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1.  What Primary Care Providers Need to Know about Pre-Exposure Prophylaxis (PrEP) for HIV Prevention: Narrative Review 
Annals of internal medicine  2012;157(7):490-497.
As HIV prevalence climbs globally, including more than 50,000 new infections per year in the United States, we need effective HIV prevention strategies. The use of antiretrovirals for pre-exposure prophylaxis (known as “PrEP”) among high-risk HIV-uninfected persons is emerging as one such strategy. Randomized controlled trials have demonstrated that once daily oral PrEP decreased HIV incidence among at-risk MSM and African heterosexuals, including HIV serodiscordant couples. An additional randomized control trial of a pericoital topical application of antiretroviral microbicide gel reduced HIV incidence among at-risk heterosexual South African women. Two other studies in African women did not demonstrate the efficacy of oral or topical PrEP, raising concerns about adherence patterns and efficacy in this population. The FDA Antiretroviral Advisory Panel reviewed these studies and additional data in May 2012 and recommended the approval of oral tenofovir-emtricitabine for PrEP in high-risk populations. Patients may seek PrEP from their primary care providers and those on PrEP require monitoring. Thus, primary care providers should become familiar with PrEP. This review outlines the current state of knowledge about PrEP as it pertains to primary care including identification of individuals likely to benefit from PrEP, counseling to maximize adherence and minimize potential increases in risky behavior, and monitoring for potential drug toxicities, HIV acquisition, and antiretroviral drug resistance. Issues related to cost and insurance coverage are also discussed. Recent data suggest that PrEP, in conjunction with other prevention strategies, holds promise in helping to curtail the HIV epidemic.
doi:10.7326/0003-4819-157-7-201210020-00510
PMCID: PMC3790586  PMID: 22821365
2.  HIV-infected Men Who Have Sex With Men Who Engage in Very High Levels of Transmission Risk Behaviours: Establishing a Context for Novel Prevention Interventions 
Psychology, health & medicine  2013;18(5):10.1080/13548506.2012.756537.
Men who have sex with men (MSM) comprise the largest risk group of individuals living with HIV in the United States and have the highest rates of new infections. A minority of HIV-infected MSM engage in unprotected anal intercourse after learning about their infection, potentially transmitting the virus to others. The current study sought to generate self-generated descriptive themes, from a group of HIV-infected MSM who reported high rates of sexual transmission risk behavior that may be relevant for understanding sexual risk in this group. Five descriptive themes emerged during content analysis: a) serostatus attribution, b) assumption of sexual partner’s responsibility for safer-sex, c) sexual sensation seeking, d) ongoing substance use, and e) dissatisfaction with current relationships. Traditional HIV transmission risk-reduction interventions that have been known to have only modest effects should be augmented by developing HIV prevention strategies for this subgroup of MSM to address these salient themes.
doi:10.1080/13548506.2012.756537
PMCID: PMC3857998  PMID: 23323526
HIV-infection; MSM; gay and bisexual men; HIV prevention; risky sexual behavior
3.  Engaging Healthcare Providers to Implement HIV Pre-Exposure Prophylaxis 
Current opinion in HIV and AIDS  2012;7(6):593-599.
Purpose of review
Recent randomized controlled trials have demonstrated that HIV Pre-Exposure Prophylaxis (PrEP) can decrease HIV incidence among several at-risk populations, including men who have sex with men, serodiscordant couples, and heterosexual men and women. As PrEP is a biomedical intervention that requires clinical monitoring and a high level of medication adherence, maximizing the public health effectiveness of PrEP in real-world settings will require the training of a cadre of healthcare providers to prescribe PrEP. Therefore it is critical to understand provider knowledge, practices and attitudes towards PrEP prescribing, and to develop strategies for engaging and training providers to provide PrEP.
Recent findings
A limited number of studies have focused on PrEP implementation by healthcare providers. These studies suggest that some providers are knowledgeable about PrEP, but many are not, or express misgivings. Although many clinicians report willingness to provide PrEP, few have prescribed PrEP in clinical practice. Provider comfort and skills in HIV risk assessment are suboptimal, which could limit identification of individuals who are most likely to benefit from PrEP use.
Summary
Further studies to understand facilitators and barriers to HIV risk assessment and PrEP prescribing by practicing clinicians are needed. Innovative training strategies and decision-support interventions for providers could optimize PrEP implementation and therefore merit additional research.
doi:10.1097/COH.0b013e3283590446
PMCID: PMC3769645  PMID: 23032736
HIV; Prevention; Pre-Exposure Prophylaxis; Provider; Implementation
4.  ONGOING SEXUALLY TRANSMITTED DISEASE ACQUISTION AND RISK TAKING BEHAVIOR AMONG U.S. HIV-INFECTED PATIENTS IN PRIMARY CARE: IMPLICATIONS FOR PREVENTION INTERVENTIONS 
SUMMARY
A study of HIV-infected persons in primary care in four U.S. found that 13% had a prevalent STD at enrollment and 7% an incident STD six months later.
Background
To better understand the factors associated with HIV and STD transmitting behavior among HIV-infected persons, we estimated STD prevalence and incidence and associated risk factors among a diverse sample of HIV-infected patients in primary care.
Methods
We analyzed data from 557 participants in the SUN study, a prospective observational cohort of HIV-infected persons in primary care in four U.S. cities. At enrollment and six months thereafter, participants completed an audio computer-assisted self interview about their sexual behavior, and were screened for genitourinary, rectal and pharyngeal N. gonorrhoeae and C. trachomatis infections by nucleic acid amplification testing, and for serologic evidence of syphilis. Women provided cervicovaginal samples and men provided urine to screen for T. vaginalis by polymerase chain reaction.
Results
Thirteen percent of participants had a prevalent STD at enrollment and 7% an incident STD six months later. The most commonly diagnosed infections were rectal chlamydia, oropharyngeal gonorrhea, and chlamydial urethritis among the men, and trichomoniasis among the women. Other than trichomoniasis, 94% of incident STDs were identified in MSM. Polysubstance abuse other than marijuana, and having ≥ 4 sex partners in the six months prior to testing were associated with diagnosis of an incident STD.
Conclusions
STDs were commonly diagnosed among contemporary HIV-infected patients receiving routine outpatient care, particularly among sexually active MSM who used recreational drugs. These findings underscore the need for frequent STD screening, prevention counseling, and substance abuse treatment for HIV-infected persons in care.
doi:10.1097/OLQ.0b013e31823b1922
PMCID: PMC3740591  PMID: 22183836
HIV infection; sexual risk; sexually transmitted infections
5.  Multiple Determinants, Common Vulnerabilities, and Creative Responses: Addressing the AIDS Pandemic in Diverse Populations Globally 
The AIDS epidemic has been fueled by global inequities. Ranging from gender inequality and underdevelopment to homophobia impeding health care access for men who have sex with men (MSM), imbalanced resource allocations and social biases have potentiated the epidemic’s spread. However, recognition of culturally specific aspects of each microepidemic has yielded development of community-based organizations, which have resulted in locally effective responses to AIDS. This effective approach to HIV prevention, care and treatment is illustrated through examples of community-based responses in Haiti, the United States, Africa, and other impoverished settings.
doi:10.1097/QAI.0b013e31825c16d9
PMCID: PMC3740592  PMID: 22772387
Disparities; Inequity; Health Care Access; Homophobia; Gender Inequality
6.  Evolution of Massachusetts Physician Attitudes, Knowledge, and Experience Regarding the Use of Antiretrovirals for HIV Prevention 
AIDS Patient Care and STDs  2012;26(7):395-405.
Abstract
The Center for the AIDS Programme of Research in South Africa (CAPRISA) 004 and Pre-exposure Prophylaxis Initiative (iPrEx) studies demonstrated that topical or oral chemoprophylaxis could decrease HIV transmission. Yet to have an appreciable public health impact, physicians will need to be educated about these new HIV prevention modalities. Massachusetts physicians were recruited via e-mail to complete an online survey of their knowledge and use of HIV prevention interventions. Data were collected before (July–December, 2010) (n=178) and after (December, 2010–April, 2011) (n=115) the release of iPrEx data. Over the two time intervals, knowledge of oral PrEP significantly increased (79% to 92%, p<0.01), whereas knowledge about topical microbicides was already high (89% pre-iPrEx). Post-iPrEx, specialists were more knowledgeable about oral PrEP (p<0.01) and topical microbicides (p<0.001) than generalists. The majority of the respondents would prefer to prescribe topical microbicides (75%) than oral PrEP (25%; p<0.001), primarily because they perceived fewer side effects (95%). Respondents indicated that PrEP should be available if it were a highly effective, daily pill; however, ongoing concerns included: potential drug resistance (93%), decreased funds for other forms of HIV prevention (88%), medication side effects (83%), and limited data regarding PrEP's clinical efficacy (75%). Participants indicated that formal CDC guidelines would have the greatest impact on their willingness to prescribe PrEP (96%). Among Massachusetts physicians sampled, chemoprophylaxis knowledge was high, but current experience was limited. Although topical gel was preferred, responses suggest a willingness to adapt practices pending additional efficacy data and further guidance from normative bodies. Educational programs aimed at incorporating antiretroviral chemoprophylaxis into physicians' HIV prevention practices are warranted.
doi:10.1089/apc.2012.0030
PMCID: PMC3432573  PMID: 22694239
7.  UNPROTECTED SEX, UNDERESTIMATED RISK, UNDIAGNOSED HIV AND SEXUALLY TRANSMITTED DISEASES AMONG MEN WHO HAVE SEX WITH MEN ACCESSING TESTING SERVICES IN A NEW ENGLAND BATHHOUSE 
American men who have sex with men (MSM) continue to have increased rates of HIV and STD. Between 2004 and 2010, 1155 MSM were screened for HIV and/or STD at a Providence, RI, bathhouse. The prevalence of HIV was 2.3%; syphilis, 2.0%; urethral gonorrhea, 0.1%; urethral Chlamydia, 1.3%; 2.2% of the men had hepatitis C antibodies. Although 43.2% of the men engaged in unprotected anal intercourse in the prior two months, the majority of the men thought that their behaviors did not put them at increased risk for HIV or STDs. Multivariate analyses found that men who engaged in unprotected anal intercourse were more likely to have had sex with unknown status or HIV-infected partners; have sex while under the influence of drugs; tended to find partners on the internet; and were more likely to have a primary male partner. Men who were newly diagnosed with HIV or syphilis tended to be over 30 years old; had sex with an HIV-infected partner; had a prior STD diagnosis; and met partners on the internet. For 10.5% of the men, their HIV testing in the bathhouse was the first time that they had ever been screened for HIV. Of 24 men who were newly diagnosed with HIV infection, only one was not successfully linked to care. These data suggest that offering HIV and STD screening in a bathhouse setting is successful in attracting MSM who were at increased risk for HIV and/or STD acquisition or transmission, and may help decrease spread.
doi:10.1097/QAI.0b013e31823bbecf
PMCID: PMC3261361  PMID: 22027871
Sexually transmitted infections; HIV; sexual risk; men having sex with men (MSM); bathhouse
8.  Sexual risk behaviors among HIV-infected South Indian couples in the HAART era: implications for reproductive health and HIV care delivery 
AIDS care  2011;23(6):722-733.
The current study examines sexual behaviors among HIV-infected Indians in primary care, where access to highly active antiretroviral therapy (HAART) has recently increased. Between January to April 2008, we assessed the sexual behaviors of 247 HIV-infected South Indians in care. Multivariable logistic regression models were used to determine predictors of being in a HIV-seroconcordant primary relationship, being sexually active, and reporting unprotected sex. Over three-fourths (80%) of participants were HAART-experienced. Among the 58% of participants who were currently in a seroconcordant relationship, one-third were serodiscordant when first tested for HIV. Approximately two-thirds (63.2%) of participants were sexually active; 9.0% reported unprotected sex. In the multivariable analyses, participants who were in a seroconcordant primary relationship were more likely to have children, use alcohol, report unprotected sex, and have been enrolled in care for >12 months. Sexually active participants were more likely to be on HAART, have a prior tuberculosis diagnosis, test Herpes simplex type 2 antibody seropositive, and have low general health perceptions. Participants who reported unprotected sex were more likely to be in a seroconcordant relationship, be childless, want to have a child, and use alcohol. We did not document an association between HAART and unprotected sex. Among HIV-infected Indians in primary care, predictors of unprotected sex included alcohol use and desire for children. Prevention interventions for Indian couples should integrate reproductive health and alcohol use counseling at entry into care.
doi:10.1080/09540121.2010.525616
PMCID: PMC3095699  PMID: 21293990
HIV; AIDS; sexual behavior; HAART; India
9.  Interactions of HIV, Other Sexually Transmitted Diseases, and Genital Tract Inflammation Facilitating Local Pathogen Transmission and Acquisition 
Despite several decades of clinical trials assessing the impact of etiological treatment of sexually transmitted diseases (STDs) to decrease HIV acquisition and transmission, almost all of these trials have not proven to be efficacious. Increasing evidence suggests that specific STD treatment alone may not be sufficient to alter the genital tract inflammatory milieu that is created by STDs. This paper examines the associations between STDs and HIV susceptibility and infectiousness, and considers the role of chronic and refractory inflammation to create an environment that potentiates HIV and STD transmission and acquisition by reviewing biological, observational, and clinical trial data.
doi:10.1111/j.1600-0897.2010.00942.x
PMCID: PMC3077541  PMID: 21214660
10.  Chemoprophylaxis for HIV Prevention: New Opportunities and New Questions 
Growing data suggest that antiretrovirals can be used as an effective means of HIV prevention. This paper reviews the current status and future clinical prospects of utilizing antiretroviral chemoprophylaxis before and after high-risk HIV exposure to prevent HIV transmission. The discussion about using antiretrovirals as a means of primary HIV prevention has moved to the forefront of public health discourse because of a growing evidence base, the increased tolerability of the medications, the decreased cost, the ever expanding formulary, and the limitations of other approaches.
doi:10.1097/QAI.0b013e3181fbcb4c
PMCID: PMC3075435  PMID: 21406981
HIV; AIDS; primary prevention; ART; preexposure prophylaxis; postexposure prophylaxis; topical microbicides
11.  Antiretroviral Therapy for HIV Prevention: Present status and future prospects 
American journal of public health  2010;100(10):1867-1876.
doi:10.2105/AJPH.2009.184796
PMCID: PMC2936983  PMID: 20724682
HIV; AIDS; HAART; treatment; prevention
12.  Predictors of Nonadherence to Highly Active Antiretroviral Therapy Among HIV-Infected South Indians in Clinical Care: Implications for Developing Adherence Interventions in Resource-Limited Settings 
AIDS Patient Care and STDs  2010;24(12):795-803.
Abstract
In light of the increasing availability of generic highly active antiretroviral therapy (HAART) in India, further data are needed to examine variables associated with HAART nonadherence among HIV-infected Indians in clinical care. We conducted a cross-sectional analysis of 198 HIV-infected South Indian men and women between January and April 2008 receiving first-line non-nucleoside reverse transcriptase inhibitor (NNRTI)-based HAART. Nonadherence was defined as taking less than 95% of HAART doses in the last 1 month, and was examined using multivariable logistic regression models. Half of the participants reported less than 95% adherence to HAART, and 50% had been on HAART for more than 24 months. The median CD4 cell count was 435 cells per microliter. An increased odds of nonadherence was found for participants with current CD4 cell counts greater than 500 cells per microliter (adjusted odds ratio [AOR]: 2.22 [95% confidence interval {CI}: 1.04–4.75]; p = 0.038), who were on HAART for more than 24 months (AOR: 3.07 [95% CI: 1.35–7.01]; p = 0.007), who reported alcohol use (AOR: 5.68 [95%CI: 2.10-15.32]; p = 0.001), who had low general health perceptions (AOR: 3.58 [95%CI: 1.20-10.66]; p = 0.021), and who had high distress (AOR: 3.32 [95%CI: 1.19-9.26]; p = 0.022). This study documents several modifiable risk factors for nonadherence in a clinic population of HIV-infected Indians with substantial HAART experience. Further targeted culturally specific interventions are needed that address barriers to optimal adherence.
doi:10.1089/apc.2010.0153
PMCID: PMC3011993  PMID: 21091232
13.  Diagnosis of Acute HIV Infection in Connecticut 
Connecticut medicine  2009;73(6):325-331.
Acute HIV infection (AHI) is the earliest stage of HIV disease, when plasma HIV viremia, but not HIV antibodies, can be detected. Acute HIV infection often presents as a nonspecific viral syndrome. However, its diagnosis, which enables linkage to early medical care and limits further HIV transmission, is seldom made. We describe the experience of Yale's Center for Interdisciplinary Research on AIDS with AHI diagnosis in Connecticut, as a participating center in the National Institute of Mental Health Multisite AHI Study. We sought to identify AHI cases by clinical referrals and by screening for AHI at two substance abuse care facilities and an STD clinic: We identified one case by referral and one through screening of 590 persons. Screening for AHI is feasible and probably cost effective. Primary care providers should include AHI in the differential diagnosis when patients present with a nonspecific viral syndrome.
PMCID: PMC3072267  PMID: 19637661
14.  Nondisclosure of HIV Status in a Clinical Trial Setting: Antiretroviral Drug Screening Can Help Distinguish Between Newly Diagnosed and Previously Diagnosed HIV Infection 
In The HIV Prevention Trials Network 061 study, 155 human immunodeficiency virus (HIV)–infected men reported no prior HIV diagnosis; 83 of those men had HIV RNA levels of <1000 copies/mL at enrollment. Antiretroviral drug testing revealed that 65 of the 83 (78.3%) men were on antiretroviral treatment. Antiretroviral drug testing can help distinguish between newly diagnosed and previously diagnosed HIV infection.
doi:10.1093/cid/cit672
PMCID: PMC3864502  PMID: 24092804
HIV; antiretroviral; self-report; MSM; new diagnosis
15.  The Spectrum of Undiagnosed Hepatitis C Virus Infection in a US HIV Clinic 
AIDS Patient Care and STDs  2014;28(1):4-9.
Abstract
United States guidelines endorse one-time HCV antibody screening at HIV diagnosis. Rescreening HCV-seronegative patients on a regular basis is still not policy, although HIV-infected persons have reasonably substantial HCV incidence. We evaluated routine risk factor-independent HCV antibody re-testing in a Rhode Island HIV clinic. We instituted annual HCV antibody testing for HCV-seronegative patients who had not been rescreened in a year or more. Testing based on clinical suspicion continued. We conducted a chart review of new antibody-positive cases in the first year of rescreening, July 2006 to June 2007. Of 245 rescreened patients, 11 (4.5%) seroconverted. Five (45%) were female. Median time between last negative and first positive result was 32 months (range 8–98 months). Six (55%) had documented risk factors and 6 (55%) elevated ALT (>45 IU/L) between antibody tests; none prompted re-testing. One seroconverter died of hepatocellular carcinoma 3.7 years after HCV diagnosis. A twelfth was rescreened for suspected acute HCV based on ALT of 515 IU/L. He had newly detectable HCV RNA then seroconversion, and achieved SVR following 6 months of treatment in the acute phase for genotype 1 infection. Incident HCV is not uncommon among HIV-infected patients in care. Rescreening identified undiagnosed HCV in this population. HCV RNA should be checked promptly in HCV-seronegative persons with ALT elevation. We observed consequences of late diagnosis (hepatocellular carcinoma) and benefits of early diagnosis (cure with treatment of acute HCV). Adding annual rescreening to the Ryan White Program would facilitate earlier identification of undiagnosed HCV and create an instant widespread surveillance system, providing HCV incidence data.
doi:10.1089/apc.2013.0130
PMCID: PMC3894677  PMID: 24428794
16.  Examining the Correspondence between Relationship Identity and Actual Sexual Risk Behavior among HIV-Positive Men Who Have Sex with Men 
Archives of sexual behavior  2014;43(1):129-137.
Sexual behavior of men who have sex with men (MSM), within and outside of one’s primary relationship, may contribute to increased risk of HIV transmission among those living with HIV. The current study sought to understand how HIV-infected MSM report their relationship status and the degree to which this corresponds with their sexual behavior. Further, we examined rates and psychosocial associations with sexual HIV transmission risk behavior (TRB) across relationship categories. In a sample of 503 HIV-infected MSM in HIV care, 200 (39.8%) reported having a primary partner. Of these, 115 reported that their relationship was open and 85 reported that it was monogamous. Of the 85 who reported a monogamous relationship, 23 (27%) reported more than one sexual partner in the prior three months, 53 (62%) reported only one partner, and nine did not report on the number of partners in the past 3 months. Hence, there were three categories of relationships: (1) “monogamous with one sexual partner,” (2) “monogamous with more than one sexual partner,” and (3) “open relationship.” The “monogamous with more than one sexual partner” group reported higher TRB and crystal methamphetamine use compared to the “monogamous with one sexual partner” group and different patterns of relationships with TRB emerged across the three groups. Couples-based HIV prevention interventions for MSM may be enhanced by considering that there may be different definitions of monogamy among MSM, and that the context of relationship status may require tailoring interventions to meet the needs of specific subgroups of MSM couples.
doi:10.1007/s10508-013-0209-7
PMCID: PMC3947093  PMID: 24198170
HIV/AIDS; MSM; couples; sexual risk; monogamy; sexual orientation
17.  Suboptimal awareness and comprehension of published pre-exposure prophylaxis efficacy results among physicians in Massachusetts 
AIDS care  2013;26(6):684-693.
In 2010, the CAPRISA 004 and iPrEx trials (microbicide gel containing tenofovir and oral pill containing tenofovir-emtricitabine, respectively) demonstrated that antiretroviral pre-exposure prophylaxis (PrEP) reduced the risk of HIV acquisition among high-risk individuals. To determine facilitators and barriers to PrEP provision by healthcare providers, we conducted an online, quantitative survey of Massachusetts-area physicians following the publication of the CAPRISA and iPrEx results. We assessed awareness and comprehension of efficacy data, prescribing experience, and anticipated provision of oral and topical PrEP among physicians, as well as demographic and behavioral factors associated with PrEP awareness and prescribing intentions. The majority of HIV specialists and generalist physicians were aware of data from these PrEP trials and able to correctly interpret the results, however, correct interpretation of findings tended to vary according to specialty (i.e., HIV specialists had greater awareness than generalists). Additionally provider concerns regarding PrEP efficacy and safety, as well its ability to divert funds from other HIV prevention resources, were associated with decreased intentions to prescribe both oral and topical PrEP. Findings suggest that a substantial proportion of physicians who may have contact with at-risk individuals may benefit from interventions that provide accurate data on the risks and benefits of PrEP in order to facilitate effective PrEP discussions with their patients. Future studies to develop and test interventions aimed at healthcare providers should be prioritized to optimize implementation of PrEP in clinical settings.
doi:10.1080/09540121.2013.845289
PMCID: PMC4053171  PMID: 24116985
Pre-Exposure Prophylaxis; PrEP; Physicians; HIV; Prevention
18.  High Prevalence of Hepatitis Delta Virus among Patients with Chronic Hepatitis B Virus Infection and HIV-1 in an Intermediate Hepatitis B Virus Endemic Region 
We conducted a study to investigate HIV and hepatitis delta virus (HDV) coinfection among patients with chronic hepatitis B virus (HBV) infection and the triple infection’s (HIV/HBV/HDV) clinical implications in India, an intermediate HBV endemic region, with an estimated HIV-positive population of 2.5 million. A total of 450 patients (men: 270; women: 180) with chronic HBV infections and 135 healthy volunteers were screened for HIV and HDV. The incidence of the triple infection was low (4 [0.8%]) compared with dual infections of HIV-1/HBV (7 [1.5%]) and HBV/HDV (22[4.8%]). Among 21- to 40-year-olds, HBV/HDV coinfection (45.8%) and HBV/HDV/HIV-1 triple infection was predominant (75%). Among 11 patients coinfected with HIV-1/HBV, 4 (36%) were tri-infected and were also associated with chronic hepatitis and cirrhosis. The HDV coinfection was higher among patients coinfected with HBV/HIV-1, despite the declining trend in HDV infection among HIV-negative patients, as previously reported. Thus, it is important to assess the impact of HIV, chronic HBV, and HDV tri-infection in India.
doi:10.1177/2325957413488166
PMCID: PMC4114572  PMID: 23722085
coinfection in India; hepatitis delta virus (HDV); hepatitis B virus (HBV); human immunodeficiency virus (HIV)
19.  GB Virus C (GBV-C) Infection in Hepatitis C Virus (HCV) Seropositive Women with or at Risk for HIV Infection 
PLoS ONE  2014;9(12):e114467.
Background
GB virus C (GBV-C) may have a beneficial impact on HIV disease progression; however, the epidemiologic characteristics of this virus are not well characterized. Behavioral factors and gender may lead to differential rates of GBV-C infection; yet, studies have rarely addressed GBV-C infections in women or racial/ethnic minorities. Therefore, we evaluated GBV-C RNA prevalence and genotype distribution in a large prospective study of high-risk women in the US.
Results
438 hepatitis C virus (HCV) seropositive women, including 306 HIV-infected and 132 HIV-uninfected women, from the HIV Epidemiologic Research Study were evaluated for GBV-C RNA. 347 (79.2%) women were GBV-C RNA negative, while 91 (20.8%) were GBV-C RNA positive. GBV-C positive women were younger than GBV-C negative women. Among 306 HIV-infected women, 70 (22.9%) women were HIV/GBV-C co-infected. Among HIV-infected women, the only significant difference between GBV-negative and GBV-positive women was age (mean 38.4 vs. 35.1 years; p<0.001). Median baseline CD4 cell counts and plasma HIV RNA levels were similar. The GBV-C genotypes were 1 (n = 31; 44.3%), 2 (n = 36; 51.4%), and 3 (n = 3; 4.3%). The distribution of GBV-C genotypes in co-infected women differed significantly by race/ethnicity. However, median CD4 cell counts and log10 HIV RNA levels did not differ by GBV-C genotype. GBV-C incidence was 2.7% over a median follow-up of 2.9 (IQR: 1.5, 4.9) years, while GBV-C clearance was 35.7% over a median follow-up of 2.44 (1.4, 3.5) years. 4 women switched genotypes.
Conclusions
Age, injection drug use, a history of sex for money or drugs, and number of recent male sex partners were associated with GBV-C infection among all women in this analysis. However, CD4 cell count and HIV viral load of HIV/HCV/GBV-C co-infected women were not different although race was associated with GBV-C genotype.
doi:10.1371/journal.pone.0114467
PMCID: PMC4262414  PMID: 25493916
20.  Body Mass Index, Immune Status and Virological Control in HIV-Infected Men who have Sex with Men 
Background & aims
Prior cross-sectional studies have found inconsistent relationships between body mass index (BMI) and disease progression in HIV-infected individuals.
Methods
Cross-sectional and longitudinal analyses were conducted on data from a sample of 864 HIV-infected men who have sex with men (MSM) obtained from a large, nationally-distributed HIV clinical cohort.
Results
Of the 864 HIV-infected MSM, 394 (46%) were normal weight, 363 (42%) were overweight, and 107 (12%) were obese at baseline. The baseline CD4 count was 493 (SE = 9), with viral load(log10) = 2.4 (SE = .04), and 561 (65%) were virologically suppressed. Over time, controlling for viral load, HAART adherence, age, and race/ethnicity, overweight and obese HIV-infected men possessed higher CD4 counts compared to normal weight HIV-infected men. Further, overweight and obese men possessed lower viral loads compared to normal weight HIV-infected men.
Conclusions
For HIV-infected MSM, in this longitudinal cohort study, possessing a heavier than normal BMI is longitudinally associated with improved immunological health.
doi:10.1177/2325957413488182
PMCID: PMC4259246  PMID: 23719237
HIV/AIDS; Body Mass Index; Obesity; CD4; Viral Load
21.  Undisclosed Antiretroviral Drug Use in a Multinational Clinical Trial (HIV Prevention Trials Network 052) 
The Journal of Infectious Diseases  2013;208(10):1624-1628.
The HIV Prevention Trials Network 052 study enrolled serodiscordant couples. Index participants infected with human immunodeficiency virus reported no prior antiretroviral (ARV) treatment at enrollment. ARV drug testing was performed retrospectively using enrollment samples from a subset of index participants. ARV drugs were detected in 45 of 96 participants (46.9%) with an undetectable viral load, 2 of 48 (4.2%) with a low viral load, and 1 of 65 (1.5%) with a high viral load (P < .0001); they were also detected in follow-up samples from participants who were not receiving study-administered treatment. ARV drug testing may be useful in addition to self-report of ARV drug use in some clinical trial settings.
doi:10.1093/infdis/jit390
PMCID: PMC3805242  PMID: 23908493
HIV; antiretroviral drug; self-report; HPTN 052; Africa; clinical trial
22.  The disproportionate burden of HIV and STIs among male sex workers in Mexico City and the rationale for economic incentives to reduce risks 
Introduction
The objective of this article is to present the rationale and baseline results for a randomized controlled pilot trial using economic incentives to reduce HIV and sexually transmitted infection (STI) risk among male sex workers (MSWs) in Mexico City.
Methods
Participants (n=267) were tested and treated for STIs (chlamydia, gonorrhoea, syphilis and HIV) and viral hepatitis (hepatitis B and C), received HIV and STI prevention education and were randomized into four groups: (1) control, (2) medium conditional incentive ($50/six months), (3) high conditional incentive ($75/six months) and (4) unconditional incentive ($50/six months). In the conditional arms, incentives were contingent upon testing free of new curable STIs (chlamydia, gonorrhoea and syphilis) at follow-up assessments.
Results
Participants’ mean age was 25 years; 8% were homeless or lived in a shelter, 16% were unemployed and 21% lived in Mexico City less than 5 years. At baseline, 38% were living with HIV, and 32% tested positive for viral hepatitis or at least one STI (other than HIV). Participants had a mean of five male clients in the previous week; 18% reported condomless sex with their last client. For 37%, sex work was their main occupation and was conducted mainly on the streets (51%) or in bars/discotheques (24%) and hotels (24%). The average price for a sex transaction was $25 with a 35% higher payment for condomless sex.
Conclusions
The findings suggest that economic incentives are a relevant approach for HIV prevention among MSWs, given the market-based inducements for unprotected sex. This type of targeted intervention seems to be justified and should continue to be explored in the context of combination prevention efforts.
doi:10.7448/IAS.17.1.19218
PMCID: PMC4233212  PMID: 25399543
male sex workers; men who have sex with men; conditional cash transfer; conditional economic incentives; HIV/STI prevention; risk premium; compensating differential; Mexico
23.  Prevalence of Sexually Transmitted Diseases and Risk Behaviors from the NIMH Collaborative HIV/STD Prevention Trial 
This cross-sectional study describes the baseline prevalence and correlates of common bacterial and viral sexually transmitted diseases (STDs) and risk behaviors among individuals at high risk for HIV recruited in five low- and middle-income countries. Correlations of risk behaviors and demographic factors with prevalent STDs and the association of STDs with HIV prevalence are examined. Between 2,212 and 5,543 participants were recruited in each of five countries (China, India, Peru, Russia, and Zimbabwe). Standard protocols were used to collect behavioral risk information and biological samples for STD testing. Risk factors for HIV/STD prevalence were evaluated using logistic regression models. STD prevalence was significantly higher for women than men in all countries, and the most prevalent STD was Herpes simplex virus-type 2 (HSV-2). HIV prevalence was generally low (below 5%) except in Zimbabwe (30% among women, 11.7% among men). Prevalence of bacterial STDs was generally low (below 5% for gonorrhea and under 7% for syphilis in all sites), with the exception of syphilis among female sex workers in India. Behavioral and demographic risks for STDs varied widely across the five study sites. Common risks for STDs included female gender, increasing number of recent sex partners, and in some sites, older age, particularly for chronic STDs (i.e., HSV-2 and HIV). Prevalence of HIV was not associated with STDs except in Zimbabwe, which showed a modest correlation between HIV and HSV-2 prevalence (Pearson coefficient = .55). These findings underscore the heterogeneity of global STD and HIV epidemics and suggest that local, focused interventions are needed to achieve significant declines in these infections.
doi:10.1080/19317611.2010.494092
PMCID: PMC4230575  PMID: 25400718
HIV prevention; sexually transmitted diseases; behavioral risk factors; international
24.  Access to Healthcare, HIV/STI Testing, and Preferred Pre-Exposure Prophylaxis Providers among Men Who Have Sex with Men and Men Who Engage in Street-Based Sex Work in the US 
PLoS ONE  2014;9(11):e112425.
Background
Pre-exposure prophylaxis (PrEP) is a promising strategy for HIV prevention among men who have sex with men (MSM) and men who engage in sex work. But access will require routine HIV testing and contacts with healthcare providers. This study investigated men’s healthcare and HIV testing experiences to inform PrEP implementation.
Methods
We conducted 8 focus groups (n = 38) in 2012 and 56 in-depth qualitative interviews in 2013–14 with male sex workers (MSWs) (n = 31) and other MSM (n = 25) in Providence, RI. MSWs primarily met clients in street-based sex work venues. Facilitators asked participants about access to healthcare and HIV/STI testing, healthcare needs, and preferred PrEP providers.
Results
MSWs primarily accessed care in emergency rooms (ERs), substance use clinics, correctional institutions, and walk-in clinics. Rates of HIV testing were high, but MSWs reported low access to other STI testing, low insurance coverage, and unmet healthcare needs including primary care, substance use treatment, and mental health services. MSM not engaging in sex work were more likely to report access to primary and specialist care. Rates of HIV testing among these MSM were slightly lower, but they reported more STI testing, more insurance coverage, and fewer unmet needs. Preferred PrEP providers for both groups included primary care physicians, infectious disease specialists, and psychiatrists. MSWs were also willing to access PrEP in substance use treatment and ER settings.
Conclusions
PrEP outreach efforts for MSWs and other MSM should engage diverse providers in many settings, including mental health and substance use treatment, ERs, needle exchanges, correctional institutions, and HIV testing centers. Access to PrEP will require financial assistance, but can build on existing healthcare contacts for both populations.
doi:10.1371/journal.pone.0112425
PMCID: PMC4227700  PMID: 25386746
25.  Bisexuality, Sexual Risk Taking, and HIV Prevalence Among Men Who Have Sex With Men Accessing Voluntary Counseling and Testing Services in Mumbai, India 
Objectives
To describe sociodemographics, sexual risk behavior, and estimate HIV and sexually transmitted infection (STI) prevalence among men who have sex with men (MSM) in Mumbai, India.
Methods
Eight hundred thirty-one MSM attending voluntary counseling and testing (VCT) services at the Humsafar Trust, answered a behavioral questionnaire and consented for Venereal Disease Research Laboratory and HIV testing from January 2003 through December 2004. Multivariate logistic regression was performed for sociodemographics, sexual risk behavior, and STIs with HIV result as an outcome.
Results
HIV prevalence among MSM was 12.5%. MSM who were illiterate [adjusted odds ratio (AOR) 2.28; 95% confidence interval (CI): 1.08 to 4.84], married (AOR 2.70; 95% CI: 1,56 to 4.76), preferred male partners (AOR 4.68; 95% CI: 1.90 to 11.51), had partners of both genders (AOR 2.73; 95% CI: 1.03 to 7.23), presented with an STI (AOR 3.31; 95% CI: 1.96 to 5.61); or presented with a reactive venereal disease research laboratory test (AOR 4.92; 95% CI: 2.55 to 9.53) at their VCT visit were more likely to be HIV infected.
Conclusions
MSM accessing VCT services in Mumbai have a high risk of STI and HIV acquisition. Culturally appropriate interventions that focus on sexual risk behavior and promote condom use among MSM, particularly the bridge population of bisexual men, are needed to slow the urban Indian AIDS epidemic.
doi:10.1097/QAI.0b013e3181c354d8
PMCID: PMC2844633  PMID: 19934765
bisexual; homosexual; India; men who have sex with men; Mumbai; voluntary counseling and testing

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