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1.  Effects of a Social Network HIV/STD Prevention Intervention for Men Who Have Sex with Men in Russia and Hungary: A Randomized Controlled Trial 
AIDS (London, England)  2015;29(5):583-593.
Objective
To test a novel social network HIV risk reduction intervention for MSM in Russia and Hungary, where same-sex behavior is stigmatized and men may best be reached through their social network connections.
Design
A 2-arm trial with 18 sociocentric networks of MSM randomized to the social network intervention or standard HIV/STD testing/counseling.
Setting
St. Petersburg, Russia and Budapest, Hungary.
Participants
18 “seeds” from community venues invited the participation of their MSM friends who, in turn, invited their own MSM friends into the study, a process that continued outward until eighteen 3-ring sociocentric networks (mean size=35 members, n=626) were recruited.
Intervention
Empirically-identified network leaders were trained and guided to convey HIV prevention advice to other network members.
Main Outcome and Measures
Changes in sexual behavior from baseline to 3- and 12-month followup, with composite HIV/STD incidence measured at 12-months to corroborate behavior changes.
Results
There were significant reductions between baseline, first followup, and second followup in the intervention versus comparison arm for proportion of men engaging in any unprotected anal intercourse (P=.04); UAI with a nonmain partner (P=.04); and UAI with multiple partners (P=.002). The mean percentage of unprotected AI acts significantly declined (P=.001), as well as the mean number of UAI acts among men who initially had multiple partners (P=.05). Biological HIV/STD incidence was 15% in comparison condition networks and 9% in intervention condition networks.
Conclusions
Even where same-sex behavior is stigmatized, it is possible to reach MSM and deliver HIV prevention through their social networks.
doi:10.1097/QAD.0000000000000558
PMCID: PMC4497559  PMID: 25565495
2.  Low numeracy predicts reduced accuracy of retrospective reports of frequency of sexual behavior 
AIDS and behavior  2010;14(6):1320-1329.
Assessment of the frequency of sexual behavior relies on participants’ ability to arithmetically aggregate information over time and across partners. This study examines the effect of numeracy (arithmetic skills) on the accuracy of retrospective reports of sexual behavior. For 91 days, participants completed daily reports about their sexual activity. Participants then completed a survey on sexual behavior over the same period. The discrepancies between the survey-based and the diary-based measures of frequency of vaginal and anal intercourse were evaluated. Multiple regression analysis showed that the discrepancy between retrospective and diary measurements of sexual intercourse increased with lower numeracy (p=.026), lower education (p=.001), aggregate question format compared to partner-by-partner format (p=.031) and higher frequency of intercourse occasions (p<.001). Lower numeracy led to a 1.5-fold increase (adjusted-mean=14.1 to 20.9) in the discrepancy for those using the aggregate question format and a 2.0-fold increase (adjusted-mean=3.7 to 7.6) for those using the partner-by-partner format.
doi:10.1007/s10461-010-9761-5
PMCID: PMC4072320  PMID: 20640594
Numeracy; accuracy; surveys; sexual behavior; frequency
3.  Male Labor Migrants in Russia: HIV Risk Behavior Levels, Contextual Factors, and Prevention Needs 
Background
Although the dire life circumstances of labor migrants working in Russia are well-known, their HIV risk vulnerability and prevention needs are understudied. Low socioeconomic status, lack of access to services, separation from family, and limited risk awareness all contribute to migrants’ HIV vulnerability.
Methods
Male labor migrants in St. Petersburg (n=499) were administered assessments of their sexual behavior practices, substance use, and psychosocial characteristics related to risk and well-being.
Results
Thirty percent of migrants reported multiple female partners in the past 3 months. Condom use was low, ranging from 35% with permanent to 52% with casual partners. Central Asian migrants had very low AIDS knowledge, low levels of substance use, moderate sexual risk, high depression, and poor social supports. Eastern European migrants had higher AIDS knowledge, alcohol and drug use, and sexual risk.
Discussion
Improved HIV prevention efforts are needed to reduce the risk vulnerability of migrants who relocate to high disease prevalence areas.
doi:10.1007/s10903-010-9376-y
PMCID: PMC4476384  PMID: 20690041
Labor migrants; Russia; HIV/AIDS; HIV risk behavior; Psychosocial risk factors
4.  HIV/STD PREVALENCE, RISK BEHAVIOR, AND SUBSTANCE USE PATTERNS AND PREDICTORS IN RUSSIAN AND HUNGARIAN SOCIOCENTRIC SOCIAL NETWORKS OF MEN WHO HAVE SEX WITH MEN 
This study recruited four sociocentric networks (n = 156) of men who have sex with men in Budapest, Hungary, and St. Petersburg, Russia. The sampling approach was based on identifying an initial “seed” in the community for each network, and then recruiting three successive friendship group waves out from the seed. HIV prevalence in the networks was 9%, and the composite rate of other sexually transmitted diseases was 6%. 57% of participants reported both main and casual male partners, and two thirds reported unprotected anal intercourse in the past 3 months. Fifty-five percent of men’s most recent anal intercourse acts were with nonexclusive partners, and 56% of most recent anal intercourse acts were unprotected. Sexual risk predictors were generally consistent with behavioral science theory. In addition, risk was associated with more often talking with friends about AIDS, higher ecstasy use, and less often drinking. Sociocentric social network sampling approaches are feasible and constitute a modality for reaching hidden high-risk populations inaccessible through conventional methods.
doi:10.1521/aeap.2009.21.3.266
PMCID: PMC2802572  PMID: 19519240
5.  High-Risk Sexual Behavior, HIV/STD Prevalence, and Risk Predictors in the Social Networks of Young Roma (Gypsy) Men in Bulgaria 
Introduction
Roma (Gypsies), the largest and most disadvantaged ethnic minority group in Europe, are believed to be vulnerable to HIV/AIDS. This study’s aim was to examine HIV risk in 6 Roma male sociocentric networks (n=405 men) in Bulgaria.
Methods
Participants were interviewed concerning their risk practices and tested for HIV/STDs.
Results
High-risk sexual behaviors were common. Over 57% of men had multiple sexual partners in the past 3 months. Over one-third of men reported both male and female partners in the past year. Condom use was low. Greater levels of sexual risk were associated with lower intentions and self-efficacy for using condoms, drug use, having male partners, knowing HIV-positive persons, and having higher AIDS knowledge but no prior HIV testing. Two men had HIV infection, 3.7% gonorrhea, and 5.2% chlamydia.
Discussion
HIV prevention interventions directed toward high-risk social networks of Roma are needed before HIV infection becomes more widely established.
doi:10.1007/s10903-012-9596-4
PMCID: PMC4107306  PMID: 22370730
HIV Risk Behavior; Sociocentric Social Networks; Ethnic Minorities; Roma; HIV/STD Prevalence
6.  Aggregate Versus Individual-Level Sexual Behavior Assessment: How Much Detail Is Needed to Accurately Estimate HIV/STI Risk? 
Evaluation review  2010;34(1):19-34.
The sexual behaviors of HIV/sexually transmitted infection (STI) prevention intervention participants can be assessed on a partner-by-partner basis: in aggregate (i.e., total numbers of sex acts, collapsed across partners) or using a combination of these two methods (e.g., assessing five partners in detail and any remaining partners in aggregate). There is a natural trade-off between the level of sexual behavior detail and the precision of HIV/STI acquisition risk estimates. The results of this study indicate that relatively simple aggregate data collection techniques suffice to adequately estimate HIV risk. For highly infectious STIs, in contrast, accurate STI risk assessment requires more intensive partner-by-partner methods.
doi:10.1177/0193841X09353534
PMCID: PMC4091776  PMID: 20130234
HIV/STI prevention; sexual behavior; assessment; risk
7.  HIV Testing Rates, Testing Locations, and Healthcare Utilization among Urban African-American Men 
African-American men bear a disproportionate burden of HIV infection in the United States. HIV testing is essential to ensure that HIV-infected persons are aware of their HIV-positive serostatus, can benefit from early initiation of antiretroviral therapy, and can reduce their risk of transmitting the virus to sex partners. This cross-sectional study assessed HIV testing history and healthcare utilization among 352 young African-American men recruited in urban neighborhoods in a Midwestern city. The self-administered survey measured sexual risk behaviors, factors associated with HIV testing, and barriers to testing. The acceptability of community venues for HIV testing was also assessed. Of the respondents, 76% had been tested for HIV at some time in their lives, 52% during the prior 12 months. Of the participants, 70% had unprotected intercourse during the prior 12 months, 26% with two or more partners. Nearly three-quarters (72%) of participants had seen a healthcare provider during the prior year. In univariate analyses, those who had at least one healthcare provider visit during the prior 12 months and those who had a primary doctor were more likely to have been tested in the prior 12 months. In multivariate analyses, having a regular doctor who recommended HIV testing was the strongest predictor of having been tested [OR = 7.38 (3.55, 15.34)]. Having been diagnosed or treated for a sexually transmitted disease also was associated with HIV testing [OR = 1.83 (1.04, 3.21)]. The most commonly preferred testing locations were medical settings. However, community venues were acceptable alternatives. Having a primary doctor recommend testing was strongly associated with HIV testing and most HIV testing occurred at doctors’ offices. But, a substantial proportion of persons were not tested for HIV, even if seen by a doctor. These results suggest that HIV testing could be increased within the healthcare system by increasing the number of recommendations made by physicians to patients. The use of community venues for HIV testing sites could further increase the number of persons tested for HIV.
doi:10.1007/s11524-008-9339-y
PMCID: PMC2629519  PMID: 19067176
HIV; HIV testing; Healthcare utilization; Healthcare access; Community-based HIV testing; African American; Urban; Inner city
8.  Influence of Coping, Social Support, and Depression on Subjective Health Status Among HIV-Positive Adults With Different Sexual Identities 
The authors examined associations between psychosocial variables (coping self-efficacy, social support, and cognitive depression) and subjective health status among a large national sample (N = 3,670) of human immunodeficiency virus (HIV)-positive persons with different sexual identities. After controlling for ethnicity, heterosexual men reported fewer symptoms than did either bisexual or gay men and heterosexual women reported fewer symptoms than did bisexual women. Heterosexual and bisexual women reported greater symptom intrusiveness than did heterosexual or gay men. Coping self-efficacy and cognitive depression independently explained symptom reports and symptom intrusiveness for heterosexual, gay, and bisexual men. Coping self-efficacy and cognitive depression explained symptom intrusiveness among heterosexual women. Cognitive depression significantly contributed to the number of symptom reports for heterosexual and bisexual women and to symptom intrusiveness for lesbian and bisexual women. Individuals likely experience HIV differently on the basis of sociocultural realities associated with sexual identity. Further, symptom intrusiveness may be a more sensitive measure of subjective health status for these groups.
doi:10.3200/BMED.34.4.133-144
PMCID: PMC2653049  PMID: 19064372
coping; depression; HIV; sexual identity; symptoms; social support
9.  Defining, Designing, Implementing, and Evaluating Phase 4 HIV Prevention Effectiveness Trials for Vulnerable Populations 
Summary
The efficacy of behavioral HIV prevention interventions has been convincingly demonstrated in a large number of randomized controlled phase 3 research outcome trials. Little research attention has been directed toward studying the effectiveness of the same interventions when delivered by providers to their own clients or community members, however. This article argues for the need to conduct phase 4 effectiveness trials of HIV prevention interventions that have been found efficacious in the research arena. Such trials can provide important information concerning the impact of interventions when applied in heterogeneous “real-world” circumstances. This article raises design issues and methodologic questions that need to be addressed in the conduct of phase 4 trials of behavioral interventions. These issues include the selection and training of service providers engaged in such trials, maintenance of fidelity to intervention protocol in provider-delivered interventions, determination of intervention core elements versus aspects that require tailoring, selection of relevant phase 4 study outcomes, interpretation of findings indicative of field effectiveness, sustainability, and other aspects of phase 4 trial design.
doi:10.1097/QAI.0b013e3181605c77
PMCID: PMC2409151  PMID: 18301131
effectiveness trial; HIV prevention; phase 4 trial; methodology
10.  Severely Mentally Ill Women’s HIV Risk: The Influence of Social Support, Substance Use, and Contextual Risk Factors 
In structured interviews with 96 women with severe mental illness, nearly two-thirds had not used condoms during sexual intercourse in the past 3 months, more than two-thirds had sex with multiple partners, and almost one-third had been treated for a sexually transmitted infection (STI) in the past year. Women who reported fewer sexual risk context factors, such as having sex with someone the participant did not know or transactional sex, had fewer sexual partners. Larger social support networks were associated with less frequent sex after drug use. In turn, women who less often had sex after using drugs had unprotected intercourse less frequently.
doi:10.1007/s10597-006-9069-0
PMCID: PMC2410084  PMID: 17143730
sexual risk behavior; HIV/AIDS; serious mental illness; women’s health
11.  Prevention of HIV and sexually transmitted diseases in high risk social networks of young Roma (Gypsy) men in Bulgaria: randomised controlled trial 
BMJ : British Medical Journal  2006;333(7578):1098.
Objective To determine the effects of a behavioural intervention for prevention of HIV and sexually transmitted diseases that identified, trained, and engaged leaders of Roma (Gypsy) men's social networks to counsel their own network members.
Design A two arm randomised controlled trial.
Setting A disadvantaged, impoverished Roma settlement in Bulgaria.
Participants 286 Roma men from 52 social networks recruited in the community.
Intervention At baseline all participants were assessed for HIV risk behaviour, tested and treated for sexually transmitted diseases, counselled in risk reduction, and randomised to intervention or control groups. Network leaders learnt how to counsel their social network members on risk prevention. Networks were followed up three and 12 months after the intervention to determine evidence of risk reduction.
Main outcome measure Occurrence of unprotected intercourse during the three months before each assessment.
Results Reported prevalence of unprotected intercourse in the intervention group fell more than in control group (from 81% and 80%, respectively, at baseline to 65% and 75% at three months and 71% and 86% at 12 months). Changes were more pronounced among men with casual partners. Effects remained strong at long term follow-up, consistent with changes in risk reduction norms in the social network. Other measures of risk reduction corroborated the intervention's effects.
Conclusions Endorsement and advice on HIV prevention from the leader of a social network produces well maintained change in the reported sexual practices in members of that network. This model has particular relevance for health interventions in populations such as Roma who may be distrustful of outsiders.
Trial registration Clinical Trials NCT00310973.
doi:10.1136/bmj.38992.478299.55
PMCID: PMC1661707  PMID: 17040924
12.  Predictors of Pessimistic Breast Cancer Risk Perceptions in a Primary Care Population 
OBJECTIVE
To identify sociodemographic characteristics, numeracy level, and breast cancer risk factors that are independently associated with the accuracy of lifetime and 5-year breast cancer risk perceptions.
DESIGN
Cross-sectional survey. A probability scale was used to measure lifetime and 5-year risk perceptions. The absolute difference between perceived risk and the Gail model risk of breast cancer was calculated. Linear regression models were built to predict lifetime and 5-year breast cancer risk estimation error.
SETTING
Primary care internal medicine practices (N = 2).
PARTICIPANTS
Two hundred fifty-four women 40 to 85 years of age.
RESULTS
The mean lifetime and 5-year calculated breast cancer risk was 8.4% (SD [standard deviation] 6.1) and 1.5% (SD 1.3), respectively. Subjects had a mean estimation error for lifetime and 5-year risk of 29.5% (SD 22.9) and 24.8% (SD 23.9), respectively. In multivariate analyses, lower numeracy scores (0.005), higher number of previous breast biopsies (0.016), and a higher number of first-degree relatives (0.054) were predictive of larger estimation error for lifetime breast cancer risk. White race (0.014), lower educational levels (0.009), higher number of previous breast biopsies (0.008), and higher number of first-degree relatives (0.014) were predictive of larger estimation error for 5-year risk.
CONCLUSION
Among a primary care population, breast cancer risk factors may be more consistently associated with pessimistic perceptions of breast cancer risk than other factors studied during a lifetime and 5-year time span. Primary care physicians should consider counseling patients about individual breast cancer risk factors and risk over time.
doi:10.1111/j.1525-1497.2004.20801.x
PMCID: PMC1492192  PMID: 15061739
breast neoplasm; risk perception; pessimism; numeracy

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