There is a need for feasible, evidence-based interventions that support HIV risk reduction among heterosexual Black men. In this article, we describe the process for development of the Barbershop Talk With Brothers (BTWB) program and evaluation. The BTWB program is a theoretically grounded and community-based HIV prevention program that seeks to improve individual skills and motivation to decrease sexual risk, and that builds men’s interest in and capacity for improving their community’s health. Formative data collection included barbershop observations and barber focus groups, brief behavioral risk assessments of men in barbershops, and focus groups and individual interviews. Based on this information and in consultation with our steering committee, we developed the BTWB program and accompanying program evaluation. From April through November 2011, 80 men were recruited and completed a baseline assessment of a pilot test of the program; 78 men completed the program and 71 completed a 3-month assessment. The pilot evaluation procedures were feasible to implement, and assessments of pre- and post-test measures indicate that key behavioral outcomes and proposed mediators of those outcomes changed in hypothesized directions. Specifically, attitudes and self-efficacy toward consistent condom use improved, and respondents reported lower levels of sexual risk behavior from baseline to follow-up (all p < 0.05). Perceptions of community empowerment also increased (p = 0.06). While HIV stigma decreased, this difference did not reach statistical significance. Our approach to community-engaged program development resulted in an acceptable, feasible approach to reaching and educating heterosexual Black men about HIV prevention in community settings.
To compare sexual problems among HIV-positive and HIV-negative women, and describe clinical and psychosocial factors associated with these problems.
Data were collected during a study visit of the Women’s Interagency HIV Study (WIHS). The WIHS studies the natural and treated history of HIV among women in the United States.
Between 10/01/2006 and 3/30/2007, 1,805 women (1,279 HIV-positive and 526 HIV-negative) completed a study visit that included administration of the Female Sexual Function Index (FSFI). In addition, the visit included completion of standardized, interviewer-administered surveys, physical and gynecological examinations, and blood sample collection.
Women with HIV reported greater sexual problems than did those without HIV. Women also reported lower sexual function if they were classified as menopausal, had symptoms indicative of depression, or if they reported not being in a relationship. CD4+ cell count was associated with FSFI scores, such that those with CD4 ≤199 cells/µL reported lower functioning as compared to those whose cell count was 200 or higher.
Given research documenting relationships between self-reported sexual problems and both clinical diagnoses of sexual dysfunction and women’s quality of life, greater attention to this issue as a potential component of women’s overall HIV care is warranted.
HIV; Women; Sexual Behavior; Sexual Problems
To assess the relationships between HIV transmission risk behaviours, HIV serostatus and knowledge of HIV serostatus among active injection drug users (IDUs) residing in Tallinn, Estonia, we conducted HIV testing and administered a standardized interview to 266 participants reporting recent injection drug use. In total, 45% were HIV positive, and of those, 39% knew their HIV serostatus. Those who knew their HIV-positive serostatus were less likely to report giving someone else their needle after they used it (9%) than were HIV-negative participants (23%) and those who were HIV positive but unaware of their HIV-positive serostatus (25%). There were no statistically significant differences in unprotected sex or other drug use behaviours between the groups. Most participants reported that HIV can be transmitted through sharing needles (98%) and unprotected sexual activity (93%). Prevention needs of IDUs in this area include increasing the rates of HIV testing and implementing effective programmes to reduce sexual and drug use risk behaviours.
HIV; substance abuse; intravenous; sexual behaviour; Baltic states
Sexual minority women with and at-risk for human immunodeficiency virus (HIV) may face increased risks of violence.
To understand the relationship between sexual minority status and violence; and how high-risk sex and substance use mediate that relationship among women with and at-risk for HIV.
DESIGN & PARTICIPANTS
Longitudinal study of 1,235 HIV infected and 508 uninfected women of the Women's Interagency HIV Study (WIHS) cohort, from New York City, NY, Chicago, IL, Washington D.C., and San Francisco, CA, 1994–2012.
Primary exposures are sexual identity (heterosexual, bisexual, lesbian/gay) and sexual behavior (male, female, or male & female partners). Primary outcomes are sexual abuse, intimate partner violence (IPV) and physical violence; high-risk sex and substance use were examined as mediators.
Bisexual women were at increased odds for sexual abuse [aOR 1.56 (1.00, 2.44)], IPV [aOR 1.50 (1.08, 2.09)], and physical violence [aOR 1.77 (1.33, 2.37)] compared to heterosexual women. In a separate analysis, women who reported sex with men and women (WSMW) had increased odds for sexual abuse [aOR 1.65 (0.99, 2.77], IPV [aOR 1.50 (1.09, 2.06)] and physical violence [aOR 2.24 (1.69, 2.98)] compared to women having sex only with men (WSM). Using indirect effects, multiple sex partners, cocaine and marijuana were significant mediators for most forms of abuse. Transactional sex was only a mediator for bisexual women. Women who reported sex only with women (WSW) had lower odds of sexual abuse [aOR 0.23 (0.06, 0.89)] and physical violence [aOR 0.42 (0.21, 0.85)] compared to WSM.
Women who identify as bisexual or report both male and female sex partners are most vulnerable to violence; multiple recent sex partners, transactional sex and some types of substance use mediate this relationship. Acknowledging sexual identity and behavior, while addressing substance use and high-risk sex in clinical and psychosocial settings, may help reduce violence exposure among women with and at-risk for HIV.
gay and lesbian health; IPV; sexual assault; HIV/AIDS; women’s health
Minority populations in the United States are disproportionally affected by Human Papillomavirus (HPV) infection and HPV-related cancer. We sought to understand physician practices, knowledge and beliefs that affect utilization of the HPV vaccine in primary care settings serving large minority populations in areas with increased rates of HPV-related cancer.
Cross-sectional survey of randomly selected primary care providers, including pediatricians, family practice physicians and internists, serving large minority populations in Brooklyn, N.Y. and in areas with higher than average cervical cancer rates.
Of 156 physicians randomly selected, 121 eligible providers responded to the survey; 64% were pediatricians, 19% were internists and 17% were family practitioners. Thirty-four percent of respondents reported that they routinely offered HPV vaccine to their eligible patients. Seventy percent of physicians reported that the lack of preventive care visits for patients in the eligible age group limited their ability to recommend the HPV vaccine and 70% of those who reported this barrier do not routinely recommend HPV vaccine. The lack of time to educate parents about the HPV vaccine and cost of the vaccine to their patients were two commonly reported barriers that affected whether providers offered the vaccine.
Our study found that the majority of providers serving the highest risk populations for HPV infection and HPV-related cancers are not routinely recommending the HPV vaccine to their patients. Reasons for providers' failure to recommend the HPV vaccine routinely are identified and possible areas for targeted interventions to increase HPV vaccination rates are discussed.
Human Papillomavirus Vaccine; HPV vaccine barriers; HPV vaccine and primary care providers
The use of single-tablet ART regimens and its implications on adherence among HIV-infected women have not been well-described.
Participants were enrolled in the Women’s Interagency HIV Study (WIHS), a longitudinal study of HIV infection in U.S. women. We examined semiannual trends in single-tablet regimen use and ART adherence, defined as self-reported 95% adherence in the past 6 months, during 2006–2013. In a nested cohort study, we assessed the comparative effectiveness of a single-tablet versus a multiple-tablet regimen with respect to adherence, virologic suppression, quality of life, and AIDS-defining events, using propensity score matching to account for demographic, behavioral, and clinical confounders. We also examined these outcomes in a subset of women switching from a multiple- to single-tablet regimen, using a case-crossover design.
15,523 person-visits, representing 1,727 women (53% black, 29% Hispanic, 25% IDU, median age 47), were included. Use of single-tablet regimens among ART users increased from 7% in 2006 to 27% in 2013; adherence increased from 78% to 85% during the same period (both p<0.001). Single-tablet regimen use was significantly associated with increased adherence (adjusted RR 1.05, 95% CI 1.03–1.08) and virologic suppression (RR 1.06, 95% CI 1.01–1.11), while associations with improved quality of life and fewer AIDS-defining events did not achieve statistical significance. Similar findings were observed among the subset of switchers.
Single-tablet regimen use was associated with increased adherence and virologic suppression. Despite this, 15% of women prescribed ART were still not optimally adherent; additional interventions are needed to maximize therapeutic benefits.
adherence; antiretroviral therapy; HIV; time factors; United States; viral load; women
To describe changes in knowledge of cervical cancer prevention, human papillomavirus (HPV), and HPV vaccination among women at high risk for cervical cancer in the first five years after introduction of HPV vaccination.
In 2007, 2008–9, and 2011, women in a multicenter U.S. cohort study completed 44-item self-report questionnaires assessing knowledge of cervical cancer prevention, HPV, and HPV vaccination. Results across time were assessed for individuals, and three study enrollment cohorts were compared. Knowledge scores were correlated with demographic variables, measures of education and attention, and medical factors. Associations were assessed in multivariable models.
In all, 974 women completed three serial questionnaires; most were minority, low income, and current or former smokers. The group included 652 (67%) HIV infected and 322 (33%) uninfected. Summary knowledge scores (possible range 0–24) increased from 2007 (12.8, S.D. 5.8) to 2008–9 (13.9, S.D. 5.3, P < 0.001) and to 2011 (14.3, S.D. 5.2, P < 0.0001 vs 2007 and < 0.04 vs 2008–9). Higher knowledge scores at first and follow-up administration of questionnaires, higher income, and higher education level were associated with improved knowledge score at third administration. Women not previously surveyed had scores similar to those of the longitudinal group at baseline.
Substantial gaps in understanding of HPV and cervical cancer prevention exist despite years of health education. While more effective educational interventions may help, optimal cancer prevention may require opt-out vaccination programs that do not require nuanced understanding.
•Women at high risk for cervical cancer have substantial knowledge gaps about prevention.•Knowledge gaps improved after an intervention, but little additional improvement followed.•Poor and less educated women have lower knowledge scores despite higher cancer risk.
Human papillomavirus; Cervical cancer prevention; Pap test; Health education; Human immunodeficiency virus in women
To describe HIV risk factors among adult heterosexual Black men recruited from four barbershops located in high HIV seroprevalent neighborhoods of Brooklyn, NY. Data on HIV-risk related behaviors and other characteristics were collected from barbershop clients. All participants (n=60) completed brief risk assessments; and a subset (n=22) also completed focus groups and/or individual interviews. Of the subset of 22 men, 68% were US born, 59% had been in jail/prison, 32% were unemployed; and during the 3 months before the interviews, 68% reported at least two partners and 45% reported unprotected vaginal or anal sex with two or more women. Emergent themes included: 1) the psychological function of multiple partnerships; 2) calculated risk taking regarding condom use; 3) the role of emotional attachment and partner trust in condom use; 4) low perceived HIV risk and community awareness; and 5) lack of relationship between HIV testing and safer sex practices. Interventions among heterosexual Black men should focus not only on increasing HIV awareness and reducing sexual risk, but also on contextual and interpersonal factors that influence sexual risk.
HIV risk behaviors; Non-Hispanic Black men; Non-injection drug users; Heterosexual men; Brooklyn, NY
Stark racial/ethnic disparities in health outcomes exist among those living with HIV in the United States. One of three primary goals of the National HIV/AIDS Strategy is to reduce HIV-related disparities and health inequities.
Using data from HIV-infected women participating in the Women’s Interagency HIV Study from April 2006 to March 2011, we measured virologic failure (HIV RNA >200 copies/mL) following suppression (HIV RNA <80 copies/mL) on HAART. We identified predictors of virologic failure using discrete-time survival analysis and calculated racial/ethnic-specific population attributable fractions (PAFs).
Of 887 eligible women, 408 (46%) experienced virologic failure during the study period. Hispanic and White women had significantly lower hazards of virologic failure than African-American women (Hispanic hazard ratio, HR=0.8, 95% confidence interval [0.6, 0.9]; White HR=0.7 [0.5, 0.9]). The population attributable fraction of virologic failure associated with low income was higher in Hispanic (aHR=2.2 [0.7, 6.5], PAF=49%) and African-American women (aHR=1.8 [1.1, 3.2], PAF=38%) than among White women (aHR=1.4 [0.6, 3.4], PAF=16%). Lack of health insurance compared to public health insurance was associated with virologic failure only among Hispanic (aHR=2.0 [0.9, 4.6], PAF=22%) and White women (aHR=1.9 [0.7, 5.1], PAF=13%). By contrast, depressive symptoms were associated with virologic failure only among African-American women (aHR=1.6 [1.2, 2.2], PAF=17%).
In this population of treated HIV-infected women, virologic failure was common, and correlates of virologic failure varied by race/ethnicity. Strategies to reduce disparities in HIV treatment outcomes by race/ethnicity should address racial/ethnic-specific barriers including depression and low income to sustain virologic suppression.
disparities; race/ethnicity; virologic failure; HAART; HIV; women
The recommendation for the frequency for routine clinical monitoring of persons with well-controlled HIV infection is based on evidence that relies on observed rather than intended follow-up intervals. We sought to determine if the scheduled follow-up interval is associated with subsequent virologic failure. Participants in this 6-clinic retrospective cohort study had an index clinic visit in 2008 and HIV viral load (VL) ≤400 c/mL. Univariate and multivariate tests evaluated if scheduling the next follow-up appointment at 3, 4, or 6 months predicted VL >400 c/mL at 12 months (VF). Among 2171 participants, 66%, 26%, and 8% were scheduled next follow-up visits at 3, 4, and 6 months, respectively. With missing 12-month VL considered VF, 25%, 25%, and 24% of persons scheduled at 3, 4, and 6 months had VF, respectively (p=0.95). Excluding persons with missing 12-month VL, 7.1%, 5.7%, and 4.5% had VF, respectively (p=0.35). Multivariable models yielded nonsignificant odds of VF by scheduled follow-up interval both when missing 12-month VL were considered VF and when persons with missing 12-month VL were excluded. We conclude that clinicians are able to make safe decisions extending follow-up intervals in persons with viral suppression, at least in the short-term.
HIV-infected women with excessive alcohol consumption are at risk for adverse health outcomes, but little is known about their long-term drinking trajectories. This analysis included longitudinal data, obtained from 1996–2006, from 2791 women with HIV from the Women’s Interagency HIV Study. Among these women, the proportion in each of five distinct drinking trajectories was: continued heavy drinking (3%), reduction from heavy to non-heavy drinking (4%), increase from non-heavy to heavy drinking (8%), continued non-heavy drinking (36%), and continued non-drinking (49%). Depressive symptoms, other substance use (crack/cocaine, marijuana, and tobacco), co-infection with HCV, and heavy drinking prior to enrollment were associated with trajectories involving future heavy drinking. In conclusion, many women with HIV change their drinking patterns over time. Clinicians and those providing alcohol-related interventions might target those with depression, current use of tobacco or illicit drugs, HCV infection, or a previous history of drinking problems.
Alcohol consumption; women; HIV-infection; trajectories
We examined the interaction of illicit drug use and depressive symptoms, and how they affect the subsequent likelihood of highly active antiretroviral therapy (HAART) use among women with HIV/AIDS.
Subjects included 1,710 HIV-positive women recruited from six sites in the U.S. including Brooklyn, Bronx, Chicago, Los Angeles, San Francisco/Bay Area, and Washington, DC. Cases of probable depression were identified using depressive symptom scores on the Centers for Epidemiologic Studies Depression Scale. Crack, cocaine, heroin, and amphetamine use were self-reported at 6-month time intervals. We conducted multivariate logistic random regression analysis of data collected during sixteen waves of semiannual interviews conducted from April 1996 through March 2004.
We found an interaction effect between illicit drug use and depression that acted to suppress subsequent HAART use, controlling for virologic and immunologic indicators, socio-demographic variables, time, and study site.
This is the first study to document the interactive effects of drug use and depressive symptoms on reduced likelihood of HAART use in a national cohort of women. Since evidence-based behavioral health and antiretroviral therapies for each of these three conditions are now available, comprehensive HIV treatment is an achievable public health goal.
HIV; depression; HAART; drug use
The Met allele of the catechol-o-methyltransferase (COMT) Val158Met polymorphism is associated with increased cortical dopamine and risk behaviors including illicit drug use and unprotected sex. Therefore, we examined whether or not the distribution of the Val158Met genotype differed between HIV-infected and HIV-uninfected women. We conducted an Armitage-Cochran Test and logistic regression to compare genotype frequencies between 1,848 HIV-infected and 612 HIV-uninfected women from the Women’s Interagency HIV Study (WIHS). The likelihood of carrying one or two Met alleles was greater in HIV-infected women (61%) compared to HIV-uninfected women (54%), Z = −3.60, p < 0.001. We report the novel finding of an association between the Val158Met genotype and HIV serostatus that may be mediated through the impact of dopamine function on propensity for risk-taking.
Measuring retention in HIV primary care is complex as care includes multiple visits scheduled at varying intervals over time. We evaluated six commonly used retention measures in predicting viral load (VL) suppression and the correlation among measures.
Clinic-wide patient-level data from six academic HIV clinics were used for 12-months preceding implementation of the CDC/HRSA Retention in Care intervention. Six retention measures were calculated for each patient based upon scheduled primary HIV provider visits: count and dichotomous missed visits, visit adherence, 6-month gap, 4-month visit constancy, and the HRSA HAB retention measure. Spearman correlation coefficients and separate unadjusted logistic regression models compared retention measures to one another and with 12-month VL suppression, respectively. The discriminatory capacity of each measure was assessed with the c-statistic.
Among 10,053 patients, 8,235 (82%) had 12-month VL measures, with 6,304 (77%) achieving suppression (VL<400 c/mL). All six retention measures were significantly associated (P<0.0001) with VL suppression (OR;95%CI, c-statistic): missed visit count (0.73;0.71–0.75,0.67), missed visit dichotomous (3.2;2.8–3.6,0.62), visit adherence (3.9;3.5–4.3,0.69), gap (3.0;2.6–3.3,0.61), visit constancy (2.8;2.5–3.0,0.63), HRSA HAB (3.8;3.3–4.4,0.59). Measures incorporating “no show” visits were highly correlated (Spearman coefficient=0.83–0.85), as were measures based solely upon kept visits (Spearman coefficient=0.72–0.77). Correlation coefficients were lower across these two groups of measures (Range=0.16–0.57).
Six retention measures displayed a wide range of correlation with one another, yet each measure had significant association and modest discrimination for VL suppression. These data suggest there is no clear gold standard, and that selection of a retention measure may be tailored to context.
Retention in care; Adherence; Engagement in care; Viral load
Despite the major benefits of effective antiretroviral therapy (ART) on HIV-related survival, there is an ongoing need to help alleviate medication side effects related to ART use. Initial studies suggest marijuana use may reduce HIV-related symptoms, but medical marijuana use among HIV-infected individuals has not been well described.
We evaluated trends in marijuana use and reported motivations for use among 2,776 HIV-infected women in the Women’s Interagency HIV Study (WIHS) between October 1994 and March 2010. Predictors of any and daily marijuana use were explored in multivariate logistic regression models clustered by person using GEE. In 2009 participants were asked if their marijuana use was medical, “meaning prescribed by a doctor”, or recreational, or both.
Over the sixteen years of this study the prevalence of current marijuana use decreased significantly from 21% to 14%. In contrast, daily marijuana use almost doubled from 3.3% to 6.1% of all women, and from 18% to 51% of current marijuana users. Relaxation, appetite improvement, reduction of HIV-related symptoms, and social use were reported as common reasons for marijuana use. In 2009, most marijuana users reported either purely medicinal use (26%) or both medicinal and recreational usage (29%). Daily marijuana use was associated with higher CD4 cell count, quality of life, and older age. Demographic characteristics and risk behaviors were associated with current marijuana use overall, but were not predictors of daily use.
This study suggests that both recreational and medicinal marijuana use are relatively common among HIV-infected women in this U.S.
marijuana; cannabis; HIV; medicinal
Data from 6 human immunodeficiency virus clinics showed improvements in clinic attendance after versus before a clinic-wide intervention (7% on short-term measure; 3% on longer-term measure). Several subgroups showed larger improvements: younger patients, new or reengaging patients, and patients with elevated viral loads.
Background. Retention in care for human immunodeficiency virus (HIV)–infected patients is a National HIV/AIDS Strategy priority. We hypothesized that retention could be improved with coordinated messages to encourage patients' clinic attendance. We report here the results of the first phase of the Centers for Disease Control and Prevention/Health Resources and Services Administration Retention in Care project.
Methods. Six HIV-specialty clinics participated in a cross-sectionally sampled pretest-posttest evaluation of brochures, posters, and messages that conveyed the importance of regular clinic attendance. 10 018 patients in 2008–2009 (preintervention period) and 11 039 patients in 2009–2010 (intervention period) were followed up for clinic attendance. Outcome variables were the percentage of patients who kept 2 consecutive primary care visits and the mean proportion of all primary care visits kept. Stratification variables were: new, reengaging, and active patients, HIV RNA viral load, CD4 cell count, age, sex, race or ethnicity, risk group, number of scheduled visits, and clinic site. Data were analyzed by multivariable log-binomial and linear models using generalized estimation equation methods.
Results. Clinic attendance for primary care was significantly higher in the intervention versus preintervention year. Overall relative improvement was 7.0% for keeping 2 consecutive visits and 3.0% for the mean proportion of all visits kept (P < .0001). Larger relative improvement for both outcomes was observed for new or reengaging patients, young patients and patients with elevated viral loads. Improved attendance among the new or reengaging patients was consistent across the 6 clinics, and less consistent across clinics for active patients.
Conclusion. Targeted messages on staying in care, which were delivered at minimal effort and cost, improved clinic attendance, especially for new or reengaging patients, young patients, and those with elevated viral loads.
To estimate trends in contraceptive use, especially long-acting reversible contraceptives (LARC) and condoms, among human immunodeficiency virus (HIV)-seropositive and HIV-seronegative women.
HIV-seropositive and HIV-seronegative women in a multicenter longitudinal cohort were interviewed semiannually between 1998 and 2010 about sexual behaviors and contraceptive use. Trends in contraceptive use by women aged 18–45 years who were at risk for unintended pregnancy but not trying to conceive were analyzed using generalized estimating equations.
Condoms were the dominant form of contraception for HIV-seropositive women and showed little change across time. Fewer than 15% of these women used no contraception. Between 1998 and 2010, LARC use rose among HIV-seronegative women from 4.8% (6/126) to 13.5% (19/141, p=0.02), but not significantly among seropositive women (0.9% (4/438) to 2.8% (6/213, p = 0.09). Use of highly effective contraceptives, including pills, patches, rings, injectable progestin, implants and intrauterine devices, ranged from 15.2% (53/348) in 1998 to 17.4% (37/213) in 2010 (p = 0.55). HIV-seronegative but not seropositive LARC users were less likely than nonusers to use condoms consistently (HR=0.51, 95% C.I. 0.32–0.81, p = 0.004 for seronegative women; HR = 1.09, 95% C.I. 0.96, 1.23 for seropositive women).
Although most HIV-seropositive women use contraception, they rely primarily on condoms and have not experienced the increase in LARC use seen among seronegative women. Strategies to improve simultaneous use of condoms and LARC are needed to minimize risk of unintended pregnancy as well as HIV transmission and acquisition of sexually transmitted infections.
Few studies have examined the psychosocial factors associated with sexual transmission behaviors among HIV-positive men who have sex with men (MSM), heterosexual men (MSW) and women. We enrolled 1,050 sexually active HIV-positive patients at seven HIV clinics in six US cities as part of a clinic-based behavioral intervention. We describe the sexual transmission behaviors and examine demographic, clinical, psychosocial, and clinic prevention variables associated with unprotected anal or vaginal intercourse (UAVI). Twenty-three percent of MSM, 12.3% of MSW and 27.8% of women engaged in UAVI with partners perceived to be HIV-negative or of unknown serostatus. Among MSM and MSW, having multiple partners and lower self-efficacy were associated with increased odds of UAVI. Self-rating one’s health status as excellent/very good was a risk factor for UAVI among MSM. Among women, binge drinking and stressful life events were associated with UAVI. These findings identify variables that warrant attention in targeted interventions.
HIV; HIV prevention; Sexual behavior; STDs; STD prevention
To assess the impact of knowledge of cervical cancer biology and prevention as well as noncognitive measures on compliance with colposcopy referral in a high risk population.
Participants in a U.S. cohort of women with human immunodeficiency virus (HIV) and at risk comparison women completed behavior questionnaires and instruments measuring knowledge of cervical cancer prevention, depressive symptoms, trust in doctors, and perceived stress. Examinations including Pap tests also were conducted. Associations with compliance with resulting indicated colposcopy were assessed in multivariable models.
Of 326 women with indicated colposcopy, 222 (68%) were compliant with colposcopy referral and 104 (32%) noncompliant. In multivariable analysis, better colposcopy compliance was associated with less education (O.R. for compliance 2.24, 95% C.I. 1.12–4.51 vs more than high school), prior abnormal Pap (O.R. per prior abnormal Pap 1.08 95% C.I. 1.01–1.15), study site (O.R. for site with best vs worst compliance 16.1, 95% C.I. 2.91–88.6), and higher stress (O.R. for Perceived Stress Scale-10 score >16 vs lower 3.25, 95% C.I. 1.45–7.26).
Noncognitive factors and how sites manage abnormal Pap testing affect colposcopy compliance. Educational interventions alone are unlikely to improve colposcopy compliance in similar high-risk populations.
HPV; cervical cancer prevention; Pap test; health education; perceived stress; HIV in women
Depression is common in people with cardiovascular diseases (CVD) and those with HIV, and is a risk factor for CVD-related mortality. However, little is known about whether HIV influences the relationship between depression and cardiovascular risk. 526 HIV-infected and 132 uninfected women from the Women’s Interagency HIV Study were included in an analysis of women who completed twice-yearly study visits over 9.5 years. CVD risk was calculated at baseline and approximately 9.5 years later using the Framingham Risk Score (FRS). Chronic depressive symptoms were defined as Center for Epidemiologic Studies Depression Scale scores of 16 or greater at ≥75% of study visits. Over the follow-up period, 22.8% of HIV-infected women and 15.9% of HIV-uninfected women had chronic depressive symptoms (p=0.08). Baseline FRS were similar between HIV infected and uninfected women (M=−5.70±SE=0.30 vs. M=−6.90± SE=0.60, p=0.07) as was follow-up FRS (M=0.82±SE=0.30 vs. M=−0.44± SE=0.73, p=0.11). Among HIV-infected and uninfected women, together, follow-up FRS were higher among women with chronic depressive symptoms as compared to those without (M=1.3± SE=0.6 vs. M=−0.3± SE=0.40, p<0.01), after adjusting for baseline FRS and other covariates. HIV status did not modify the relationship between chronic depressive symptoms and FRS. Chronic depressive symptoms accelerated CVD risk scores to a similar extent in both HIV infected and uninfected women. This implies that the diagnosis and treatment of depression may be an important consideration in CV risk reduction in the setting of HIV-infection. The determination of factors that mediate the depression/CVD relationship merits further study.
To generate insights into how migration shapes sexual risk and protection, we interviewed 36 female and 20 male West Indian (WI) immigrants attending a public sexually transmitted disease (STD) clinic in Brooklyn, NY between 2004 and 2005. Migration theory suggests that shifts in sexual partnership patterns, bi-directional travel, and changes in sexual norms may alter risk. We found evidence of sexual mixing across ethnic groups: a large proportion of participants’ partners were not born in the WIs, despite what is expected among first generation immigrants. Recent travel “home,” another potential source of risk, was uncommon. In open-ended interviews, two themes around sexual and social networks emerged. First, immigrants believed that access to wider, more anonymous sexual networks in NYC and the weakening of social controls that limit multiple partnerships (especially for women) promoted greater risk. Second, immigrants experienced greater opportunities for protection in NYC, both through exposure to safer sex messages and availability of condoms. Reported changes in their own condom use, however, were not attributed to migration. WI immigrants’ risk in NYC may be driven by access to wider sexual networks but failure to alter reliance on “networks of knowledge” for protection.
Caribbean; West Indian; migration; sexual health; sexual networks; HIV/STD
Serosorting, the practice of selectively engaging in unprotected sex with partners of the same HIV serostatus, has been proposed as a strategy for reducing HIV transmission risk among men who have sex with men (MSM). However, there is a paucity of scientific evidence regarding whether women engage in serosorting. We analyzed longitudinal data on women’s sexual behavior with male partners collected in the Women’s Interagency HIV Study from 2001 to 2005. Serosorting was defined as an increasing trend of unprotected anal or vaginal sex (UAVI) within seroconcordant partnerships over time, more frequent UAVI within seroconcordant partnerships compared to non-concordant partnerships, or having UAVI only with seroconcordant partners. Repeated measures Poisson regression models were used to examine the associations between serostatus partnerships and UAVI among HIV-infected and HIV-uninfected women. The study sample consisted of 1,602 HIV-infected and 664 HIV-uninfected women. Over the follow-up period, the frequency of seroconcordant partnerships increased for HIV-uninfected women but the prevalence of UAVI within seroconcordant partnerships remained stable. UAVI was reported more frequently within HIV seroconcordant partnerships than among serodiscordant or unknown serostatus partnerships, regardless of the participant’s HIV status or types of partners. Among women with both HIV-infected and HIV-uninfected partners, 41% (63 HIV-infected and 9 HIV-uninfected) were having UAVI only with seroconcordant partners. Our analyses suggest that serosorting is occurring among both HIV-infected and HIV-uninfected women in this cohort.
HIV; Unprotected sex; Serosorting; Risk reduction; Condom use
To estimate changes in high risk women’s knowledge of cervical cancer prevention, human papillomavirus (HPV), and HPV vaccination since introduction and marketing of HPV vaccines.
At study visits in 2006 and 2008, women with the human immunodeficiency virus (HIV) and at-risk comparison women in a multicenter U.S. cohort study completed 44-item self-report questionnaires exploring their knowledge of cervical cancer prevention, HPV, and HPV vaccination. Results from 2006 were compared to those obtained in 2008. Knowledge scores were correlated with demographic variables, measures of education and attention, and medical factors. Significant associations were assessed in multivariable models.
HIV-seropositive women had higher knowledge scores than seronegative women at baseline (13.2 +/− 5.7 vs 11.8 +/− 6.0, P = 0.0002) and follow-up (14.1 +/− 5.3 vs 13.2 +/− 5.5, P = 0.01), but the change in scores was similar (0.9 +/− 5.3 vs 1.5 +/− 5.5, P = 0.13). Knowledge that cervical cancer is caused by a virus rose significantly (P = 0.005), but only to 24%. Belief that cervical cancer is preventable only rose from 52% to 55% (P = 0.04), but more than 90% of women in both periods believed regular Pap testing was important. In ANCOVA models, higher baseline score, younger age, higher education level, higher income, and former- as opposed to never-drug users, but not HIV status, were associated with improved knowledge.
High-risk women’s understanding of cervical cancer and HPV has improved, but gaps remain. Improvement has been weakest for less-educated and lower-income women.
Relationships between non-use of highly active anti-retroviral therapy (HAART), race/ethnicity, violence, drug use and other risk factors are investigated using qualitative profiles of five risk factors (unprotected sex, multiple male partners, heavy drinking, crack, cocaine or heroin use, and exposure to physical violence) and association of the profiles and race/ethnicity with non-use of HAART over time.
A Hidden Markov Model (HMM) was used to summarize risk factor profiles and changes in profiles over time in a longitudinal sample of HIV-infected women enrolled in the Women's Interagency HIV Study (WIHS) with follow-up from 2002 to 2005 (N=802).
Four risk factor profiles corresponding to four distinct latent states were identified from the five risk factors. Trajectory analysis indicated that states characterized by high probabilities of all risk factors or by low probabilities of all risk factors were both relatively stable over time. Being in the highest risk state did not significantly elevate the odds of HAART non-use (OR: 1.05; 95% CI: 0.6-1.8). However, being in a latent state characterized by elevated probabilities of heavy drinking and exposure to physical violence, along with slight elevations in three other risk factors, significantly increased odds of HAART non-use (OR: 1.4; 95% CI: 1.1-1.9).
The research suggests that HAART use might be improved by interventions aimed at women who are heavy drinkers with recent exposure to physical violence and evidence of other risk factors. More research about the relationship between clustering and patterns of risk factors and use of HAART is needed.
We examined racial/ethnic disparities in highly active antiretroviral therapy (HAART) use and whether differences are moderated by substance use or insurance status, using data from the Women’s Interagency HIV Study (WIHS).
Logistic regression examined HAART use in a longitudinal cohort of women for whom HAART was clinically indicated in 2005 (N=1354).
Approximately 3 of every 10 eligible women reported not taking HAART. African American and Hispanic women were less likely than were White women to use HAART. After we adjusted for potential confounders, the higher likelihood of not using HAART persisted for African American but not for Hispanic women. Uninsured and privately insured women, regardless of race/ethnicity, were less likely than were Medicaid enrollees to use HAART. Although alcohol use was related to HAART nonuse, illicit drug use was not.
These findings suggest that expanding and improving insurance coverage should increase access to antiretroviral therapy across racial/ethnic groups, but it is not likely to eliminate the disparity in use of HAART between African American and White women with HIV/AIDS.