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1.  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
2.  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
3.  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
5.  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
6.  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
7.  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
8.  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
9.  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
10.  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
11.  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
12.  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
13.  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
15.  Interventions Delivered in Clinical Settings are Effective in Reducing Risk of HIV Transmission Among People Living with HIV: Results from the Health Resources and Services Administration (HRSA)’s Special Projects of National Significance Initiative 
AIDS and Behavior  2010;14(3):483-492.
To support expanded prevention services for people living with HIV, the US Health Resources and Services Administration (HRSA) sponsored a 5-year initiative to test whether interventions delivered in clinical settings were effective in reducing HIV transmission risk among HIV-infected patients. Across 13 demonstration sites, patients were randomized to one of four conditions. All interventions were associated with reduced unprotected vaginal and/or anal intercourse with persons of HIV-uninfected or unknown status among the 3,556 participating patients. Compared to the standard of care, patients assigned to receive interventions from medical care providers reported a significant decrease in risk after 12 months of participation. Patients receiving prevention services from health educators, social workers or paraprofessional HIV-infected peers reported significant reduction in risk at 6 months, but not at 12 months. While clinics have a choice of effective models for implementing prevention programs for their HIV-infected patients, medical provider-delivered methods are comparatively robust.
doi:10.1007/s10461-010-9679-y
PMCID: PMC2865642  PMID: 20229132
HIV Prevention with positives; Clinic-based HIV prevention; HIV risk reduction; Interventions; Study outcomes
16.  Disparities in Reported Reasons for Not Initiating or Stopping Antiretroviral Treatment Among a Diverse Sample of Persons Living with HIV 
BACKGROUND
Disparities in the use of antiretroviral therapy (ART) for HIV disease have been documented across race, gender, and substance use groups.
OBJECTIVE
The current analysis compares self-reported reasons for never taking or stopping ART among a diverse sample of men and women living with HIV.
DESIGN
Cross-sectional interview.
PARTICIPANTS
HIV + (N = 3,818) adults, 968 of whom reported discontinuing or never using ART.
MEASUREMANTS
Computerized self-administered and interviewer-administered self-reported demographic and treatment variables, including gender, race, ethnicity, CD4 count, detectable viral load, and reported reasons for not taking antiretroviral therapy.
RESULTS
Despite equivalent use of ART in the current sample, African-American respondents were 1.7 times more likely to report wanting to hide their HIV status and 1.7 times more likely to report a change in doctors/clinics as reasons for stopping ART (p = .049, and p = .042) and had odds 4.5 times those of non-African Americans of reporting waiting for viral marker counts to worsen (p = < .0001). There was a lower tendency (OR = 0.4) for women to endorse concerns of keeping their HIV status hidden as a reason for stopping ART compared to men (p = .003). Although those with an IDU history were less likely to be on ART, no differences in reasons for stopping or never initiating ART were found between those with and without an IDU history.
CONCLUSIONS
A desire to conceal HIV status as well as a change in doctors/clinics as reasons for discontinuing ART were considerably more common among African Americans, suggesting that perceived HIV/AIDS stigma is an obstacle to maintenance of treatment. Findings also indicate differences in reasons for stopping ART by gender and a perceived desire to wait for counts to worsen as a reason for not taking ART by African Americans, regardless of detectable viral load, CD4 count, age, education, employment, sexual orientation, and site.
doi:10.1007/s11606-008-0854-z
PMCID: PMC2628985  PMID: 19015925
HIV/AIDS; treatment disparities; gender; race; ethnicity; substance use
17.  Internalized Heterosexism among HIV-Positive Gay-Identified Men: Implications for HIV Prevention and Care 
Internalized heterosexism (IH), or the internalization of societal anti-homosexual attitudes, has been consistently linked to depression and low self-esteem among gay men, and inconclusively associated with substance use and sexual risk in gay and bisexual men. Using structural equation modeling, a model framed in Social Action Theory was tested in which IH is associated with HIV transmission risk and poor adherence to HIV antiretroviral therapy (ART) through the mechanisms of negative affect and stimulant use. Data from a sample of 465 gay-identified men interviewed as part of an HIV risk reduction behavioral trial were used to test the fit of the model. Results supported the hypothesized model in which IH was associated with unprotected receptive (but not insertive) anal intercourse with HIV-negative or unknown HIV status partners, and with ART non-adherence indirectly via increased negative affect and more regular stimulant use. The model accounted for 15% of the variance in unprotected receptive anal intercourse (URAI) and 17% of the variance in ART non-adherence. Findings support the potential utility of addressing IH in HIV prevention and treatment with HIV-positive gay men.
doi:10.1037/0022-006X.76.5.829
PMCID: PMC2801151  PMID: 18837600
HIV/AIDS; internalized heterosexism; homophobia; adherence; depression; methamphetamine; HIV transmission risk
18.  Project Accept (HPTN 043): A Community-Based Intervention to Reduce HIV Incidence in Populations at Risk for HIV in Sub-Saharan Africa and Thailand 
Background
Changing community norms to increase awareness of HIV status and reduce HIV-related stigma has the potential to reduce the incidence of HIV-1 infection in the developing world.
Methods
We developed and implemented a multi-level intervention providing community-based HIV mobile voluntary counseling and testing (CBVCT), community mobilization (CM), and post-test support services (PTSS). Forty-eight communities in Tanzania, Zimbabwe, South Africa and Thailand were randomized to receive the intervention or standard clinic-based VCT (SVCT), the comparison condition. We monitored utilization of CBVCT and SVCT by community of residence at 3 sites, which was used to assess differential uptake. We also developed Quality Assurance procedures to evaluate staff fidelity to the intervention.
Findings
In the first year of the study a four-fold increase in testing was observed in the intervention versus comparison communities. We also found an overall 95% adherence to intervention components. Study outcomes, including prevalence of recent HIV infection and community-level HIV stigma, will be assessed after three years of intervention.
Conclusion
The provision of mobile services, combined with appropriate support activities, may have significant effects on utilization of VCT. These findings also provide early support for community mobilization as a strategy for increasing testing rates.
doi:10.1097/QAI.0b013e31818a6cb5
PMCID: PMC2664736  PMID: 18931624
HIV prevention; HIV voluntary counseling and testing; community mobilization; post-test support services; HIV-related stigma
20.  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
21.  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 US 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
22.  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 2 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
23.  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
24.  Predictors of Attrition among High Risk HIV-Infected Participants Enrolled in a Multi-Site Prevention Trial 
AIDS and behavior  2008;12(6):974-977.
Objective
Recruiting and retaining high-risk individuals is critical for HIV prevention trials.
Design
The current analyses addressed predictors of trial dropout among high-risk HIV-infected men and women.
Results
Trial dropouts (n=74) were more likely to be younger, depressed, and not taking antiretroviral therapy than those who continued (n=815). No other background, substance use, or transmission risk differences were found, suggesting no dropout bias on key risk outcomes.
Conclusions
Efforts are warranted for early detection and treatment of depression and for improving retention of younger participants.
doi:10.1007/s10461-007-9356-y
PMCID: PMC2574761  PMID: 18202908
Clinical Trials; Prevention; Retention; Depression
25.  Effects of a behavioral intervention on antiretroviral medication adherence among people living with HIV: The Healthy Living Project randomized controlled study 
Objective
To examine the effect of a 15-session, individually delivered cognitive behavioral intervention on antiretroviral (ART) medication adherence.
Design
A multisite, two-group, randomized controlled trial.
Participants
204 HIV-infected participants with self-reported ART adherence < 85% out of 3,818 screened were randomized into the trial. Potential participants were recruited for the main trial based on sexual risk criteria in Los Angeles, Milwaukee, New York, and San Francisco.
Intervention
The primary outcome of the intervention was a reduction in HIV transmission risk behaviors. Fifteen 90-minute individually delivered sessions divided into three modules: Stress, Coping, and Adjustment; Safer Behaviors; and Health Behaviors, including an emphasis on ART adherence. Controls received no intervention until trial completion. Both groups completed follow-up assessments at 5, 10, 15, 20, and 25 months after randomization.
Main Outcome Measure
Self-reported ART adherence as measured by 3 day computerized assessment.
Results
A significance difference in rates of reported adherence was observed between intervention and control participants at months 5 and 15, corresponding to the assessments following Stress, Coping and Adjustment module (5 month time point) and after the Health Behaviors module (15 month time point). The relative improvements among the intervention group compared to the control group dissipated at follow up.
Conclusions
Cognitive behavioral intervention programs may effectively improve ART adherence, but the effects of intervention may be short-lived.
PMCID: PMC2442469  PMID: 18193499
Antiretroviral therapy; adherence; compliance; RCT

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