risk-reduction messaging.
PMCID: PMC4191902  PMID: 24922104
acute HIV infection; sexually transmitted infection; incidence; antiretroviral therapy; HIV care
6.  Putting Prevention in Their Pockets: Developing Mobile Phone-Based HIV Interventions for Black Men Who Have Sex with Men 
AIDS Patient Care and STDs  2013;27(4):211-222.
Young black men who have sex with men (MSM) bear a disproportionate burden of HIV. Rapid expansion of mobile technologies, including smartphone applications (apps), provides a unique opportunity for outreach and tailored health messaging. We collected electronic daily journals and conducted surveys and focus groups with 22 black MSM (age 18–30) at three sites in North Carolina to inform the development of a mobile phone-based intervention. Qualitative data was analyzed thematically using NVivo. Half of the sample earned under $11,000 annually. All participants owned smartphones and had unlimited texting and many had unlimited data plans. Phones were integral to participants' lives and were a primary means of Internet access. Communication was primarily through text messaging and Internet (on-line chatting, social networking sites) rather than calls. Apps were used daily for entertainment, information, productivity, and social networking. Half of participants used their phones to find sex partners; over half used phones to find health information. For an HIV-related app, participants requested user-friendly content about test site locators, sexually transmitted diseases, symptom evaluation, drug and alcohol risk, safe sex, sexuality and relationships, gay-friendly health providers, and connection to other gay/HIV-positive men. For young black MSM in this qualitative study, mobile technologies were a widely used, acceptable means for HIV intervention. Future research is needed to measure patterns and preferences of mobile technology use among broader samples.
PMCID: PMC3624691  PMID: 23565925
7.  Investigating A Sexual Network of Black Men Who Have Sex with Men: Implications for Transmission and Prevention of HIV Infection in the United States 
HIV infections increased 48% among young, Black men who have sex with men (MSM) in the United States between 2006–2009. Incomplete understanding of this trend undermines prevention strategy development. We investigated a sexual network to characterize the risk environment in which young, Black MSM acquire HIV.
Persons reported to the state following diagnosis of HIV or syphilis were included, along with sexual partners. We used network mapping alongside descriptive and bivariate statistics to characterize network connections. Generalized linear models assessed predictors of having untraceable sex partners.
The network included 398 individuals and 419 sexual relationships. Three-quarters were Black (n=299); 92% were MSM. Median age at first network appearance was 26 years and decreased over time (P<0.001). HIV prevalence was at least 29% (n=117); serostatus was unknown for 47% of the network, either because they were untraceable (n=150) or refused HIV testing (n=39). One in 5 network members diagnosed with HIV had a subsequent incident sexually transmitted infection. In multivariable models, one-time encounters increased the risk of having an untraceable partner (risk ratio 4.51, 95% CI, 2.27, 8.97), while being acutely HIV infected at diagnosis reduced it (RR 0.27, 95% CI, 0.08, 0.89).
HIV prevalence in this sexual network of young, Black MSM rivals that of sub-Saharan Africa, reflecting dramatically increased risk of acquiring HIV from the moment one entered the network. Prevention efforts for this population must consider the effect of sexual networks on HIV risk, and find ways of leveraging network structure to reduce transmission.
PMCID: PMC3494769  PMID: 22972020
HIV; African-American; men who have sex with men; sexual networks
8. Feasibility and Acceptability of Delivering an Internet Intervention to Young Black Men Who have Sex with Men 
AIDS Care  2012;24(7):910-920.
Young Black men who have sex with men (BMSM) are disproportionately affected by HIV/AIDS in the United States and continue to experience rapidly increasing HIV incidence. We designed a tailored, theory-based interactive HIV/STI prevention website for young BMSM, called (HMP) and conducted a small pilot trial comparing HMP to currently available HIV/STI websites. We present findings demonstrating feasibility and acceptability of delivering the intervention to the target population of young BMSM. Retention rates were 90% and 78% at one and three month follow-ups, respectively. Evaluation immediately after the intervention’s completion revealed that participants who used the HMP website reported high levels of user satisfaction and interest and low levels of website difficulty and frustration. At the end of the intervention, there was a trend in increased behavioral intentions to use condoms and engage in preparatory condom use behaviors in the intervention group compared to the control group (p=.10). We observed a reduction in mean scores on the CES-D scale among those in the intervention group that was not seen in the control group at the one-month follow-up, though this was not statistically significant. Feedback from exit interviews with study participants suggested that HMP is relevant to the prevention needs of young BMSM. Overall, the findings support the acceptability and feasibility of delivering this prevention program to a group that has few interventions despite bearing a significant burden of the epidemic. Future trials, combining internet and mobile phone technologies, are planned to test HMP among larger and more diverse populations of young BMSM.
PMCID: PMC3358439  PMID: 22272759
Black MSM; internet interventions; HIV-infection
10.  Developing a Predictive Model to Prioritize HIV Partner Notification in North Carolina 
Sexually transmitted diseases  2012;39(1):65-71.
Disease Intervention Specialists (DIS) in North Carolina (NC) have less time to conduct partner notification due to competing responsibilities while simultaneously facing increased case loads due to increased HIV testing. We developed a model to predict undiagnosed HIV infection in sexual partners to prioritize DIS interviews.
We abstracted demographic, behavioral, and partnership data from DIS records of HIV-infected persons reported in two NC surveillance regions between January 1, 2003 and December 31, 2007. Multiple logistic regression with generalized estimating equations was used to develop a predictive model and risk scores among newly diagnosed persons and their partners. Sensitivities and specificities of the risk scores at different cutoffs were used to examine algorithm performance.
Five factors predicted a partnership between a person with newly diagnosed HIV infection and an undiagnosed partner—four weeks or fewer between HIV diagnosis and DIS interview, no history of crack use, no anonymous sex, fewer total sexual partners reported to DIS, and sexual partnerships between an older index case and younger partner. Using this model, DIS could choose an appropriate cutoff for locating a particular partner by determining the weight of false negatives relative to false positives.
While the overall predictive power of the model is low, it is possible to reduce the number of partners that need to be located and interviewed while maintaining high sensitivity. If DIS continue to pursue all partners, the model would be useful in identifying partners in which to invest more resources for locating.
PMCID: PMC3244826  PMID: 22183850
HIV; partner notification; modeling; decision
Black men who have sex with men (BMSM) are disproportionately affected by the HIV epidemic, yet few prevention interventions have been developed specifically for them. Recent studies suggest that the Internet is a promising intervention delivery avenue. We describe results from our formative work in developing a theory-based online HIV/STI prevention intervention for young BMSM including focus groups, semistructured interviews, and usability testing. The Intervention,, was created based on the Institute of Medicine’s integrated model of behavior change with extensive input from young BMSM. Key interactive Web site features include live chats, quizzes, personalized health and “hook-up/sex” journals, and decision support tools for assessing risk behaviors. Creating an interactive HIV/sexually transmitted infection web site for BMSM was a complex process requiring many adjustments based on iterative feedback throughout all development stages. Preliminary satisfaction, content acceptability, and usability findings support the use of the Internet to deliver risk reduction messages to young BMSM.
PMCID: PMC3509545  PMID: 21341956
12.  Risk Behavior Disclosure During HIV Test Counseling 
AIDS Patient Care and STDs  2010;24(9):551-561.
Individualized risk assessments during HIV testing are an integral component of prevention counseling, a currently recommended behavioral intervention for patients in high-risk settings. Additionally, aggregate risk assessment data are the source of aggregate behavioral statistics that inform prevention programs and allocation of resources. Consequently, inaccurate or incomplete risk behavior disclosure during test counseling may impact the efficacy of the counseling intervention, as well as bias aggregate behavioral statistics. To quantify client-reported accuracy during the risk assessment and identify barriers and facilitators to risk behavior disclosure, we interviewed young men accessing HIV testing services in a southeastern United States city using mixed methodology. Data were collected from August 2007 to April 2008. Based on data collected via an audio and computer-assisted self-interview (n = 203), over 30% of men reported that they were not accurate during the risk assessment. Participants reported numerous interpersonal facilitators to complete disclosure. During qualitative interviews (n = 25), participants revealed that many did not understand the purpose of the risk assessment. Findings suggest that risk assessments completed during HIV test counseling may be incomplete. Modifications to the risk assessment process, including better explaining the role of the risk assessment in prevention counseling, may increase the validity of the data.
PMCID: PMC2957626  PMID: 20718688
13.  Sex with Older Partners Is Associated with Primary HIV Infection among Men Who Have Sex with Men in North Carolina 
Studies from the 1990s suggested sex with older partners was associated with HIV infection. We evaluated the hypothesized association between primary HIV infection (PHI) and having older sexual partners among men who have sex with men (MSM).
MSM with PHI and HIV-uninfected MSM completed audio computer-assisted self-interviews exploring behaviors involving their three most recent sexual partners prior to enrollment (if uninfected) or diagnosis (if PHI).
Of 74 men reporting any lifetime sex with men, 20 had PHI (27%). Demographics (including age) were similar between groups; 39% were non-white and 74% identified as gay. The mean age of sex partners differed significantly: men with PHI had partners on average 6 years older than themselves, while uninfected men’s partners were 4 months their junior (P<0.001). After adjusting for race, sex while intoxicated, and having a serodiscordant/serostatus unknown partner, a participant had twice the odds of PHI if his sex partner was 5 years his senior (OR 2.0, 95% CI, 1.2, 3.3).
Among a sample of young MSM, the odds of HIV infection increased significantly as the age of sexual partners increased. These findings can inform behavioral interventions in communities of at-risk MSM as well as secondary prevention efforts among those already living with HIV.
PMCID: PMC2877753  PMID: 20057320
primary HIV infection; men who have sex with men; age mixing; North Carolina
14.  Pregnancy and HIV Infection in Young Women in North Carolina 
Public Health Reports  2010;125(1):96-102.
We described young women in North Carolina (NC) who were pregnant at the time of diagnosis with human immunodeficiency virus (HIV) infection to identify an at-risk population that could be targeted for increased HIV screening. We investigated the combined effect of partner counseling and referral services (PCRS) and comprehensive prenatal HIV screening.
We conducted a retrospective review of PCRS charts on young women newly diagnosed with HIV in NC between 2002 and 2005. We determined the prevalence of pregnancy in the study sample and conducted bivariate analyses to assess predictors of pregnancy at the time of HIV diagnosis, calculating prevalence ratios (PRs) with 95% confidence intervals (CIs). We analyzed results of partner notification efforts, including timing and stage of diagnosis of HIV-positive partners.
During the four-year period, 551 women aged 18–30 years were newly diagnosed with HIV; 30% were pregnant at the time of HIV diagnosis. Pregnant women were more likely to be Hispanic (PR=1.58, 95% CI 1.15, 2.17) and not report typical risk factors. Fourteen percent of pregnant women's partners had an undiagnosed infection compared with slightly more than 8% of nonpregnant women's partners (p<0.01).
Ethnic differences in co-diagnosis of pregnancy and HIV suggest that young Hispanic women may have differential access to and acceptance of routine HIV screening. Comprehensive prenatal screening combined with partner notification can be effective in reaching infected male partners who are undiagnosed.
PMCID: PMC2789821  PMID: 20402201
15.  Identifying People with Acute HIV Infection (AHI) – Demographic Features, Risk Factors, and Use of Health Care among Individuals with AHI in North Carolina 
AIDS and behavior  2009;13(6):1075-1083.
Identifying and counseling individuals with Acute HIV Infection (AHI) offers a critical opportunity to avert preventable HIV transmission, however opportunities to recognize these individuals may be missed. We surveyed 32 adults diagnosed with AHI during voluntary HIV testing from 1/1/03 to 2/28/05 in publicly funded testing sites in NC to describe their clinical, social, and behavioral characteristics. Eighty-one percent of participants were men; 59% were African American. Seventy-five percent experienced symptoms consistent with acute retroviral syndrome; although 83% sought medical care for these symptoms, only 15% were appropriately diagnosed at that initial medical visit, suggesting opportunities to diagnose these individuals earlier were missed. Eighty-five percent of the men engaged in sex with men. More than 50% of the participants thought they were infected with HIV by a steady partner. This study yields important information to assist in identifying populations at risk for or infected with AHI and designing both primary and secondary prevention interventions.
PMCID: PMC2787774  PMID: 19127422
Acute HIV Infection (AHI); North Carolina (NC); HIV/AHI screening; AHI Epidemiology; HIV Risk Factors

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