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1.  Suboptimal awareness and comprehension of published pre-exposure prophylaxis efficacy results among physicians in Massachusetts 
AIDS care  2013;26(6):684-693.
In 2010, the CAPRISA 004 and iPrEx trials (microbicide gel containing tenofovir and oral pill containing tenofovir-emtricitabine, respectively) demonstrated that antiretroviral pre-exposure prophylaxis (PrEP) reduced the risk of HIV acquisition among high-risk individuals. To determine facilitators and barriers to PrEP provision by healthcare providers, we conducted an online, quantitative survey of Massachusetts-area physicians following the publication of the CAPRISA and iPrEx results. We assessed awareness and comprehension of efficacy data, prescribing experience, and anticipated provision of oral and topical PrEP among physicians, as well as demographic and behavioral factors associated with PrEP awareness and prescribing intentions. The majority of HIV specialists and generalist physicians were aware of data from these PrEP trials and able to correctly interpret the results, however, correct interpretation of findings tended to vary according to specialty (i.e., HIV specialists had greater awareness than generalists). Additionally provider concerns regarding PrEP efficacy and safety, as well its ability to divert funds from other HIV prevention resources, were associated with decreased intentions to prescribe both oral and topical PrEP. Findings suggest that a substantial proportion of physicians who may have contact with at-risk individuals may benefit from interventions that provide accurate data on the risks and benefits of PrEP in order to facilitate effective PrEP discussions with their patients. Future studies to develop and test interventions aimed at healthcare providers should be prioritized to optimize implementation of PrEP in clinical settings.
doi:10.1080/09540121.2013.845289
PMCID: PMC4053171  PMID: 24116985
Pre-Exposure Prophylaxis; PrEP; Physicians; HIV; Prevention
3.  Substance Use Among HIV-Infected Patients Engaged in Primary Care in the United States: Findings From the Centers for AIDS Research Network of Integrated Clinical Systems Cohort 
American journal of public health  2013;103(8):1457-1467.
Objectives
The purpose of this study was to better understand substance use behaviors and deleterious health consequences among individuals with HIV.
Methods
We examined a multicenter cohort of HIV-infected patients (n = 3413) receiving care in 4 US cities (Seattle, Birmingham, San Diego, Boston) between December 2005 and April 2010 in the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS). We used generalized estimating equations to model specific substance use outcomes.
Results
Overall, 24% of patients reported recent use of marijuana; 9% reported amphetamine use, 9% reported crack–cocaine use, 2% reported opiate use, 3.8% reported injection drug use, and 10.3% reported polydrug use. In adjusted multivariable models, those who reported unprotected anal sex had higher odds of marijuana, amphetamine, injection drug, and polydrug use. An increased number of distinct vaginal sexual partners was associated with polydrug and crack–cocaine use. Nonadherence to antiretroviral therapy was associated with the use of all substances other than marijuana.
Conclusions
The co-occurrence of substance use, unprotected intercourse, and medication nonadherence could attenuate the public health benefits of test, treat, and link to care strategies. Prevention programs are needed that address these coprevalent conditions.
doi:10.2105/AJPH.2012.301162
PMCID: PMC3752382  PMID: 23763417
4.  Transgender Health Disparities: Comparing Full Cohort and Nested Matched-Pair Study Designs in a Community Health Center 
LGBT health  2014;1(3):177-184.
Purpose
U.S. health surveillance systems infrequently include measures to identify transgender respondents or monitor the health of this underserved and marginalized population.
Methods
From 2001–2002, transgender and non-transgender adults were sampled at a Massachusetts clinic. Health differences were formatively examined by transgender identity using a cross-sectional, clinic-based sample (n=2,653); and a nested matched-pair subsample (n=155).
Results
Both designs produced virtually identical findings: (1) the prevalence of HIV, substance abuse, and smoking did not differ significantly for transgender and non-transgender patients; (2) transgender patients were more likely to endorse a lifetime suicide attempt and ideation compared to non-transgender patients (p<0.05); (3) transgender patients disproportionately reported social stressors (violence, discrimination, childhood abuse) relative to non-transgender patients (p<0.05).
Conclusion
Findings suggest that a nested design may provide an effective methodology for using clinical data to study transgender health, and underscore the need for routine collection of gender identity in clinical settings.
doi:10.1089/lgbt.2014.0009
PMCID: PMC4219512  PMID: 25379511
Health disparity; transgender; gender identity; methods; study design
5.  Does Effective Depression Treatment Alone Reduce Secondary HIV Transmission Risk? Equivocal Findings from a Randomized Controlled Trial 
AIDS and behavior  2013;17(8):2765-2772.
Depressed mood has been associated with HIV transmission risk behavior. To determine whether effective depression treatment could reduce the frequency of sexual risk behavior, we analyzed secondary outcome data from a 36-week, two-arm, parallel-design, randomized controlled trial, in which homeless and marginally housed, HIV-infected persons with comorbid depressive disorders were randomized to receive either: (a) directly observed treatment with the antidepressant medication fluoxetine, or (b) referral to a local public mental health clinic. Self-reported sexual risk outcomes, which were measured at 3, 6, and 9 months, included: total number of sexual partners, unprotected sexual intercourse, unprotected sexual intercourse with an HIV-uninfected partner or a partner of unknown serostatus, and transactional sex. Estimates from generalized estimating equations regression models did not suggest consistent reductions in sexual risk behaviors resulting from treatment. Mental health interventions may need to combine depression treatment with specific skills training in order to achieve durable impacts on HIV prevention outcomes.
doi:10.1007/s10461-013-0600-3
PMCID: PMC3805275  PMID: 23975476
HIV; Depression; Antidepressive agents; Sexual behavior; Protected sex; Homeless persons
6.  Sources of Racial/Ethnic Differences in Awareness of HIV Vaccine Trials 
American journal of public health  2014;104(8):e112-e118.
Objectives
We explored the relative effects of 2 awareness components—exposure and attention—on racial/ethnic differences in HIV vaccine trial awareness among men who have sex with men (MSM).
Methods
Surveys assessing awareness of and attitudes toward HIV vaccine trials were administered to 1723 MSM in 6 US cities. Proxy measures of exposure included use of HIV resources and other health care services, community involvement, income, and residence. Attention proxy measures included research attitudes, HIV susceptibility, and HIV message fatigue. Using logistic regression models, we assessed the extent to which these proxies accounted for racial/ethnic differences in vaccine trial awareness.
Results
White MSM reported significantly (P < .01) higher rates of HIV vaccine trial awareness (22%) compared with Latino (17%), Black (13%) and “other” (13%) MSM. Venue-based exposure proxies and research-directed attitudinal attention proxies were significantly associated with awareness, but only accounted for the White-Latino disparity in awareness. No proxies accounted for the White-Black or White- “other” differentials in awareness.
Conclusions
Sources of disparities in awareness of HIV vaccine trials remain to be explained. Future trials seeking to promote diverse participation should explore additional exposure and attention mediators.
doi:10.2105/AJPH.2014.301893
PMCID: PMC4103242  PMID: 24922153
7.  Psychosocial risk factors for HIV sexual risk among Indian men who have sex with men 
AIDS care  2013;25(9):1109-1113.
Indian men who have sex with men (MSM) are at increased risk for HIV compared to the general Indian population. Psychosocial factors may be uniquely associated with HIV risk among Indian MSM and may moderate the beneficial impact of standard HIV prevention approaches. Psychiatric diagnostic interviews and psychosocial and sexual risk assessments were conducted among 150 MSM in Mumbai, India. Logistic regression was employed to examine the association of psychiatric disorders and psychosocial problems to recent sexual risk behavior. Twenty-five percent of participants reported engaging in unprotected anal sex (UAS) during their last sexual contact with a man. Men who were married to a woman were more likely to have engaged in UAS during their last sexual contact with a man (35% vs. 17%, p = 0.018). In multivariable models, significant predictors of engaging in UAS were current major depression (adjusted odds ratio [AOR] = 2.61; 95% confidence interval [CI] 1.07, 6.39) and number of stressful life events (AOR = 0.91; 95% CI 0.83, 0.99). Alcohol dependence, anxiety, and self-esteem were not associated with engaging in UAS. Indian MSM with depression are at higher odds of engaging in UAS compared to MSM without depression. HIV prevention programs for Indian MSM may benefit from incorporating treatment or triage for mental health problems.
doi:10.1080/09540121.2012.749340
PMCID: PMC3708996  PMID: 23339580
men who have sex with men (MSM); Mumbai; India; mental health; depression; minority stress; HIV
8.  A Pilot Trial of Integrated Behavioral Activation and Sexual Risk Reduction Counseling for HIV-Uninfected Men Who Have Sex with Men Abusing Crystal Methamphetamine 
AIDS Patient Care and STDs  2012;26(11):681-693.
Abstract
Crystal methamphetamine use is a major driver behind high-risk sexual behavior among men who have sex with men (MSM). Prior work suggests a cycle of continued crystal methamphetamine use and high-risk sex due to loss of the ability to enjoy other activities, which appears to be a side effect of this drug. Behavioral activation (BA) is a treatment for depression that involves learning to reengage in life's activities. We evaluated a novel intervention for crystal methamphetamine abuse and high-risk sex in MSM, incorporating 10 sessions of BA with integrated HIV risk reduction counseling (RR). Forty-four subjects were screened, of whom 21 met initial entry criteria. A total of 19 participants enrolled; 16 completed an open-phase study of the intervention. Behavioral assessments were conducted at baseline, 3 months postbaseline, and 6 months postbaseline. Linear mixed effects regression models were fit to assess change over time. Mean unprotected anal intercourse (UAI) episodes decreased significantly from baseline to acute postintervention (β=−4.86; 95% confidence interval [CI]=−7.48, −2.24; p=0.0015) and from baseline to 6 months postbaseline (β=−5.07; 95% CI=−7.85, −2.29; p=0.0017; test of fixed effects χ2=16.59; df=2,13; p=0.0002). On average, there was a significant decrease over time in the number of crystal methamphetamine episodes in the past 3 months (χ2=22.43; df=2,15; p<0.0001), and the number of days of crystal methamphetamine use in the past 30 days (χ2=9.21; df=2,15; p=0.010). Statistically significant reductions in depressive symptoms and poly-substance use were also maintained. Adding behavioral activation to risk reduction counseling for MSM with problematic crystal methamphetamine use may augment the potency of a risk reduction intervention for this population. Due to the small sample size and time intensive intervention, future testing in a randomized design is necessary to determine efficacy, with subsequent effectiveness testing.
doi:10.1089/apc.2012.0216
PMCID: PMC3495110  PMID: 23030605
9.  Psychosocial Predictors of Non-Adherence and Treatment Failure in a Large Scale Multi-National Trial of Antiretroviral Therapy for HIV: Data from the ACTG A5175/PEARLS Trial 
PLoS ONE  2014;9(8):e104178.
Background
PEARLS, a large scale trial of antiretroviral therapy (ART) for HIV (n = 1,571, 9 countries, 4 continents), found that a once-daily protease inhibitor (PI) based regimen (ATV+DDI+FTC), but not a once-daily non-nucleoside reverse transcriptase inhibitor/nucleoside reverse transcriptase inhibitor (NNRTI/NRTI) regimen (EFV+FTC/TDF), had inferior efficacy compared to a standard of care twice-daily NNRTI/NRTI regimen (EFV+3TC/ZDV). The present study examined non-adherence in PEARLS.
Methods
Outcomes: non-adherence assessed by pill count and by self-report, and time to treatment failure. Longitudinal predictors: regimen, quality of life (general health perceptions  =  QOL-health, mental health  =  QOL-mental health), social support, substance use, binge drinking, and sexual behaviors. “Life-Steps” adherence counseling was provided.
Results
In both pill-count and self-report multivariable models, both once-a-day regimens had lower levels of non-adherence than the twice-a-day standard of care regimen; although these associations attenuated with time in the self-report model. In both multivariable models, hard-drug use was associated with non-adherence, living in Africa and better QOL-health were associated with less non-adherence. According to pill-count, unprotected sex was associated with non-adherence. According to self-report, soft-drug use was associated with non-adherence and living in Asia was associated with less non-adherence. Both pill-count (HR = 1.55, 95% CI: 1.15, 2.09, p<.01) and self-report (HR = 1.13, 95% CI: 1.08, 1.13, p<.01) non-adherence were significant predictors of treatment failure over 72 weeks. In multivariable models (including pill-count or self-report nonadherence), worse QOL-health, age group (younger), and region were also significant predictors of treatment failure.
Conclusion
In the context of a large, multi-national, multi-continent, clinical trial there were variations in adherence over time, with more simplified regimens generally being associated with better adherence. Additionally, variables such as QOL-health, regimen, drug-use, and region play a role. Self-report and pill-count adherence, as well as additional psychosocial variables, such QOL-health, age, and region, were, in turn, associated with treatment failure.
doi:10.1371/journal.pone.0104178
PMCID: PMC4143224  PMID: 25153084
10.  Global Burden of HIV among Men Who Engage in Transactional Sex: A Systematic Review and Meta-Analysis 
PLoS ONE  2014;9(7):e103549.
Background
Men who engage in transactional sex, the exchange of sex for money, goods, or other items of value, are thought to be at increased risk of HIV, but there have been no systematic attempts to characterize HIV burden in this population. We undertook a systematic review and meta-analysis to quantify the burden in this population compared with that of men in the general population to better inform future HIV prevention efforts.
Methods
We searched seven electronic databases, national surveillance reports, and conference abstracts for studies of men who engage in transactional sex published between 2004–2013. Random effects meta-analysis was used to determine pooled HIV prevalence and prevalence ratios (PR) for the difference in HIV prevalence among men who engage in transactional sex as compared to general population men.
Findings
Of 66 studies included representing 31,924 men who had engaged in transactional sex in 28 countries, pooled biological assay-confirmed HIV prevalence was 10.5% (95% CI = 9.4 to 11.5%). The highest pooled HIV prevalence was in Sub-Saharan Africa (31.5%, 95% CI = 21.6 to 41.5%), followed by Latin America (19.3%, 95% CI = 15.5 to 23.1%), North America (16.6%, 95% CI = 3.7 to 29.5%), and Europe (12.2%, 95% CI = 6.0 to 17.2%). Men who engaged in transactional sex had an elevated burden of HIV compared to the general male population (PR = 20.7, 95% CI = 16.8 to 25.5).
Conclusions
The global burden of HIV is disproportionately high among men who engage in transactional sex compared with the general male population. There is an urgent need to include this population in systematic surveillance as well as to scale-up access to quality HIV prevention programs.
doi:10.1371/journal.pone.0103549
PMCID: PMC4113434  PMID: 25068720
11.  The influence of stigma on HIV risk behavior among men who have sex with men in Chennai, India 
AIDS care  2012;24(11):1401-1406.
Stigma has been shown to increase vulnerability to HIV acquisition in many settings around the world. However, limited research has been conducted examining its role among men who have sex with men (MSM) in India, whose HIV prevalence is far greater than the general population. In 2009, 210 MSM in Chennai completed an interviewer-administered assessment, including questions about stigma, sexual-risk, demographics, and psychosocial variables. More than one fifth of the MSM reported unprotected anal sex (UAS) in the past three months. Logistic regression procedures were used to examine correlates of having experienced stigma. The 11-item stigma scale had high internal consistency reliability (Cronbach's alpha=0.99). Almost 2/5ths (39%) reported a high-level of experienced stigma (≥12 mean scale-score) in their lifetime, and the mean stigma scale score was 12 (SD=2.0). Significant correlates of having experienced prior stigma, after adjusting for age and educational attainment, included: identifying as a kothi (feminine acting/appearing and predominantly receptive in anal sex) compared to a panthi (masculine appearing, predominantly insertive) (AOR= 63.23; 95% CI: 15.92, 251.14; p<0.0001); being “out” about one's MSM behavior (AOR=5.63; 95% CI: 1.46, 21.73; p=0.01); having clinically significant depressive symptoms (AOR=2.68; 95% CI: 1.40, 5.12; p=0.003); and engaging in sex work in the prior 3 months (AOR=4.89; 95% CI: 2.51, 9.51; p<0.0001). These findings underscore the need to address psychosocial issues of Indian MSM. Unless issues such as stigma are addressed, effective HIV prevention interventions for this hidden population remain a challenge.
doi:10.1080/09540121.2012.672717
PMCID: PMC3634562  PMID: 22519945
men who have sex with men; MSM; depression; India; HIV; stigma
12.  HIV Sexual Risk Behavior among Black Men Who Meet Other Men on the Internet for Sex 
Using the Internet to meet sexual partners is associated with increased HIV risk behavior, including substance use, sex with multiple or anonymous partners, and unprotected anal sex (UAS), among diverse samples of MSM, yet little is known about Internet use and HIV risk among Black MSM specifically. In 2008, a sample of 197 Black MSM completed an interviewer-administered assessment and voluntary HIV counseling and testing. One fifth of the sample (20 %) reported meeting a sexual partner via the Internet in the past 12 months. Men who met sexual partners over the Internet had significantly more male sex partners (M = 13.44, SD = 20.01) than men who did not meet partners in this manner (M = 4.11, SD = 4.14, p < 0.001) and reported significantly higher rates of UAS (p < 0.05). Adjusting for sociodemographic and other HIV-related covariates, factors significantly associated with the increased odds of engaging in at least one episode of UAS with a male partner in the past 12 months included: meeting sexual partners on the Internet, identifying as gay, and lower knowledge about HIV transmission. These findings highlight the unique HIV risk behaviors among Black MSM meeting sexual partners via the Internet and warrant tailoring of prevention activities to address the specific behaviors and social influences that may contribute to increased HIV spread among this population.
doi:10.1007/s11524-012-9701-y
PMCID: PMC3665969  PMID: 22689294
MSM; Internet; African American/Black; HIV; Sexual risk
13.  ENSURING IT WORKS: A COMMUNITY-BASED APPROACH TO HIV PREVENTION INTERVENTION DEVELOPMENT FOR MEN WHO HAVE SEX WITH MEN IN CHENNAI, INDIA 
Men who have sex with men (MSM) in India have an HIV seroprevalence 22 times greater than the country’s general population and face unique challenges that may hinder the effectiveness of current HIV prevention efforts. To obtain an understanding of the logistical and sociocultural barriers MSM experience while accessing HIV prevention services, focus groups and key informant interviews were conducted with 55 MSM in Chennai, India. Qualitative data were analyzed using descriptive qualitative content analysis. Sixty-five percent of participants identified as kothi (receptive partners), 9% as panthi (insertive partners), 22% as double decker (receptive and insertive), and 4% did not disclose. Themes included: (a) fatigue with current HIV risk reduction messages; (b) increased need for non-judgmental and confidential services; and (c) inclusion of content that acknowledges individual and structural-level determinants of risk such as low self-esteem, depression, and social discrimination. MSM interventions may benefit from approaches that address multilevel psychosocial factors, including skills building and strategies to foster self-acceptance and increased social support.
doi:10.1521/aeap.2012.24.6.483
PMCID: PMC3613222  PMID: 23206199
14.  Trends in the Spectrum of Engagement in HIV Care and Subsequent Clinical Outcomes Among Men Who Have Sex with Men (MSM) at a Boston Community Health Center 
AIDS Patient Care and STDs  2013;27(5):287-296.
Abstract
Despite known benefits, only 19–28% of HIV-infected Americans are virologically suppressed (defined as ≤200 copies/mL). Engagement in HIV care represents a continuum from patients unaware they are infected to virological suppression. The electronic medical record of all newly diagnosed HIV-infected MSM seen at Fenway Health between 2000 and 2010 were reviewed. Patients were “engaged” if they had one negative HIV test and/or one physical exam within 24 months prior to their HIV diagnosis (n=291). All others were considered “new” (n=463). MSM engaged in care prior to HIV diagnosis were more often identified in acute retroviral syndrome or on routine screening, more rapidly linked to care, and less often diagnosed with a concomitant STI than those who were not engaged in care. Nearly 19% of all patients were diagnosed with AIDS the same time they were diagnosed with HIV. Blacks and those with higher CD4 counts at diagnosis were less likely to be virologically suppressed at 1 year. Between 2000 and 2010, patients retained in care were more likely to initiate ART and be virologically suppressed within 1 year independent of initial HIV viral load and CD4 count. Engagement in care prior to seroconversion influences important HIV outcomes. Programs that care for at risk populations should institute routine opt-out HIV testing and test-and-treat programs to optimize HIV care and prevention.
doi:10.1089/apc.2012.0471
PMCID: PMC3701314  PMID: 23651106
15.  Barriers to Routine HIV Testing Among Massachusetts Community Health Center Personnel 
Public Health Reports  2011;126(5):643-652.
Objectives
We assessed the extent to which Centers for Disease Control and Prevention (CDC) recommendations have influenced routine HIV testing among Massachusetts community health center (CHC) personnel, and identified specific barriers and facilitators to routine testing.
Methods
Thirty-one CHCs were enrolled in the study. We compared those that did and did not receive funding support from the federal Ryan White HIV/AIDS Program. An anonymous survey was administered to a maximum five personnel from each CHC, including a senior administrator, the medical director, and three medical providers. Overall, 137 participants completed the survey.
Results
Among all CHCs, 53% of administrators reported having implemented routine HIV testing at their CHCs; however, only 33% of medical directors/providers reported having implemented routine HIV testing in their practices (p<0.05). Among administrators, 60% of those from Ryan White-supported CHCs indicated that both they and their CHCs were aware of CDC's recommendations, compared with 27% of administrators from non-Ryan White-supported CHCs. The five most frequently reported barriers to the implementation of routine HIV testing were (1) constraints on providers' time (68%), (2) time required to administer counseling (65%), (3) time required to administer informed consent (52%), (4) lack of funding (35%), and (5) need for additional training (34%). In a multivariable logistic regression model, the provision of on-site HIV testing by nonmedical staff resulted in increased odds of conducting routine HIV testing (odds ratio [OR] = 9.84, 95% confidence interval [CI] 1.77, 54.70). However, the amount of time needed to administer informed consent was associated with decreased odds of providing routine testing (OR=0.21, 95% CI 0.05, 0.92).
Conclusions
Routine HIV testing is not currently being implemented uniformly among Massachusetts CHCs. Future efforts to increase implementation should address personnel concerns regarding time and staff availability.
PMCID: PMC3151181  PMID: 21886324
16.  Walking the line: Stimulant use during sex and HIV risk behavior among Black urban MSM 
Drug and alcohol dependence  2010;110(0):30-37.
Background
Although the association of stimulant use to sexual risk taking and HIV transmission has been well documented among white gay men, stimulant use during sex continues to be under-explored among Black men who have sex with men (MSM).
Methods
Black MSM (n = 197) recruited via modified respondent-driven sampling between January and July 2008 completed an interviewer-administered quantitative assessment and optional HIV counseling and testing. Bivariate logistic regression procedures were employed to examine the association of demographics, sexual risk, and other psychosocial factors with stimulant use (at least monthly during sex in the past 12 months). Variable elimination using the backward selection process was used to fit two separate final multivariable logistic regression models examining stimulant use as the outcome and HIV sexual risk in the past 12 months by gender as the primary predictor: (1) Model 1: HIV sexual risk behavior with a casual male sex partner as a primary, forced predictor; (2) Model 2: HIV sexual risk behavior with a female sex partner as primary, forced predictor.
Results
One-third (34%) of Black MSM reported using stimulants monthly or more frequently during sex in the past 12 months. The following factors were independently associated with stimulant use during sex: (1) Model 1: unprotected anal sex with a casual male sex partner in the past 12 months (AOR = 2.61; 95% CI = 1.06–6.42; p = 0.01), older age (AOR = 1.09; 95% CI = 1.05–1.15; p < 0.001), erectile dysfunction (ED) medication use monthly or more during sex in the past 12 months (AOR = 7.81; 95% CI = 1.46–41.68; p = 0.02), problematic alcohol use (AOR = 3.31; 95% CI = 1.312–8.38; p = 0.005), and higher HIV treatment optimism (AOR = 0.86; 95% CI = 0.76–0.97; p = 0.01). (2) Model 2: unprotected vaginal or anal sex with a female partner in the past 12 months (AOR = 3.54; 95% CI = 1.66–7.56; p = 0.001), older age (AOR = 1.10; 95% CI = 1.05–1.14; p < 0.001), ED use monthly or more during sex in the past 12 months (AOR = 3.70; 95% CI = 1.13–12.13; p = 0.03), clinically significant depressive symptoms (CES-D) at the time of study enrollment (AOR = 3.11; 95% CI = 1.45–6.66; p = 0.004), and supportive condom use norms (AOR = 0.69; 95% CI = 0.49–0.97; p = 0.03).
Conclusion
Frequent stimulant use is an important factor in HIV and STD sexual risk among Black MSM, particularly for older men and those with co-occurring psychosocial morbidities. HIV and STD prevention interventions in this population may benefit from addressing the precipitants of stimulant use and sexual risk taking.
doi:10.1016/j.drugalcdep.2010.01.017
PMCID: PMC3947405  PMID: 20334986
Stimulant use; Black; MSM; HIV; Sexual risk behavior
17.  Clinically Significant Depressive Symptoms as a Risk Factor for HIV Infection Among Black MSM in Massachusetts 
AIDS and behavior  2009;13(4):798-810.
High rates of depression have been observed among men who have sex with men (MSM) relative to the general adult male population; however, a dearth of research has explored depression among Black MSM. Black MSM (n = 197) recruited via modified respondent-driven sampling between January and July 2008 completed an interviewer-administered quantitative assessment and voluntary HIV counseling and testing. Bivariate and multivariable logistic regression procedures examined the associations of demographics, behavioral HIV risk factors, and psychosocial variables with depressive symptoms by severity, using the 20-item Center for Epidemiologic Studies Depression Scale (CES-D). Adjusting for demographic and behavioral variables, significant factors associated with (1) clinically significant depressive symptoms (33%; CES-D score ≥ 16): being publicly insured by Medicaid, having serodiscordant anal sex with a casual male partner, and being diagnosed with an STD in the prior 12 months; (2) moderate depressive symptoms (19%; CES-D score 16–26): having serodiscordant unprotected anal sex with a casual male partner and being diagnosed with an STD in the prior 12 months; (3) severe depressive symptoms (14%; CES-D score 27+): being publicly insured by Medicaid and reporting difficulty accessing healthcare in the past 12 months. Moderately depressed Black MSM may be more likely to engage in behaviors that place them at increased risk for HIV and other STDs. HIV prevention interventions for Black MSM may benefit from incorporating screening and/or treatment for depression, allowing MSM who are depressed to respond more effectively to behavioral change approaches.
doi:10.1007/s10461-009-9571-9
PMCID: PMC3947411  PMID: 19462228
MSM; Depression; African American; HIV; STD
18.  Suicidality, clinical depression, and anxiety disorders are highly prevalent in men who have sex with men in Mumbai, India: Findings from a community-recruited sample 
Psychology, health & medicine  2011;16(4):450-462.
In India men who have sex with men (MSM) are a stigmatized and hidden population, vulnerable to a variety of psychosocial and societal stressors. This population is also much more likely to be HIV-infected compared to the general population. However, little research exists about how psychosocial and societal stressors result in mental health problems. A confidential, quantitative mental-health interview was conducted among 150 MSM in Mumbai, India at The Humsafar Trust, the largest non-governmental organization serving MSM in India. The interview collected information on sociodemographics and assessed self-esteem, social support and DSM-IV psychiatric disorders using the Mini International Neuropsychiatric Interview (MINI). Participants' mean age was 25.1 years (SD=5.1); 21% were married to women. Forty-five percent reported current suicidal ideation, with 66% low risk, 19% moderate risk, and 15% high risk for suicide per MINI guidelines. Twenty-nine percent screened in for current major depression and 24% for any anxiety disorder. None of the respondents reported current treatment for any psychiatric disorder. In multivariable models controlling for age, education, income and sexual identity, participants reporting higher levels of self-esteem and greater levels of satisfaction with the social support they receive from family and friends were at lower risk of suicidality (self-esteem AOR=0.85, 95% CI: 0.78-0.93; social support AOR=0.76, 95% CI: 0.62-0.93) and major depression (self-esteem AOR=0.79, 95% CI: 0.71-0.89; social support AOR=0.68, 95% CI: 0.54-0.85). Those who reported greater social support satisfaction were also at lower risk of a clinical diagnosis of an anxiety disorder (AOR=0.80; 95% CI: 0.65-0.99). MSM in Mumbai have high rates of suicidal ideation, depression and anxiety. Programs to improve self-esteem and perceived social support may improve these mental health outcomes. Because they are also a high-risk group for HIV, MSM HIV prevention and treatment services may benefit from incorporating mental health services and referrals into their programs.
doi:10.1080/13548506.2011.554645
PMCID: PMC3136931  PMID: 21749242
Men who have sex with men (MSM); Mumbai; India; mental health; suicide; depression; anxiety
19.  Childhood Sexual Abuse Is Highly Associated With HIV Risk–Taking Behavior and Infection Among MSM in the EXPLORE Study 
Background
Previous studies have found high rates of childhood sexual abuse (CSA) among US men who have sex with men (MSM). CSA history has been associated with a variety of negative effects later in life including behaviors that place MSM at greater risk for HIV acquisition and transmission. The present analysis is the first to examine the longitudinal association between CSA and HIV infection, unprotected anal sex, and serodiscordant unprotected anal sex, as well as mediators of these relationships among a large sample of HIV-uninfected MSM.
Methods
The EXPLORE Study was a behavioral intervention trial conducted in 6 US cities over 48 months with HIV infection as the primary efficacy outcome. Behavioral assessments were done every 6 months via confidential computerized assessments. Longitudinal regression models were constructed, adjusting for randomization arm, geographical location of study site, age at enrollment, education, and race/ethnicity.
Results
Of the 4295 participants enrolled, 39.7% had a history of CSA. Participants with a history of CSA [adjusted hazards ratio = 1.30, 95% confidence interval (CI): 1.02 to 1.69] were at increased risk for HIV infection over study follow-up. A significant association was seen between history of CSA and unprotected anal sex (adjusted odds ratio = 1.24, 95% CI: 1.12 to 1.36) and serodiscordant unprotected anal sex (adjusted odds ratio = 1.30, 95% CI: 1.18 to 1.43). Among participants reporting CSA, the EXPLORE intervention had no effect in reducing HIV infection rates. Participants reporting CSA were significantly more likely to have symptoms of depression and use nonprescription drugs.
Conclusions
A predictive relationship between a history of CSA and subsequent HIV infection was observed among this large sample of HIV-uninfected MSM. Findings indicate that HIV-uninfected MSM with CSA histories are at greater risk for HIV infection, report higher rates of HIV sexual risk behavior, and may derive less benefit from prevention programs. Future HIV prevention interventions should address the specific mental health concerns of MSM with a history of CSA.
doi:10.1097/QAI.0b013e3181a24b38
PMCID: PMC3292283  PMID: 19367173
child sexual abuse; EXPLORE; HIV; MSM; sexual risk taking
20.  Substance Use Predictors of Poor Medication Adherence: The Role of Substance Use Coping Among HIV-Infected Patients in Opioid Dependence Treatment 
AIDS and behavior  2013;17(1):168-173.
Many HIV-infected injection drug users (IDUs) continue to use illicit substances despite being in substance use treatment. Substance use is associated with non-adherence to HIV medications; however underlying mechanisms regarding this relation are understudied. The current investigation examined the role of substance use coping in terms of the relation between substance use and HIV medication adherence. Participants were 121 HIV-infected IDUs (41 % female, M age = 47, SD = 7.1) in opioid dependence treatment. Participants completed self-report questionnaires, were administered clinical interviews and oral toxicology screens, and used a medication-event-monitoring-system cap to assess 2 week HIV medication adherence. The use of cocaine and multiple substances were significantly related to decreased medication adherence. Substance use coping mediated these associations. Findings highlight the importance of assessing, monitoring, and targeting ongoing substance use, and ways to increase positive coping for HIV-infected IDUs in substance use treatment to aid in HIV medication adherence.
doi:10.1007/s10461-012-0319-6
PMCID: PMC3632258  PMID: 23008124
HIV/AIDS; Medication adherence; Substance use; Coping; Cocaine
21.  “We fear the police, and the police fear us”: Structural and individual barriers and facilitators to HIV medication adherence among injection drug users in Kiev, Ukraine 
AIDS care  2010;22(11):1305-1313.
Ukraine has one of the most severe HIV/AIDS epidemics in Europe, with an estimated 1.63% of the population living with HIV/AIDS in 2007. Injection drug use (IDU) remains the predominant mode of transmission in Kiev—the capital and largest city. Prior reports suggest that the HIV infection rate among IDUs in Kiev reaches 33%, and many have poor and inequitable access to highly active antiretroviral therapy (HAART). Among those with access to HAART, little is understood about barriers and facilitators to HAART medication adherence.
In 5/2009, two semi-structured focus groups were conducted with HIV-infected IDUs seeking treatment at the City AIDS Center, Kiev. The goal was to use this information to adapt and tailor, to Ukrainian culture, an evidence-based intervention for improving adherence to HAART. All 16 participants attributed HIV infection to IDU. Their average age was 31.6 (SD=7.0), average time with HIV 5.7 years (SD=4.0), average time on HAART 2.5 years (SD=1.7), average time as IDU 14.6 years (SD=6.8), and 88% were on opioid substitution therapy.
The most salient themes related to adherence barriers included: (1) harassment and discrimination by police; (2) opioid dependence; (3) complexity of drug regimen; (4) side effects; (5) forgetting; (6) co-occurring mental health problems; and (7) HIV stigma. Facilitators of adherence included: (1) cues for pill taking; (2) support and reminders from family, significant other, and friends; (3) opioid substitution therapy; and (4) wanting improved health. Additional factors explored included: 1) knowledge about HAART; (2) storage of medications; and (3) IDU and sexual risk behaviors.
Findings highlighted structural and individual barriers to adherence. At the structural level, police discrimination and harassment was reported to be a major barrier to adherence to opioid substitution therapy and HAART. Privacy and stigma were barriers at the individual level. Recommendations for adherence interventions included education, training, and identification cards to show police that medication was for treatment of HIV, not for abuse; and involving family members and other systems of support for HIV treatment.
doi:10.1080/09540121003758515
PMCID: PMC2952728  PMID: 20640954
HIV; ARV; IDU; Ukraine; opioid substitution therapy; adherence
22.  Sexual frequency and planning among at-risk men who have sex with men (MSM) in the US: implications for event-based intermittent pre-exposure prophylaxis (iPrEP) 
Intermittent dosing of pre-exposure prophylaxis (iPrEP) has potential to decrease costs, improve adherence, and minimize toxicity. Practical event-based dosing of iPrEP requires men who have sex with men (MSM) to be sexually active on fewer than 3 days each week and plan for sexual activity. MSM who may be most suitable for event-based dosing were older, more educated, more frequently used sexual networking websites, and more often reported that their last sexual encounter was not with a committed partner. A substantial proportion of these MSM endorse high-risk sexual activity, and event-based iPrEP may best target this population.
doi:10.1097/QAI.0b013e31825bd87d
PMCID: PMC3427423  PMID: 22592590
intermittent pre-exposure prophylaxis (iPrEP); pre-exposure prophylaxis (PrEP); event-based dosing; men-who-have-sex-with-men (MSM); HIV; sexual frequency; sexual planning
23.  HIV Prevention Interventions in Chennai, India: Are Men Who Have Sex with Men Being Reached? 
AIDS Patient Care and STDs  2009;23(11):981-986.
Abstract
India has the greatest number of HIV infections in Asia and the third highest total number of infected persons globally. Men who have sex with men (MSM) are considered by the Government of India's National AIDS Control Organization (NACO) a “core risk group” for HIV in need of HIV prevention efforts. However there is a dearth of information on the frequency of participation in HIV prevention interventions and subsequent HIV risk and other correlates among MSM in India. Recruited through peer outreach workers, word of mouth and snowball sampling techniques, 210 MSM in Chennai completed an interviewer-administered assessment, including questions about participating in any HIV prevention interventions in the past year, sexual risk taking, demographics, MSM identities, and other psychosocial variables. Bivariate and multivariable logistic regression procedures were used to examine behavioral and demographic correlates with HIV prevention intervention participation. More than a quarter (26%) of the sample reported participating in an HIV prevention intervention in the year prior to study participation. Participants who reported engaging in unprotected anal sex (UAS; odds ratio [OR] = 0.28; p = 0.01) in the 3 months prior to study enrollment were less likely to have participated in an HIV prevention program in the past year. MSM who were older (OR = 1.04; p = 0.05), kothis (feminine acting/appearing and predominantly receptive partners in anal sex) compared to panthis (masculine appearing, predominantly insertive partners; OR = 5.52, p = 0.0004), those with higher educational attainment (OR = 1.48, p = 0.01), being “out” about having sex with other men (OR = 4.03, p = 0.0001), and MSM who reported ever having been paid in exchange for sex (OR = 2.92, p = 0.001) were more likely to have reported participation in an HIV prevention intervention in the preceding year. In a multivariable model, MSM reporting UAS in the prior 3 months were less likely to have participated in an HIV prevention intervention (AOR = 0.34, p = 0.04). MSM who were older (AOR = 1.05, p = 0.05), those with higher educational attainment (AOR = 1.92, p = 0.0009), and MSM who were “out” about having sex with other men (AOR = 2.71, p = 0.04) were more likely to have reported participating in an HIV prevention program. Findings suggest that exposure to HIV prevention interventions may be protective against engaging in UAS for some MSM in India. Understanding predictors of participation in an HIV prevention intervention is helpful for identifying Indian MSM who might have had no exposure to HIV prevention information and skills building, hence allowing researchers and prevention workers to focus efforts on individuals at greatest need.
doi:10.1089/apc.2009.0092
PMCID: PMC2859779  PMID: 19821722
24.  A Review of HIV Antiretroviral Adherence and Intervention Studies Among HIV–Infected Youth 
Advances in antiretroviral medications have resulted in precipitous declines in HIV-associated morbidity and mortality; however, high levels of adherence are crucial to the success of HIV therapies. This article reviews published studies in the United States on HIV-infected youth (ages 13 to 24 years), focusing on adherence to antiretroviral regimens and interventions designed to enhance adherence. A systematic search yielded 21 articles published between 1999 and 2008 that reported data on medication adherence in HIV-infected youth, of which 7 described unique interventions to enhance medication adherence. Five thematic areas were identified to classify factors associated with adherence. Findings suggest psychosocial factors, in particular depression and anxiety, were consistently associated with poorer adherence across studies. Three types of adherence interventions with HIV-infected youth were found. Results suggest that examining adherence within the broader contextual issues present in the lives of youth, including HIV stigma and disclosure, caregiver stress, peer relations, mental health and substance use, and length of time on medications, may be most important to understanding how best to intervene with adherence among this population. Secondary HIV prevention interventions for youth represent a possible mode through which to deliver individually tailored adherence skill building and counseling to improve medication adherence.
PMCID: PMC3752381  PMID: 19270345
25.  Health System and Personal Barriers Resulting in Decreased Utilization of HIV and STD Testing Services among At-Risk Black Men Who Have Sex with Men in Massachusetts 
AIDS Patient Care and STDs  2009;23(10):825-835.
Abstract
Testing for HIV and other sexually transmitted diseases (STD) remains a cornerstone of public health prevention interventions. This analysis was designed to explore the frequency of testing, as well as health system and personal barriers to testing, among a community-recruited sample of Black men who have sex with men (MSM) at risk for HIV and STDs. Black MSM (n = 197) recruited via modified respondent-driven sampling between January and July 2008 completed an interviewer-administered assessment, with optional voluntary HIV counseling and testing. Logistic regression procedures examined factors associated with not having tested in the 2 years prior to study enrollment for: (1) HIV (among HIV-uninfected participants, n = 145) and (2) STDs (among the entire mixed serostatus sample, n = 197). The odds ratios and their 95% confidence intervals obtained from this analysis were converted to relative risks. (1) HIV: Overall, 33% of HIV-uninfected Black MSM had not been tested for HIV in the 2 years prior to study enrollment. Factors uniquely associated with not having a recent HIV test included: being less educated; engaging in serodiscordant unprotected sex; and never having been HIV tested at a community health clinic, STD clinic, or jail. (2) STDs: Sixty percent had not been tested for STDs in the 2 years prior to study enrollment, and 24% of the sample had never been tested for STDs. Factors uniquely associated with not having a recent STD test included: older age; having had a prior STD; and never having been tested at an emergency department or urgent care clinic. Overlapping factors associated with both not having had a recent HIV or STD test included: substance use during sex; feeling that using a condom during sex is “very difficult”; less frequent contact with other MSM; not visiting a health care provider (HCP) in the past 12 months; having a HCP not recommend HIV or STD testing at their last visit; not having a primary care provider (PCP); current PCP never recommending they get tested for HIV or STDs. In multivariable models adjusting for relevant demographic and behavioral factors, Black MSM who reported that a HCP recommended getting an HIV test (adjusted relative risk [ARR] = 0.26; p = 0.01) or STD test (ARR = 0.11; p = 0.0004) at their last visit in the past 12 months were significantly less likely to have not been tested for HIV or STDs in the past 2 years. Many sexually active Black MSM do not regularly test for HIV or STDs. HCPs play a pivotal role in encouraging testing for Black MSM. Additional provider training is warranted to educate HCPs about the specific health care needs of Black MSM, in order to facilitate access to timely, culturally competent HIV and STD testing and treatment services for this population.
doi:10.1089/apc.2009.0086
PMCID: PMC2859760  PMID: 19803696

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