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1.  Linkage to HIV Care in San Francisco: Implications of Measure Selection 
In this paper, we describe a San Francisco collaboration’s process to select optimal measures of linkage to care in response to the CDC’s Enhanced Comprehensive HIV Prevention Planning (ECHPP) program, and to understand the implications of measure selection and the challenges of accessing data sources to measure outcomes along the HIV care continuum.
Challenges identified are the variety of definitions of linkage to care and the non-integrative nature of the multiple data systems necessary to measure linkage to care and other continuum outcomes. The choice of linkage measures, which at the extremes is a choice between higher-resolution measures based on clinical visit data in a subset of patients vs. a lower resolution proxy measure based on surveillance data, has key implications. Choosing between the options needs to be informed by the primary use of the measure. For representing trends in overall performance and response to interventions more generalizable measures based on surveillance data are optimal. For identifying barriers to linkage to care for specific populations and potential intervention targets within the linkage process, higher-resolution measures of linkage that include clinical, laboratory, and social work visit information are optimal.
Cataloging the different data systems along the continuum and observations of challenges of data sharing between systems highlighted the promise of integrated data management systems that span HIV surveillance and care systems. Such integrated data management systems would have the ability to support detailed investigation and would provide simplified data to match newly developed, cross-agency HHS measures of HIV care continuum outcomes.
doi:10.1097/QAI.0b013e3182a99c73
PMCID: PMC4078743  PMID: 24126446
2.  Understanding and Addressing Socio-Cultural Barriers to Medical Male Circumcision in Traditionally Non-Circumcising Rural Communities in Sub-Saharan Africa 
Culture, health & sexuality  2013;15(9):10.1080/13691058.2013.807519.
Given the success of recent clinical trials establishing the safety and efficacy of adult medical male circumcision in Africa, attention has now shifted to barriers and facilitators to programmatic implementation in traditionally non-circumcising communities. In this study, we attempted to develop a fuller understanding of the role of cultural issues in the acceptance of adult circumcision. We conducted four focus group discussions with 28 participants in Mutoko in Zimbabwe, and 33 participants in Vulindlela, in KwaZulu-Natal, South Africa, as well as 19 key informant interviews in both settings. We found the concept of male circumcision to be an alien practice, particularly as expressed in the context of local languages. Cultural barriers included local concepts of ethnicity, social groups, masculinity, and sexuality. On the other hand, we found that concerns about the impact of HIV on communities resulted in willingness to consider adult male circumcision as an option if it would result in lowering the local burden of the epidemic. Adult medical male circumcision promotional messages that create a synergy between understandings of both traditional and medical circumcision will be more successful in these communities.
doi:10.1080/13691058.2013.807519
PMCID: PMC3810456  PMID: 23815101
HIV; male circumcision; barriers; cultural identity; sexuality
3.  Effect of community-based voluntary counselling and testing on HIV incidence and social and behavioural outcomes (NIMH Project Accept; HPTN 043): a cluster-randomised trial 
The lancet global health  2014;2(5):e267-e277.
Background
NIMH Project Accept (HPTN 043) was a cluster-randomized trial that tested whether a multicomponent, multi-level prevention strategy (community-based voluntary counselling and testing [CBVCT]) reduced HIV incidence compared to standard voluntary counselling and testing (SVCT).
Methods
Forty-eight communities were enrolled at five sites in South Africa, Tanzania, Zimbabwe, and Thailand. CBVCT was designed to make testing more accessible in communities, engage communities through outreach, and provide post-test support services. SVCT comprised standard VCT services established at existing facilities. Communities were randomized in matched pairs to 36 months of CBVCT or SVCT. Data were collected at baseline (n=14,567) and post-intervention (n=56,683) by cross-sectional random surveys of 18–32 year-old community residents. HIV incidence was estimated using a cross-sectional multi-assay algorithm. Thailand was excluded from incidence analyses due to low HIV prevalence.
Findings
The estimated incidence in the CBVCT was 1.52% vs. 1.81% in the SVCT with an estimated reduction in HIV incidence of 13·9% (relative risk [RR]=0·86; 95% confidence interval [CI]=0·725–1·023; p=0·08). Women older than 24 years had RR=0·70 (95% CI=0·54–0·90; p=0·009). CBVCT increased testing rates by 25% overall (95% CI=12%–39%; p=0·0003), by 45% among men and 15% among women. No overall effect on sexual risk behaviour was observed. However, among HIV-infected participants, CBVCT reduced the number of sexual partners by 8% (95% CI=1%–15%; p=0.03) and the proportion of multiple partnerships by 30% (95% CI=8%-46%; p=0.01). Social norms regarding HIV testing were improved in CBVCT communities.
Interpretations
The intervention was effective in increasing HIV testing, particularly among men, promoted positive social norms regarding testing, and reduced behavioural risk among HIV-infected participants. A modest reduction in HIV incidence was observed. This intervention focused primarily on HIV detection. Current and future studies that include strategies for HIV treatment and viral suppression should demonstrate further incidence reductions.
doi:10.1016/S2214-109X(14)70032-4
PMCID: PMC4131207  PMID: 25103167
HIV; incidence; Project Accept; Africa; HPTN 043
5.  California's “Bridge to Reform”: Identifying Challenges and Defining Strategies for Providers and Policymakers Implementing the Affordable Care Act in Low-Income HIV/AIDS Care and Treatment Settings 
PLoS ONE  2014;9(3):e90306.
Background
In preparation for full Affordable Care Act implementation, California has instituted two healthcare initiatives that provide comprehensive coverage for previously uninsured or underinsured individuals. For many people living with HIV, this has required transition either from the HIV-specific coverage of the Ryan White program to the more comprehensive coverage provided by the county-run Low-Income Health Programs or from Medicaid fee-for-service to Medicaid managed care. Patient advocates have expressed concern that these transitions may present implementation challenges that will need to be addressed if ambitious HIV prevention and treatment goals are to be achieved.
Methods
30 semi-structured, in-depth interviews were conducted between October, 2012, and February, 2013, with policymakers and providers in 10 urban, suburban, and rural California counties. Interview topics included: continuity of patient care, capacity to handle payer source transitions, and preparations for healthcare reform implementation. Study team members reviewed interview transcripts to produce emergent themes, develop a codebook, build inter-rater reliability, and conduct analyses.
Results
Respondents supported the goals of the ACA, but reported clinic and policy-level challenges to maintaining patient continuity of care during the payer source transitions. They also identified strategies for addressing these challenges. Areas of focus included: gaps in communication to reach patients and develop partnerships between providers and policymakers, perceived inadequacy in new provider networks for delivering quality HIV care, the potential for clinics to become financially insolvent due to lower reimbursement rates, and increased administrative burdens for clinic staff and patients.
Conclusions
California's new healthcare initiatives represent ambitious attempts to expand and improve health coverage for low-income individuals. The state's challenges in maintaining quality care and treatment for people living with HIV experiencing these transitions demonstrate the importance of setting effective policies in anticipation of full ACA implementation in 2014.
doi:10.1371/journal.pone.0090306
PMCID: PMC3943953  PMID: 24599337
6.  Receipt of Prevention Services Among HIV-Infected Men Who Have Sex with Men 
American journal of public health  2008;98(6):1011-1014.
Unprotected sexual intercourse remains a primary mode of HIV transmission in the United States. We found that receipt of services to reduce HIV transmission-risk behaviors was low among 3787 HIV-infected individuals and that men who have sex with men were especially unlikely to receive these services even though they were more likely to report unprotected sexual intercourse with seronegative and unknown serostatus casual partners. Greater efforts should be made to ensure that prevention counseling is delivered to all HIV-infected persons, especially men who have sex with men.
doi:10.2105/AJPH.2007.124933
PMCID: PMC2377307  PMID: 18445790
7.  A Behavioral Intervention Reduces HIV Transmission Risk by Promoting Sustained Serosorting Practices Among HIV-Infected Men Who Have Sex with Men 
Objective
To examine factors that explain the effect of a cognitive-behavioral intervention on reductions in HIV transmission risk among HIV-infected men who have sex with men (MSM).
Method
Of the 1,910 HIV-infected MSM screened, 616 participants considered to be at risk of transmitting HIV were randomized to a 15-session, individually delivered cognitive-behavioral intervention (n = 301) or a wait-list control (n = 315).
Results
Consistent with previous intent-to-treat findings, there was an overall reduction in transmission risk acts among MSM in both intervention and control arms, with significant intervention effects observed at the 5, 10, 15, and 20 month assessments (Risk Ratios = .78, .62, .48, and .38, respectively). These intervention-related decreases in HIV transmission risk acts appeared to be partially due to sustained serosorting practices. MSM in the intervention condition reported a significantly greater proportion of sexual partners who were HIV-infected at the 5 and 10 month assessments (Risk Ratio = 1.14 and 1.18).
Conclusions
The Healthy Living Project, a cognitive-behavioral intervention, is efficacious in reducing transmission risk acts among MSM. This appears to have been due in large part to the fact that MSM in the intervention condition reported sustained serosorting practices.
doi:10.1097/QAI.0b013e31818d5def
PMCID: PMC2659703  PMID: 18989221
Men Who Have Sex with Men; Prevention with Positives; Randomized Controlled Trial; Prevention Case Management
8.  Positive provider interactions, adherence self-efficacy, and adherence to antiretroviral medications among HIV infected adults: A mediation model 
AIDS patient care and STDs  2006;20(4):258-268.
Adherence to antiretroviral (ARV) therapy for HIV infection is critical for maximum benefit from treatment and for the prevention of HIV-related complications. There is evidence that many factors determine medication adherence, including adherence self-efficacy (confidence in one's ability to adhere) and relations with health care providers. However, there are no studies that examine how these two factors relate to each other and their subsequent influence on HIV medication adherence. The goal of the current analysis was to explore a model of medication adherence in which the relationship between positive provider interactions and adherence is mediated by adherence self-efficacy. Computerized self administered and interviewer administered self reported measures of medication adherence, demographic and treatment variables, provider interactions, and adherence self-efficacy were administered to 2765 HIV infected adults on ARV. Criteria for mediation were met, supporting a model in which adherence self-efficacy is the mechanism for the relationship between positive provider interactions and adherence. The finding was consistent when the sample was stratified by gender, race, injection drug use history, and whether the participant reported receipt of HIV specialty care. Positive provider interactions may foster greater adherence self-efficacy, which is associated with better adherence to medications. Results suggest implications for improving provider interactions in clinical care, and future directions for clarifying inter-relationships among provider interactions, adherence self-efficacy, and medication adherence are supported.
doi:10.1089/apc.2006.20.258
PMCID: PMC2432422  PMID: 16623624
HIV/AIDS; Provider Relations; Adherence/Compliance
9.  Estimation of HIV Incidence in a Large, Community-Based, Randomized Clinical Trial: NIMH Project Accept (HIV Prevention Trials Network 043) 
PLoS ONE  2013;8(7):e68349.
Background
National Institute of Mental Health Project Accept (HIV Prevention Trials Network [HPTN] 043) is a large, Phase III, community-randomized, HIV prevention trial conducted in 48 matched communities in Africa and Thailand. The study intervention included enhanced community-based voluntary counseling and testing. The primary endpoint was HIV incidence, assessed in a single, cross-sectional, post-intervention survey of >50,000 participants.
Methods
HIV rapid tests were performed in-country. HIV status was confirmed at a central laboratory in the United States. HIV incidence was estimated using a multi-assay algorithm (MAA) that included the BED capture immunoassay, an avidity assay, CD4 cell count, and HIV viral load.
Results
Data from Thailand was not used in the endpoint analysis because HIV prevalence was low. Overall, 7,361 HIV infections were identified (4 acute, 3 early, and 7,354 established infections). Samples from established infections were analyzed using the MAA; 467 MAA positive samples were identified; 29 of those samples were excluded because they contained antiretroviral drugs. HIV prevalence was 16.5% (range at study sites: 5.93% to 30.8%). HIV incidence was 1.60% (range at study sites: 0.78% to 3.90%).
Conclusions
In this community-randomized trial, a MAA was used to estimate HIV incidence in a single, cross-sectional post-intervention survey. Results from this analysis were subsequently used to compare HIV incidence in the control and intervention communities.
Trial Registration
ClinicalTrials.gov NCT00203749
doi:10.1371/journal.pone.0068349
PMCID: PMC3708944  PMID: 23874597
10.  Community member perspectives from transgender women and men who have sex with men on pre-exposure prophylaxis as an HIV prevention strategy: implications for implementation 
Background
An international randomized clinical trial (RCT) on pre-exposure prophylaxis (PrEP) as an human immunodeficiency virus (HIV)-prevention intervention found that taken on a daily basis, PrEP was safe and effective among men who have sex with men (MSM) and male-to-female transgender women. Within the context of the HIV epidemic in the United States (US), MSM and transgender women are the most appropriate groups to target for PrEP implementation at the population level; however, their perspectives on evidenced-based biomedical research and the results of this large trial remain virtually unknown. In this study, we examined the acceptability of individual daily use of PrEP and assessed potential barriers to community uptake.
Methods
We conducted semi-structured interviews with an ethnoracially diverse sample of thirty HIV-negative and unknown status MSM (n = 24) and transgender women (n = 6) in three California metropolitan areas. Given the burden of disease among ethnoracial minorities in the US, we purposefully oversampled for these groups. Thematic coding and analysis of data was conducted utilizing an approach rooted in grounded theory.
Results
While participants expressed general interest in PrEP availability, results demonstrate: a lack of community awareness and confusion about PrEP; reservations about PrEP utilization, even when informed of efficacious RCT results; and concerns regarding equity and the manner in which a PrEP intervention could be packaged and marketed in their communities.
Conclusions
In order to effectively reduce HIV health disparities at the population level, PrEP implementation must take into account the uptake concerns of those groups who would actually access and use this biomedical intervention as a prevention strategy. Recommendations addressing these concerns are provided.
doi:10.1186/1748-5908-7-116
PMCID: PMC3527231  PMID: 23181780
Men who have sex with men (MSM); Male-to-female (MTF) transgender women; HIV/AIDS; Pre-exposure prophylaxis (PrEP); Qualitative research; Health disparities
11.  Psychiatric Risk Factors for HIV Disease Progression: The Role of Inconsistent Patterns of Anti-Retroviral Therapy Utilization 
Background
In the era of anti-retroviral therapy (ART), depression and substance use predict hastened HIV disease progression but the underlying biological or behavioral mechanisms that explain these effects are not fully understood.
Methods
Using outcome data from 603 participants enrolled in a randomized controlled trial of a behavioral intervention, binary logistic and linear regression were employed to examine whether inconsistent patterns of ART utilization partially mediated the effects of depression and substance use on higher HIV viral load over a 25-month follow-up.
Results
Elevated affective symptoms of depression independently predicted ART discontinuation (Adjusted OR [AOR] = 1.39, 95% CI = 1.08 – 1.78), and use of stimulants at least weekly independently predicted intermittent ART utilization (AOR = 2.62, 95% CI = 1.45 – 4.73). After controlling for the average self-reported percentage of ART doses taken and baseline T-helper (CD4+) count, elevated depressive symptoms predicted a 50% higher mean viral load, and weekly stimulant use predicted a 137% higher mean viral load. These effects became non-significant after accounting for inconsistent patterns of ART utilization, providing evidence of partial mediation.
Conclusions
Inconsistent patterns of ART utilization may partially explain the effects of depression and stimulant use on hastened HIV disease progression.
doi:10.1097/QAI.0b013e318201df63
PMCID: PMC3494991  PMID: 21116186
Access; Adherence; Antiretroviral; Cocaine; Depression; Disease Progression; Highly Active; HIV/AIDS; HIV Viral Load; Methamphetamine; Substance Use; Utilization
12.  Socio-economic status and health care utilization in rural Zimbabwe: findings from Project Accept (HPTN 043) 
Zimbabwe’s HIV epidemic is amongst the worst in the world, and disproportionately effects poorer rural areas. Access to almost all health services in Zimbabwe includes some form of cost to the client. In recent years, the socio-economic and employment status of many Zimbabweans has suffered a serious decline, creating additional barriers to HIV treatment and care. We aimed to assess the impact of i) socio-economic status (SES) and ii) employment status on the utilization of health services in rural Zimbabwe. Data were collected from a random probability sample household survey conducted in the Mutoko district of north-western Zimbabwe in 2005. We selected variables that described the economic status of the respondent, including: being paid to work, employment status, and SES by assets. Respondents were also asked about where they most often utilized healthcare when they or their family was sick or hurt. Of 2,874 respondents, all forms of healthcare tended to be utilized by those of high or medium-high SES (65%), including private (65%), church-based (61%), traditional (67%), and other providers (66%) (P=0.009). Most respondents of low SES utilized government providers (74%) (P=0.009). Seventy-one percent of respondents utilizing health services were employed. Government (71%), private (72%), church (71%), community-based (78%) and other (64%) health services tended to be utilized by employed respondents (P=0.000). Only traditional health services were equally utilized by unemployed respondents (50%) (P=0.000). A wide range of health providers are utilized in rural Zimbabwe. Utilization is strongly associated with SES and employment status, particularly for services with user fees, which may act as a barrier to HIV treatment and care access. Efforts to improve access in low-SES, high HIV-prevalence settings may benefit from the subsidization of the health care payment system, efforts to improve SES levels, political reform, and the involvement of traditional providers.
doi:10.4081/jphia.2012.e13
PMCID: PMC3436598  PMID: 22962629
Africa; socio-economic status; HIV/AIDS; access
13.  No “Magic Bullet”: Exploring Community Mobilization Strategies Used in a Multi-site Community Based Randomized Controlled Trial: Project Accept (HPTN 043) 
AIDS and Behavior  2012;16(5):1217-1226.
As community-level interventions become more common in HIV prevention, processes such as community mobilization (CM) are increasingly utilized in public health programs and research. Project Accept, a multi-site community randomized controlled trial, is testing the hypothesis that CM coupled with community-based mobile voluntary counseling and testing and post-test support services will alter community norms and reduce the incidence of HIV. By using a multiple-case study approach, this qualitative study identifies seven major community mobilization strategies used in Project Accept, including stakeholder buy-in, formation of community coalitions, community engagement, community participation, raising community awareness, involvement of leaders, and partnership building, and describes three key elements of mobilization success.
doi:10.1007/s10461-011-0009-9
PMCID: PMC3400971  PMID: 21822627
Community mobilization; HIV/AIDS; Voluntary Counseling and Testing (VCT); Case study
14.  A Qualitative Study of Provider Thoughts on Implementing Pre-Exposure Prophylaxis (PrEP) in Clinical Settings to Prevent HIV Infection 
PLoS ONE  2012;7(7):e40603.
Background
A recent clinical trial demonstrated that a daily dose tenofovir disoproxil fumarate and emtricitabrine (TDF-FTC) can reduce HIV acquisition among men who have sex with men (MSM) and transgender (TG) women by 44%, and up to 90% if taken daily. We explored how medical and service providers understand research results and plan to develop clinical protocols to prescribe, support and monitor adherence for patients on PrEP in the United States.
Methods
Using referrals from our community collaborators and snowball sampling, we recruited 22 healthcare providers in San Francisco, Oakland, and Los Angeles for in-depth interviews from May-December 2011. The providers included primary care physicians seeing high numbers of MSM and TG women, HIV specialists, community health clinic providers, and public health officials. We analyzed interviews thematically to produce recommendations for setting policy around implementing PrEP. Interview topics included: assessing clinician impressions of PrEP and CDC guidance, considerations of cost, office capacity, dosing schedules, and following patients over time.
Results
Little or no demand for PrEP from patients was reported at the time of the interviews. Providers did not agree on the most appropriate patients for PrEP and believed that current models of care, which do not involve routine frequent office visits, were not well suited for prescribing PrEP. Providers detailed the need to build capacity and were concerned about monitoring side effects and adherence. PrEP was seen as potentially having impact on the epidemic but providers also noted that community education campaigns needed to be tailored to effectively reach specific vulnerable populations.
Conclusions
While PrEP may be a novel and clinically compelling prevention intervention for MSM and TG women, it raises a number of important implementation challenges that would need to be addressed. Nonetheless, most providers expressed optimism that they eventually could prescribe and monitor PrEP in their practice.
doi:10.1371/journal.pone.0040603
PMCID: PMC3394704  PMID: 22792384
15.  Health diplomacy the adaptation of global health interventions to local needs in sub-Saharan Africa and Thailand: Evaluating findings from Project Accept (HPTN 043) 
BMC Public Health  2012;12:459.
Background
Study-based global health interventions, especially those that are conducted on an international or multi-site basis, frequently require site-specific adaptations in order to (1) respond to socio-cultural differences in risk determinants, (2) to make interventions more relevant to target population needs, and (3) in recognition of ‘global health diplomacy' issues. We report on the adaptations development, approval and implementation process from the Project Accept voluntary counseling and testing, community mobilization and post-test support services intervention.
Methods
We reviewed all relevant documentation collected during the study intervention period (e.g. monthly progress reports; bi-annual steering committee presentations) and conducted a series of semi-structured interviews with project directors and between 12 and 23 field staff at each study site in South Africa, Zimbabwe, Thailand and Tanzania during 2009. Respondents were asked to describe (1) the adaptations development and approval process and (2) the most successful site-specific adaptations from the perspective of facilitating intervention implementation.
Results
Across sites, proposed adaptations were identified by field staff and submitted to project directors for review on a formally planned basis. The cross-site intervention sub-committee then ensured fidelity to the study protocol before approval. Successfully-implemented adaptations included: intervention delivery adaptations (e.g. development of tailored counseling messages for immigrant labour groups in South Africa) political, environmental and infrastructural adaptations (e.g. use of local community centers as VCT venues in Zimbabwe); religious adaptations (e.g. dividing clients by gender in Muslim areas of Tanzania); economic adaptations (e.g. co-provision of income generating skills classes in Zimbabwe); epidemiological adaptations (e.g. provision of ‘youth-friendly’ services in South Africa, Zimbabwe and Tanzania), and social adaptations (e.g. modification of terminology to local dialects in Thailand: and adjustment of service delivery schedules to suit seasonal and daily work schedules across sites).
Conclusions
Adaptation selection, development and approval during multi-site global health research studies should be a planned process that maintains fidelity to the study protocol. The successful implementation of appropriate site-specific adaptations may have important implications for intervention implementation, from both a service uptake and a global health diplomacy perspective.
doi:10.1186/1471-2458-12-459
PMCID: PMC3552975  PMID: 22716131
Adaptations; Voluntary counseling and testing; Global health diplomacy; HIV; Sub-Saharan Africa
16.  Recent HIV Type 1 Infection Among Participants in a Same-Day Mobile Testing Pilot Study in Zimbabwe 
Abstract
We estimated HIV-1 incidence and characterized risk factors associated with recent infection among participants of a mobile HIV voluntary counseling and testing (VCT) pilot program in two communities in Zimbabwe (N = 1096). HIV-1 infection was diagnosed using a parallel rapid testing algorithm. Recent HIV-1 infections were characterized using the BED immunoglobulin G capture enzyme immunoassay (BED-CEIA). HIV prevalence was 28.9% overall and nearly twice as high in women compared to men (39.5% vs. 21.4%, p < 0.001). HIV-1 incidence was 1.91% and was comparable between men and women (1.99% vs.1.88%; p = 0.626). Although not significant, the proportion of recent infections among all infections was highest among persons ages 25 to 34 years old (10.5%) for both men (11.9%) and women (9.2%). Persons recently infected compared to those with long-term infections were more likely to report STD symptoms (33% vs. 13%; OR = 3.2; p = 0.075) and prior STD treatment (13% vs. 6%; OR = 3.4; p = 0.187) in the previous 6 months. There were no associations found between recent versus long-term HIV infection status and perceived risk or expectation of negative test results. Recent HIV-1 infection detection among mobile VCT participants is a valuable measure for tracking the spread of the epidemic among persons who might otherwise not have access to HIV testing due to practical and logistical barriers. Mobile VCT presents opportunities to expand HIV testing services and evaluate at-risk populations within community settings. Given the challenges of longitudinal cohort studies, recent infection may be a practical endpoint for community-based prevention intervention trials employing mobile testing.
doi:10.1089/aid.2010.0249
PMCID: PMC3101086  PMID: 21087196
17.  Understanding patient acceptance and refusal of HIV testing in the emergency department 
BMC Public Health  2012;12:3.
Background
Despite high rates of patient satisfaction with emergency department (ED) HIV testing, acceptance varies widely. It is thought that patients who decline may be at higher risk for HIV infection, thus we sought to better understand patient acceptance and refusal of ED HIV testing.
Methods
In-depth interviews with fifty ED patients (28 accepters and 22 decliners of HIV testing) in three ED HIV testing programs that serve vulnerable urban populations in northern California.
Results
Many factors influenced the decision to accept ED HIV testing, including curiosity, reassurance of negative status, convenience, and opportunity. Similarly, a number of factors influenced the decision to decline HIV testing, including having been tested recently, the perception of being at low risk for HIV infection due to monogamy, abstinence or condom use, and wanting to focus on the medical reason for the ED visit. Both accepters and decliners viewed ED HIV testing favorably and nearly all participants felt comfortable with the testing experience, including the absence of counseling. While many participants who declined an ED HIV test had logical reasons, some participants also made clear that they would prefer not to know their HIV status rather than face psychosocial consequences such as loss of trust in a relationship or disclosure of status in hospital or public health records.
Conclusions
Testing for HIV in the ED as for any other health problem reduces barriers to testing for some but not all patients. Patients who decline ED HIV testing may have rational reasons, but there are some patients who avoid HIV testing because of psychosocial ramifications. While ED HIV testing is generally acceptable, more targeted approaches to testing are necessary for this subgroup.
doi:10.1186/1471-2458-12-3
PMCID: PMC3267671  PMID: 22214543
Emergency department; HIV testing; HIV test refusal; HIV test acceptance
18.  A comparative evaluation of the process of developing and implementing an emergency department HIV testing program 
Background
The 2006 Centers for Disease Control and Prevention (CDC) HIV testing guidelines recommend screening for HIV infection in all healthcare settings, including the emergency department (ED). In urban areas with a high background prevalence of HIV, the ED has become an increasingly important site for identifying HIV infection. However, this public health policy has been operationalized using different models. We sought to describe the development and implementation of HIV testing programs in three EDs, assess factors shaping the adoption and evolution of specific program elements, and identify barriers and facilitators to testing.
Methods
We performed a qualitative evaluation using in-depth interviews with fifteen 'key informants' involved in the development and implementation of HIV testing in three urban EDs serving sizable racial/ethnic minority and socioeconomically disadvantaged populations. Testing program HIV prevalence ranged from 0.4% to 3.0%.
Results
Three testing models were identified, reflecting differences in the use of existing ED staff to offer and perform the test and disclose results. Factors influencing the adoption of a particular model included: whether program developers were ED providers, HIV providers, or both; whether programs took a targeted or non-targeted approach to patient selection; and the extent to which linkage to care was viewed as the responsibility of the ED. A common barrier was discomfort among ED providers about disclosing a positive HIV test result. Common facilitators were a commitment to underserved populations, the perception that testing was an opportunity to re-engage previously HIV-infected patients in care, and the support and resources offered by the medical setting for HIV-infected patients.
Conclusions
ED HIV testing is occurring under a range of models that emerge from local realities and are tailored to institutional strengths to optimize implementation and overcome provider barriers.
doi:10.1186/1748-5908-6-30
PMCID: PMC3073926  PMID: 21450053
19.  Relationships over Time between Mental Health Symptoms and Transmission Risk Among Persons Living with HIV 
Relationships between mental health symptoms (anxiety and depression) or a positive state of mind and behavior associated with HIV transmission (substance use and risky sexual behavior) were explored in a longitudinal study on persons living with HIV (PLH; n = 936) who were participants in a transmission-prevention trial. Bivariate longitudinal regressions were used to estimate the correlations between mental health symptoms and HIV-related transmission acts for three time frames: at the baseline interview; over 25 months; and from assessment to assessment. At baseline, mental health symptoms were associated with transmission acts. Elevated levels of mental health symptoms at baseline were associated with decreasing alcohol or marijuana use over 25 months. Over 25 months, an increasingly positive state of mind was associated with decreasing alcohol or marijuana use; an increasingly positive state of mind in the immediate condition and increasing depressive symptoms in the lagged condition were related to increasing risky sexual behavior. Our findings suggest that mental health symptoms precede a decrease in substance use and challenge self-medication theories. Changes in mental health symptoms and sexual behavior occur more in tandem.
doi:10.1037/a0018190
PMCID: PMC2845324  PMID: 20307117
HIV; Mental Health; Depression; Anxiety; Substance Abuse; Sexual behavior
20.  Psychiatric Context of Acute/Early HIV Infection. The NIMH Multisite Acute HIV Infection Study: IV 
AIDS and behavior  2009;13(6):1061-1067.
Acute/early HIV infection is a period of high risk for HIV transmission. Better understanding of behavioral aspects during this period could improve interventions to limit further transmission. Thirty-four participants with acute/early HIV infection from six U.S. cities were assessed with the Mini International Diagnostic Interview, Beck Depression Inventory II, State-Trait Anxiety Inventory, Brief COPE, and an in-depth interview. Most had a pre-HIV history of alcohol or substance use disorder (85%); a majority (53%) had a history of major depressive or bipolar disorder. However, post-diagnosis coping was predominantly adaptive, with only mild to moderate elevations of anxious or depressive mood. Respondents described challenges managing HIV in tandem with pre-existing substance abuse problems, depression, and anxiety. Integration into medical and community services was associated with adaptive coping. The psychiatric context of acute/early HIV infection may be a precursor to infection, but not necessarily a barrier to intervention to reduce forward transmission of HIV among persons newly infected.
doi:10.1007/s10461-009-9585-3
PMCID: PMC2785895  PMID: 19517225
Acute HIV infection; psychiatric disorder; substance use disorder; coping
21.  Behavior Change Following Diagnosis with Acute/Early HIV Infection—A Move to Serosorting with Other HIV-Infected Individuals. The NIMH Multisite Acute HIV Infection Study: III 
AIDS and behavior  2009;13(6):1054-1060.
Risk reductions behaviors are especially important during acute/early HIV infection, a period of high transmission risk. We examined how sexual behaviors changed following diagnosis of acute/early HIV infection. Twenty-eight individuals completed structured surveys and in-depth interviews shortly after learning of their infection and two months later. Quantitative analyses revealed significant changes after diagnosis, including reductions in total partners and decreases in the proportion of unprotected sex acts occurring with uninfected partners (serosorting). Qualitative findings indicated that these changes were motivated by concerns about infecting others. However, participants were less successful at increasing the frequency with which they used condoms. These results suggest that the initial diagnosis with HIV may constitute an important component of interventions to promote risk reduction during the acute/early stages of the disease.
doi:10.1007/s10461-009-9582-6
PMCID: PMC2785897  PMID: 19504178
acute HIV; serosorting; behavior change; HIV prevention
22.  Strategies Used in the Detection of Acute/Early HIV Infections. The NIMH Multisite Acute HIV Infection Study: I 
AIDS and behavior  2009;13(6):1037-1045.
Acute/early HIV infection plays a critical role in onward HIV transmission. Detection of HIV infections during this period provides an important early opportunity to offer interventions which may prevent further transmission. In six U.S. cities, persons with acute/early HIV infection were identified using either HIV RNA testing of pooled sera from persons screened HIV antibody negative or through clinical referral of persons with acute or early infections. Fifty-one cases were identified and 34 (68%) were enrolled into the study; 28 (82%) were acute infections and 6 (18%) were early infections. Of those enrolled, 13 (38 %) were identified through HIV pooled testing of 7,633 HIV antibody negative sera and 21 (62%) through referral. Both strategies identified cases that would have been missed under current HIV testing and counseling protocols. Efforts to identify newly infected persons should target specific populations and geographic areas based on knowledge of the local epidemiology of incident infections.
doi:10.1007/s10461-009-9580-8
PMCID: PMC2785898  PMID: 19495954
Acute HIV infection; nucleic acid amplification tests; HIV RNA testing; early detection of acute HIV infection
23.  Lack of Understanding of Acute HIV Infection among Newly-Infected Persons – Implications for Prevention and Public Health. The NIMH Multisite Acute HIV Infection Study: II 
AIDS and behavior  2009;13(6):1046-1053.
Acute/early HIV infection is a period of high HIV transmission. Consequently, early detection of HIV infection and targeted HIV prevention could prevent a significant proportion of new transmissions. As part of an NIMH-funded multisite study, we used in-depth interviews to explore understandings of acute HIV infection (AHI) among 34 individuals diagnosed with acute/early HIV infection in six U.S. cities. We found a marked lack of awareness of AHI-related acute retroviral symptoms and a lack of clarity about AHI testing methods. Most participants knew little about the meaning and/or consequences of AHI, particularly that it is a period of elevated infectiousness. Over time and after the acute stage of infection, many participants acquired understanding of AHI from varied sources, including the Internet, HIV-infected friends, and health clinic employees. There is a need to promote targeted education about AHI to reduce the rapid spread of HIV associated with acute/early infection within communities at risk for HIV.
doi:10.1007/s10461-009-9581-7
PMCID: PMC2787764  PMID: 19533323
HIV/AIDS; Awareness; Acute HIV; HIV prevention
24.  Lessons Learned about Behavioral Science and Acute/Early HIV Infection. The NIMH Multisite Acute HIV Infection Study: V 
AIDS and behavior  2009;13(6):1068-1074.
Acute/early HIV infection is a period of heightened HIV transmission and a window of opportunity for intervention to prevent onward disease transmission. The NIMH Multisite Acute HIV Infection (AHI) Study was an exploratory initiative aimed at determining the feasibility of recruiting persons with AHI into research, assessing their psychosocial and behavioral characteristics, and examining short-term changes in these characteristics. This paper reports on lessons learned in the study, including: (1) the need to establish the cost-effectiveness of AHI testing; (2) challenges to identifying persons with AHI; (3) the need to increase awareness of acute-phase HIV transmission risks; (4) determining the goals of behavioral interventions following AHI diagnosis; and (5) the need for “rapid response” public health systems that can move quickly enough to intervene while persons are still in the AHI stage. There are untapped opportunities for behavioral and medical science collaborations in these areas that could reduce the incidence of HIV infection.
doi:10.1007/s10461-009-9579-1
PMCID: PMC2787956  PMID: 19504179
Acute HIV infection; HIV prevention; Public health

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