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1.  Correlates of Antiretroviral Adherence and Viral Load among Transgender Women Living with HIV 
AIDS care  2014;26(8):976-982.
Transgender women are 49 times more likely to become HIV infected than other groups, yet they are drastically underserved by current treatment efforts and report lower rates of treatment adherence then other groups. The objective of this study was to explore correlates of antiretroviral (ART) adherence and viral load among HIV-positive transgender women on ART utilizing a cross-sectional survey of a convenience sample of 59 transgender women. In multivariate models of ART adherence, correlates were age, stress appraisal of transphobic experiences, importance of gender affirmation, and adherence to hormone therapy. In multivariate models of self-reported viral load, correlates were stress appraisal of transphobic experiences and being in a relationship. This study provides preliminary evidence of transgender-relevant correlates of ART adherence and viral load.
PMCID: PMC4054817  PMID: 24646419
Transgender Persons; HIV; Medication Adherence; Viral Load; Health Disparities
2.  Racial Discrimination and Posttraumatic Stress Symptoms as Pathways to Sexual HIV Risk Behaviors Among Urban Black Heterosexual Men 
AIDS care  2014;26(8):1050-1057.
In light of evidence that racial discrimination and posttraumatic stress symptoms (PTSS) are neither rare nor extraordinary for many Black urban men, we examined the relationship between everyday racial discrimination and sexual HIV risk behaviors in a predominantly low-income sample of 526 urban Black heterosexually-identified men; 64% of whom were unemployed and 55% of whom reported a history of incarceration. We tested the hypothesis that PTSS would mediate the relationship between everyday racial discrimination and sexual risk. Participants in the predominantly low-income urban sample ranged in age from 18 to 45 (M = 28.80, SD = 7.57). Three multiple regression models were used to test the study’s mediational model. As hypothesized, PTSS mediated the relationship between everyday racial discrimination and sexual risk behaviors. Most participants (97%) reported experiences with everyday racial discrimination. Results empirically support the notion of racial discrimination-based traumatic stress as a pathway to Black heterosexual men’s increased sexual risk behaviors. Results also highlighted key demographic differences with older men reporting fewer PTSS and sexual risk behaviors compared with younger men. Incarceration was related to both PTSS and sexual risk, underscoring the role that incarceration may play in Black heterosexual men’s adverse health outcomes. Our study highlights the need for more qualitative and quantitative research to understand the nature of PTSS in Black heterosexual men and mechanisms such as substance use that may link traumatic experiences and sexual risk. Future research could also assess experiences with childhood sexual abuse, violence, and incarceration to gain a more in-depth understanding of the sources of traumatic stress in Black heterosexual men’s lives. We advocate for the development of community-based individual and structural level interventions to help Black heterosexual men in urban areas develop effective strategies to cope with racial discrimination-based traumatic stress to reduce sexual HIV risk behaviors in Black communities.
PMCID: PMC4156284  PMID: 24797317
Racial discrimination; sexual HIV risk behaviors; Black heterosexual men; posttraumatic stress symptoms
3.  Substance-Use and Sexual Harm-Reduction Strategies of Methamphetamine-Using Men Who Have Sex with Men and Inject Drugs 
AIDS care  2015;27(8):1047-1054.
Research indicates that men who have sex with men (MSM), use methamphetamine, and inject drugs are at high risk of HIV infection and they employ multiple harm reduction strategies simultaneously to reduce that risk. In this study, we identified substances most commonly injected and harm reduction strategies most often employed by methamphetamine-using MSM, used latent class analysis (LCA) to identify patterns of harm reduction strategies, and differentiated MSM within each class by individual characteristics. We analyzed data from 284 participants who completed an online cross-sectional survey. Commonly injected substances were methamphetamine (93.70%), gamma-hydroxybutyrate/gamma-butyrolactone (41.55%), flunitrazepam (40.49%), and cocaine (35.56%). The substance-use strategies most often used were avoidance of sharing needles (85.92%) and use of bleach to clean drug paraphernalia (64.08%). The sexual strategy most often used was avoidance of condomless anal intercourse (CAS) while using drugs (77.11%). Using an LCA approach, we identified three classes distinguishable by age, race/ethnicity, and outness. One class (19%) employed lay strategies to reduce harm: they avoided sharing drug preparation equipment, serosorted when sharing needles and equipment or having CAS, and practiced withdrawal when having CAS. The largest class (53%) combined sexual and substance use strategies: they avoided sharing needles, used bleach to clean needles and equipment, avoided CAS when using drugs, and used extra lubricant when having CAS. The remaining class (28%) employed only substance-use rather than sexual strategies. More MSM of color were in the substance-use class, and more young, non-Hispanic White men were in the lay class. The low utilization of sexual strategies by younger, non-Hispanic White men in the lay class is concerning as they are just as likely as older, non-Hispanic White men in the combined class to have CAS with multiple male partners. Interventionists should consider these differences when developing interventions tailored to methamphetamine-using MSM.
PMCID: PMC4425584  PMID: 25837492
HIV prevention; gay men; latent class analysis; injection drug use; methamphetamine
4.  Suboptimal antiretroviral therapy adherence among HIV-infected adults in Guangzhou, China 
AIDS care  2014;26(8):988-995.
Despite China“s free antiretroviral treatment (ART) program, there are high rates of treatment failure, large sociodemographic disparities in care outcomes and emerging medication resistance. Understanding patient medication adherence behaviors and challenges could inform adherence interventions to maximize the individual and prevention benefits of ART. This study assessed recent non-adherence and treatment interruption among 813 HIV-infected adult outpatients in Guangzhou, China. Participants completed a behavioral survey, underwent chart review, and were tested for syphilis, gonorrhea, and chlamydia. Factors associated with suboptimal adherence were identified using univariate and multivariate logistic regression. Among 721 HIV-infected adults receiving ART, 18.9% reported recent non-adherence (any missed ART in the past 4 weeks) and 6.8% reported treatment interruption (four or more weeks of missed ART in the past year). Lower education, living alone, alcohol use and being on ART one to three years were associated with recent non-adherence. Male gender, lower education and being on ART one to three years were associated with treatment interruption. ART medication adherence interventions are needed in China that include individualized, long-term adherence plans sensitive to patients“ educational and economic situations. These interventions should also consider possible gender disparities in treatment outcomes and address the use of alcohol during ART. Successful ART medication adherence interventions in China can inform other international settings that face similar adherence challenges and disparities.
PMCID: PMC4024070  PMID: 24666239
antiretroviral therapy; ART; ARV; adherence; alcohol; China
5.  Risk factors for recent non-fatal overdose among HIV-infected Russians who inject drugs 
AIDS care  2014;26(8):1013-1018.
Overdoses and HIV infection are common among Russians who inject drugs, yet risk factors have not been studied. We analyzed baseline data of 294 participants with 30 day injection drug use from an HIV secondary prevention trial for persons reporting “heavy” alcohol use (NIAAA risky drinking definition) and risky sex in the past 6 months. The outcome was any self-reported overdose in the previous 3 months. We examined demographic, HIV-related, criminal justice, mental health, substance use and injection risk factors. Participants’ characteristics included median age 29 years, 117/294 (40%) female, and median CD4 cell count 345/μl. Over three quarters 223/294 (76%) reported a history of overdose; 47/294 (16%) reported overdose in the past 3 months. Past month injection frequency (AOR 4.77, 95%CI: 1.63-14.0 highest vs. lowest quartile; AOR 3.58, 95%CI: 1.20-10.69 second highest vs. lowest quartile) and anti-retroviral therapy at time of interview (AOR 3.96 95%CI: 1.33-11.83) were associated with 3-month overdose. Nonfatal overdose among HIV-infected Russians who inject drugs is common. Risk factors include injection frequency and anti-retroviral therapy, which warrant further study. Overdose prevention efforts are needed among HIV-infected Russians who inject drugs.
PMCID: PMC4040021  PMID: 24382133
Overdose; Russia; injection drug use; anti-retroviral therapy; HIV
6.  Age Group Differences in HIV Risk and Mental Health Problems among Female Sex Workers (FSWs) in Southwest China 
AIDS care  2014;26(8):1019-1026.
HIV risk and mental health problems are prevalent among female sex workers (FSWs) in China. The purpose of this research was to study age group differences in HIV risk and mental health problems in this population. In the current study we divided a sample of 1,022 FSWs into three age groups (≤20 years, 21– 34 years, and ≥35 years). Results showed that among the three groups (a) older FSWs (≥35 years) were likely to be socioeconomically disadvantaged (e.g., rural residency, little education, employment in low-paying venues, and low monthly income); (b) older FSWs reported the highest rates of inconsistent, ineffective condom use and STD history; (c) younger FSWs (≤20 years) reported the highest level of depression, suicidal thoughts and suicide attempts, regular-partner violence, and substance use; (d) all health-related risks except casual-partner violence were more prevalent among older and younger FSWs than among FSW aged 21–34 years; (e) age had a significant effect on all health indicators except suicide attempts after controlling for several key demographic factors. These findings indicate the need for intervention efforts to address varying needs among FSWs in different age groups. Specific interventional efforts are needed to reduce older FSWs’ exposure to HIV risk; meanwhile, more attention should be given to improve FSWs’ mental health status, especially among younger FSWs.
PMCID: PMC4231719  PMID: 24410298
7.  Computer technology-based interventions in HIV prevention: state of the evidence and future directions for research 
AIDS care  2011;23(5):525-533.
Computer technology-based interventions (CBIs) represent a promising area for HIV prevention behavioral intervention research. Such programs are a compelling prevention option given their potential for broad reach, customized content, and low cost delivery. The purpose of the current article is to provide a review of the state of the literature on CBIs. First, we define CBIs in HIV prevention and highlight the many advantages of such interventions. Next, we provide an overview of what is currently known regarding the efficacy of CBIs in HIV prevention, focusing on two recent meta-analyses of this literature. Finally, we propose an agenda for future directions for research in the area of CBIs, using the RE-AIM model as an organizing guide. We conclude that with the continued growth of computer technologies, opportunities to apply such technologies in HIV prevention will continue to blossom. Further research is greatly needed to advance an understanding of not only how and under what circumstances CBIs can be efficacious, but also how the reach, adoption, implementation, and maintenance of such programs in clinical and community settings can be achieved.
PMCID: PMC4516027  PMID: 21287420
computer technology; HIV prevention; behavioral intervention; theory; condom use; tailoring; targeting; dissemination; computers
8.  Levels of alcohol use and history of HIV testing among female sex workers in Mombasa, Kenya 
AIDS care  2014;26(12):1619-1624.
HIV testing is a critical first step to accessing HIV care and treatment, particularly for high-risk groups such as female sex workers (FSWs). Alcohol use may be a barrier to accessing HIV services, including HIV testing. We analyzed data from a cross-sectional survey of 818 FSWs in Mombasa, Kenya, and estimated the association between different levels of alcohol use and having never tested for HIV. In multivariable analyses, higher levels of alcohol consumption were associated with having never tested for HIV (PR 1.60; 95% CI: 1.07, 2.40). Future interventions should explore whether reducing harmful drinking improves HIV testing among FSWs.
PMCID: PMC4320941  PMID: 25040114
HIV testing; alcohol use; female sex workers; HIV prevention
9.  Alcohol and Drug Use Outcomes Among Vulnerable Women Living with HIV: Results from the Western Cape Women’s Health CoOp 
AIDS care  2014;26(12):1494-1499.
Alcohol and other drug use can negatively affect adherence to and retention in antiretroviral therapy (ART) among people living with HIV. Yet, there are few brief interventions that reduce these behaviors among this population. This article presents the findings from a randomized field experiment that assessed the effects of a woman-focused intervention (the Women’s Health CoOp [WHC]) on reducing alcohol and other drug use among vulnerable women in Cape Town, South Africa. The analyses were limited to 84 women living with HIV who reported drinking alcohol at baseline. Because of the small sample size, analyses were performed using an exact logistic regression procedure. At 12-month follow-up, women in the WHC arm were more likely to be abstinent from alcohol (Odds Ratio [OR] = 3.61; 95% Confidence Intervals [CI] = 1.23, 11.70; p = 0.016) and somewhat more likely to test negative for other drugs (OR = 3.07; 95% CI = 0.83,12.31; p = 0.105), compared with women in the comparison arms. This study provides preliminary evidence of the efficacy of a brief, woman-focused intervention in reducing alcohol and other drug use among vulnerable women living with HIV and it has implications for HIV treatment.
PMCID: PMC4505545  PMID: 25040338
Alcohol and other drug use; HIV/AIDS; Women’s Health CoOp; intervention; South Africa
10.  Multisystemic Therapy for Poorly Adherent Youth with HIV: Results from a Pilot Randomized Controlled Trial 
AIDS care  2012;25(4):507-514.
Adherence to antiretroviral medication for the treatment of HIV is a significant predictor of virologic suppression and is associated with dramatic reductions in mortality and morbidity and other improved clinical outcomes for pediatric patient populations. Effective strategies for addressing adherence problems in youth infected with HIV are needed and require significant attention to the complex interplay of multiple, interacting causal risk factors that lead to poor self-care.
Within the context of a pilot randomized trial, we evaluated the feasibility and initial efficacy of a multisystemic therapy (MST) intervention adapted to address HIV medication adherence problems against a usual care condition that was bolstered with a single session of motivational interviewing (MI). For 34 participating youth, health outcomes (viral load and CD4 count) were obtained from approximately 10 months pre-baseline through approximately 6 months post-baseline and self-reported medication adherence outcomes were obtained quarterly from baseline through 9 months post-baseline. Using mixed-effects regression models we examined within and between-groups differences in the slopes of these outcomes.
Feasibility was supported, with a 77% recruitment rate and near-maximal treatment and research retention and completion rates. Initial efficacy also was supported, with the MST condition but not the MI condition demonstrating statistically and clinically significant viral load reductions following the start of treatment. There also was some support for improved CD4 count and self-reported medication adherence for the MST but not the MI condition.
MST was successfully adapted to improve the health outcomes of youth poorly adherent to antiretroviral medications. Replication trials and studies designed to identify mechanisms of action are important next steps.
PMCID: PMC4489694  PMID: 22909294
11.  The Influence of Sexually Explicit Online Media on Sex: Do Men who have Sex with Men Believe they “Do What They See”? 
AIDS care  2014;26(7):931-934.
Over the past two decades, men who have sex with men (MSM) have engaged in increasing consumption of MSM-specific sexually explicit online media (i.e., online pornography). Furthermore, the amount of MSM-specific sexually explicit online media portraying unprotected anal intercourse (UAI) has increased, raising concerns about HIV transmission among the actors and the encouragement of risky sex among consumers. The influence of sexually explicit online media on sexual risk-taking, at present largely understudied, could lead to new avenues for innovative HIV prevention strategies targeting at-risk MSM. In this preliminary assessment, in-depth qualitative interviews were conducted with sixteen MSM in the Seattle area to elucidate MSM’s perceptions about the influence of sexually explicit online media on their own and other MSM’s sexual behaviors. Participants reported that sexually explicit online media: 1) plays an educational role; 2) increases comfort with sexuality; and 3) sets expectations about sexual behaviors. While participants overwhelmingly reported not feeling personally influenced by viewing UAI in sexually explicit online media, they believed viewing UAI increased sexual risk-taking among other MSM. Specifically, participants reported that the high prevalence of UAI in sexually explicit online media sends the message, at least to other MSM, that: 1) engaging in UAI is common; 2) UAI is acceptable and “ok” to engage in; and 3) future partners will desire or expect UAI. Overall, this preliminary assessment indicates that sexually explicit online media exposure may have both positive (e.g., helping MSM become more comfortable with their sexuality) and negative (e.g., normalizing UAI) impacts on the sexual health of MSM and may be useful in the development of novel HIV-prevention interventions.
PMCID: PMC3989406  PMID: 24382316
HIV; men who have sex with men (MSM); sexually explicit online media; pornography; sexual risk-taking
12.  Gender and risk behaviors for HIV and sexually transmitted infections among recently released inmates: A prospective cohort study 
AIDS care  2013;26(7):872-881.
Women in prison have a higher prevalence of HIV than men. After release from prison, former inmates have the opportunity to engage in risk behaviors for HIV and other sexually transmitted infections (STI). We sought to assess change in risk behaviors over time and the association of gender with risk behavior in the post-release period. In this prospective cohort study, we interviewed 200 former inmates (51 women) approximately 2 weeks (baseline) and 3 months (follow-up) after release and tested them for HIV infection at follow-up. We examined the association of gender with unprotected vaginal or anal sex in the last seven days using chi-square and Fisher’s exact tests and multivariable logistic regression. At baseline, 22% of men and 41% of women reported unprotected vaginal sex (p<0.01) and 5% of men and 8% of women reported unprotected anal sex (p=0.51). Being younger (OR for each decade increase 0.48, 95% CI 0.29-0.80), being gay/lesbian or being bisexual (compared with being heterosexual, OR=4.74 95% CI 1.01–22.17, OR=3.98, 95% CI 1.41–11.26, respectively), or reporting a drug of choice of heroin/speedballs or cocaine/crack (compared with marijuana/no drug of choice, OR=24.00, 95% CI 5.15–111.81 and OR=3.49, 95% CI 1.20–10.18, respectively) were associated with unprotected vaginal or anal sex after adjusting for race, homelessness, and hazardous drinking. At follow-up, 21% of men and 44% of women reported unprotected sex (p=0.005), and female gender (OR=4.42, 95% CI 1.79–10.94) and hazardous drinking (compared with not meeting criteria for hazardous drinking, OR=3.64, 95% CI 1.34–9.86) were associated with unprotected sex, adjusting for race and homelessness. In this population with a high prevalence of HIV, we demonstrated persistent engagement in sexual risk behavior during the post-release period. Enhanced efforts to promote sexual health and reduced risk behavior among both male and female current and former prison inmates are needed, including improved access to preventive care and HIV and STI screening, testing and treatment.
PMCID: PMC3989499  PMID: 24266415
HIV; prisoners; gender; drug use; women’s health; epidemiology; sexually transmitted infections
13.  Barriers to antiretroviral treatment access for injecting drug users living with HIV in Chennai, South India 
AIDS care  2013;26(7):835-841.
India’s National AIDS Control Organization provides free antiretroviral treatment (ART) to people living with HIV (PLHIV), including members of marginalized groups such as injecting drug users (IDUs). To help inform development of interventions to enhance ART access, we explored barriers to free ART access at government ART centers for IDUs living with HIV in Chennai by conducting three focus groups (n = 19 IDUs) and four key informant interviews. Data were explored using framework analysis to identify categories and derive themes. We found interrelated barriers at the family and social, health-care system, and individual levels. Family and social level barriers included lack of family support and fear of societal discrimination, as well as unmet basic needs, including food and shelter. Health-care system barriers included actual or perceived unfriendly hospital environment and procedures such as requiring proof of address and identity from PLHIV, including homeless IDUs; provider perception that IDUs will not adhere to ART, resulting in ART not being initiated; actual or perceived inadequate counseling services and lack of confidentiality; and lack of effective linkages between ART centers, needle/syringe programs, and drug dependence treatment centers. Individual-level barriers included active drug use, lack of self-efficacy in ART adherence, low motivation to initiate ART stemming from a fatalistic attitude, and inadequate knowledge about ART. These findings indicate that to facilitate IDUs gaining access to ART, systemic changes are needed, including steps to make the environment and procedures at government ART centers more IDU-friendly and steps to decrease HIV- and drug use-related stigma and discrimination faced by IDUs from the general public and health-care providers. Housing support for homeless IDUs and linkage of IDUs with drug dependence treatment are also essential.
PMCID: PMC4017592  PMID: 24283220
access to health care; antiretroviral treatment; injecting drug users; India; HIV; AIDS
14.  Depressive Symptoms, Self-Esteem, HIV Symptom Management Self-Efficacy and Self-Compassion in People Living with HIV 
AIDS care  2013;26(7):795-803.
The aims of this study were to examine differences in self-schemas between persons living with HIV/AIDS with and without depressive symptoms, and the degree to which these self-schemas predict depressive symptoms in this population. Self-schemas are beliefs about oneself and include self-esteem, HIV symptom management self-efficacy, and self-compassion. Beck’s cognitive theory of depression guided the analysis of data from a sample of 1766 PLHIV from the U.S. and Puerto Rico. Sixty-five percent of the sample reported depressive symptoms. These symptoms were significantly (p ≤ .05), negatively correlated with age (r= −.154), education (r= −.106), work status (r= −.132), income adequacy (r= −.204, self-esteem (r= −.617), HIV symptom self-efficacy (r=−.408) and self-kindness (r=−.284); they were significantly, positively correlated with gender (female/transgender) (r=.061), white or Hispanic race/ethnicity (r= .047) and self-judgment (r=.600). Fifty-one percent of the variance (F=177.530 (df=1524); p<.001) in depressive symptoms was predicted by the combination of age, education, work status, income adequacy, self-esteem, HIV symptom self-efficacy, and self-judgment. The strongest predictor of depressive symptoms was self-judgment. Results lend support to Beck’s theory that those with negative self-schemas are more vulnerable to depression and suggest that clinicians should evaluate PLHIV for negative self-schemas. Tailored interventions for the treatment of depressive symptoms in PLHIV should be tested and future studies should evaluate whether alterations in negative self-schemas are the mechanism of action of these interventions and establish causality in the treatment of depressive symptoms in PLHIV.
PMCID: PMC4259284  PMID: 24093715
HIV; Beck’s cognitive theory of depression; self-esteem; HIV symptom management self-efficacy; self-compassion
15.  A qualitative study on commercial sex behaviors among male clients in Sichuan Province, China 
AIDS care  2010;22(2):246-252.
Males who seek commercial sex have been identified as an important “bridging population” in the transmission of HIV. There is little information on the HIV-related risk perceptions and behaviors among commercial sex male clients (CSMCs) in China. This study reports qualitative findings from six focus groups and 41 in-depth interviews with CSMCs in Sichuan Province, China. Commercial sex visits were described as a group activity and associated with patterns of social-network specific interactions and norms. Primary motivations for visiting female sex workers included peer pressure, stress reduction, and fulfilling a need for an intimate and emotional support. Male clients’ decisions about condom use were influenced by their perceived norms of condom use, susceptibility of HIV infection, and the condom policy and availability in the establishments. Implications of these findings for further research and interventions are discussed.
PMCID: PMC4487632  PMID: 20390503
commercial sex; male clients; China; HIV; qualitative; social norms
16.  Exploring HIV-testing intentions in young Asian/Pacific Islander (API) women as it relates to acculturation, theory of gender and power (TGP), and the AIDS risk reduction model (ARRM) 
AIDS care  2013;26(5):642-647.
While HIV rates are low for Asian/Pacific Islanders (APIs), they have been increasing, especially for API women in the USA. We conducted a cross-sectional study with 299 young API women (18–24 years old) in the Inland Empire region of Southern California to better understand their intention for HIV testing and their perceptions about HIV/AIDS. Data analyses included descriptive statistics, bivariate exploration for model building and multivariate analyses to determine variables associated with HIV-testing intentions. Results suggest that more lifetime sexual partners, greater perceived gender susceptibility, higher HIV/AIDS knowledge, sexually active, more positive attitudes about HIV testing and higher self-perceptions/experiences related to risk contribute to stronger intentions for HIV testing in young API women. Findings from this study will contribute to the limited literature on HIV/AIDS in API women and provide information that can be used for developing and implementing culturally appropriate programs that encourage HIV prevention and testing in this population.
PMCID: PMC4486074  PMID: 24111859
HIV/AIDS; sexual risk; HIV testing; API; women
AIDS care  2012;24(9):1126-1135.
The study investigated the behavioral and brain effects of childhood trauma and HIV-infection, both separately and in combination, and assessed potential interactions in women who were dually affected.
83 HIV-positive and 47 matched HIV-negative South African women underwent neuromedical, neuropsychiatric and neurocognitive assessments. Univariate tests of significance assessed if either HIV infection or childhood trauma, or the combination, had a significant effect on neurocognitive performance.
The majority of women were Black (96%) and had an average age of 30. An analysis of covariance revealed significant HIV effects for the Hopkins Verbal Learning Test (HVLT) learning and delay trials (p < .01) and the Halstead Category test (p < .05). A significant trauma effect was seen on the HVLT delay trial (p < .05).
The results provide evidence for neurocognitive dysfunction in memory and executive functions in HIV-infected women and memory disturbances in trauma exposed women.
PMCID: PMC4476396  PMID: 22672200
HIV/AIDS; childhood trauma; memory; executive functions; neurocognition
18.  Patient satisfaction with HIV/AIDS care at private clinics in Dar es Salaam, Tanzania 
AIDS care  2014;26(9):1150-1154.
Health system responsiveness measures quality of care from the patient’s perspective, an important component of ensuring adherence to medication and care among HIV patients. We examined health system responsiveness in private clinics serving HIV patients in Dar es Salaam, Tanzania. We surveyed 640 patients 18 or older receiving care at one of 10 participating clinics, examining socioeconomic factors, HIV regimen, and self-reported experience with access and care at the clinic. Ordered logistic regression, adjusted for clustering of the clinic sites, was used to measure the relationships between age, gender, education, site size and overall quality of care rating, as well as between the different HSR domains and overall rating. Overall, patients reported high levels of satisfaction with care received. Confidentiality, communication, and respect were particularly highly rated, while timeliness received lower ratings despite relatively short wait times, perhaps indicating high expectations when receiving care at a private clinic. Respect, confidentiality, and promptness were significantly associated with overall rating of health care, while provider skills and communication were not significantly associated. Patients reported that quality of service and confidentiality, rather than convenience of location, were the most important factors in their choice of a clinic. Site size (patient volume) was also positively correlated with patient satisfaction. Our findings suggest that, in the setting of urban private-sector clinics, flexible clinics hours, prompt services, and efforts to improve respect, privacy and confidentiality may prove more helpful in increasing visit adherence than geographic accessibility. While a responsive health system is valuable in its own right, more work is needed to confirm that improvements in health system responsiveness in fact lead to improved adherence to care.
PMCID: PMC4465080  PMID: 24499337
HIV; patient satisfaction; private sector; Tanzania; Quality of Care
19.  A Binational Comparison of HIV Provider Attitudes Towards the Use of Complementary and Alternative Medicine among HIV-Positive Latino Patients Receiving Care in the US-Mexico Border Region 
AIDS care  2012;25(8):990-997.
Use of complementary and alternative medicine (CAM) is common among Latinos living with HIV in the United States (U.S.)-Mexico border region. Health providers may vary in their approach to communicating acceptance or non acceptance of CAM use, which can undermine patient confidence in disclosing CAM use. Patient-provider communication about CAM is important because certain types of CAM can affect antiretroviral therapy (ART) adherence. We undertook the present binational study to understand U.S. and Mexican provider beliefs, and perceptions surrounding CAM use among Latino patients, and to learn if and how CAM communication occurs. Between July and December 2010, we conducted in-depth, qualitative interviews in Tijuana and San Diego. Analysis procedures drew upon principles of Grounded Theory. The sample was comprised of 19 HIV-health care providers, including 7 women and 12 men. Emerging CAM-related themes were: Provider's perceptions, attitudes and knowledge about CAM; CAM types and modalities; and patient-provider CAM communication. Many clinicians were uncomfortable supporting CAM use with their patients. San Diego providers reported more frequent instances of CAM use among Latino patients than Tijuana providers. Providers from both cities reported that patients infrequently disclose CAM use and almost half do not routinely ask patients about CAM practices. Most of the providers acknowledged that they lack information about CAM, and are concerned about the drug interaction as well as the effects of CAM on adherence. Our findings have important implications for understanding provider communication surrounding CAM use in a highly transnational population and context. Because CAM use may undermine ART adherence and is highly prevalent among Latinos, provider communication about CAM is critical to improved health outcomes among HIV-positive Latinos. Considering the significant growth of U.S. Latinos, especially in the U.S.-Mexico border region, assessment of Mexican and U.S. provider training and communication needs surrounding Latino patient CAM use is warranted.
PMCID: PMC4456174  PMID: 23088506
Patient-Physician communication; HIV/AIDS; ART Adherence; alternative and complementary medicine; perceptions and attitudes
20.  Childbearing motivations and pregnancy desires among urban female youth: Does HIV-infection status make a difference? 
AIDS care  2011;24(1):1-11.
Despite a growing literature assessing pregnancy desires among HIV-infected women enrolled in clinical care, little attention has been paid to HIV-infected youth for whom pregnancy is a very relevant issue. In urban areas with high rates of teen pregnancy and HIV infection, further understanding of childbearing motivations and relationship dynamics influencing pregnancy desires among female youth is needed. This study compares the childbearing motivations, pregnancy desires, and perceived partner desire for a pregnancy among predominately African American HIV-infected (n=46) and HIV-uninfected (n=355) female youth (15-24 years). An HIV-infected status was not significantly associated with childbearing motivations or the desire for a future pregnancy, p> 0.10. HIV-infection was, however, associated with an increased likelihood to perceive that one's partner would have a positive response to a pregnancy (OR 2.7, p=0.03) compared to uninfected peers. While race was not associated with participants' own desire for a child, white youth were significantly less likely to perceive a positive partner response to becoming pregnant than their African American peers (aOR 0.23 (.09-.56), p=0.001). These data suggest that the desire for childbearing is not diminished by HIV infection among urban female youth, highlighting the need for routine, provider-initiated discussions about childbearing with urban youth to minimized unintended pregnancies and HIV transmission.
PMCID: PMC4451594  PMID: 21777077
childbearing motivations; pregnancy desires; pregnancy intentions; perceived partner desire; urban adolescents and youth; HIV; African-American
21.  The feasibility, acceptance and key features of a prevention-focused oral health education program for HIV+ adults 
AIDS care  2013;26(6):763-768.
Poor oral health is common in HIV+ adults. We explored the feasibility, acceptance and key features of a prevention-focused oral health education program for HIV+ adults. This was a pilot sub-study of a parent study in which all subjects (n=112) received a baseline periodontal disease (PD) examination and provider-delivered oral health messages informed by the Information-Motivation-Behavioral Skills (IMB) Model. Forty-one parent study subjects were then eligible for the sub-study; of these subjects, a volunteer sample was contacted and interviewed 3–6 months after the baseline visit. At the recall visit, subjects self-reported behavior changes that they had made since the baseline. PD was re-assessed using standard clinical assessment guidelines and results were shared with each subject. At recall, individualized, hands-on oral hygiene coaching was performed and patients provided feedback on this experience. Statistics included frequency distributions, means and chi-square testing for bivariate analyses. Twenty two (22) HIV+ adults completed the study. At recall, subjects had modest, but non-significant (p>0.05) clinician observed improvement in PD. Each subject reported adopting, on average, 3.8 (± 1.5) specific oral health behavior changes at recall. By self-report, subjects attributed most behavior changes (95%) to baseline health messages. Behavior changes were self-reported for increased frequency of flossing (55%) and tooth-brushing (50%), enhanced tooth-brushing technique (50%), and improved eating habits (32%). As compared to smokers, non-smokers reported being more optimistic about their oral health (p=.024) at recall and were more likely to have reported changing their oral health behaviors (p=.009). All subjects self-reported increased knowledge after receiving hands-on oral hygiene coaching performed at the recall visit. In HIV+ adults, IMB-informed oral health messages promoted self-reported behavior change; subjects preferred more interactive, hands-on coaching. We describe a holistic clinical behavior change approach that may provide a helpful framework when creating more rigorously-designed IMB-informed studies on this topic.
PMCID: PMC3943585  PMID: 24134855
HIV; Oral Health; periodontal disease; Behavior Theory; prevention and communication
22.  Effects of an Intervention Addressing Information, Motivation, and Behavioral Skills on HIV Care Adherence in a Southern Clinic Cohort 
AIDS care  2013;26(6):674-683.
Multiple studies have shown that sub-therapeutic appointment adherence and medication adherence are associated with worse clinical outcomes for people living with HIV disease. Thus, poor appointment and medication adherence diminish individual and community HIV control and transmission. Yet not enough is known about interventions that can improve retention in HIV care. The purpose of this study was to test an intervention to improve retention and/or medication adherence in a public clinic in the Deep South. One hundred participants with retention or medication adherence difficulties were randomized to either a six-month intervention or usual care, and followed longitudinally for one year. The intervention was multidimensional, based on the Information-Motivation-Behavioral Skills (IMB) Model. The intervention addressed information about HIV and the importance of retention/adherence, motivation to be retained and/or adhere to medications, and the behavioral skills needed to manage and maintain these healthy behaviors in a combination of face-to-face and telephone sessions. The proportion of those with at least one visit in each 4-month block (third) of the year increased in those with minimal exposure to the intervention (three out of eight intervention contacts) as compared to those with less intervention exposure (p = .098). Those with at least this minimal exposure averaged a significantly higher number of thirds that included a clinic visit as compared to those with less intervention exposure (p = .013). The intervention did not demonstrate a significant effect on medication adherence, though this is contradictory to a previous study testing a version of this intervention designed to address only medication adherence. Further study to increase uptake of the intervention is needed to increase its efficacy.
PMCID: PMC3943644  PMID: 24116922
HIV; medication adherence; patient care; retention; IMB
23.  Factors associated with desire for children among HIV-infected women and men: A quantitative and qualitative analysis from Malawi and implications for the delivery of safer conception counseling 
AIDS care  2013;26(6):769-776.
Improved health outcomes have resulted in people with HIV facing decisions about childbearing. We sought to understand factors associated with desire for a child among men and women in Malawi. HIV-infected men and women ages 18-40 were invited to participate in a brief interview about fertility desires. Single variable logistic regression was used to evaluate factors associated with the outcome of fertility desire. Additionally, multiple logistic regression was used to assess the relationship of all the factors together on the outcome of fertility desire. In-depth interviews with women were performed to understand experiences with reproductive healthcare. A total of 202 brief interviews were completed with 75 men (37.1%) and 127 women (62.9%), with 103 (51.0%) of respondents desiring a child. Being in a relationship (OR 3.48, 95% CI: 1.58 to 7.65, p = 0.002) and duration of HIV more than two years (OR 2.00, 95% CI: 1.08 to 3.67, p=0.03) were associated with increased odds of desire for a child. Age 36-40 years (OR 0.64, 95% CI: 0.46 to 0.90, p = 0.009) and having a living child (OR 0.24, 95% CI: 0.07 to 0.84, p=0.03) were associated with decreased odds of desire for a child. Seventy percent of women (n=19 of 27 respondents) completing semi-structured interviews who responded to the question about decision-making reported that their male partners made decisions about children, while the remainder reported the decision was collaborative (n=8, 30%). Eighty-six percent of women (n=36 of 42 respondents) reported no discussion or a discouraging discussion with a provider about having children. HIV-infected women and men in Malawi maintain a desire to have children. Interventions are needed to integrate safer conception into HIV care, to improve male participation in safer conception counseling, and to empower providers to help patients make decisions about reproduction free of discrimination and coercion.
PMCID: PMC3943633  PMID: 24191735
HIV; fertility desires; safer conception; prevention of mother-to-child transmission; reproductive health
24.  A systematic review of income generation interventions, including microfinance and vocational skills training, for HIV prevention 
AIDS care  2013;26(6):659-673.
Income generation interventions, such as microfinance or vocational skills training, address structural factors associated with HIV risk. However, the effectiveness of these interventions on HIV-related outcomes in low- and middle-income countries has not been synthesized. We conducted a systematic review by searching electronic databases from 1990-2012, examining secondary references, and hand searching key journals. Peer-reviewed studies were included in the analysis if they evaluated income generation interventions in low- or middle-income countries and provided pre-post or multi-arm measures on behavioral, psychological, social, care or biological outcomes related to HIV prevention. Standardized forms were used to abstract study data in duplicate and study rigor was assessed. Of 5,218 unique citations identified, 12 studies met criteria for inclusion. Studies were geographically diverse, with 6 conducted in sub-Saharan Africa, 3 in South or Southeast Asia, and 3 in Latin America and the Caribbean. Target populations included adult women (N=6), female sex workers/bar workers (N=3), and youth/orphans (N=3). All studies targeted females except 2 among youth/orphans. Study rigor was moderate, with 2 group-randomized trials and 2 individual-randomized trials. All interventions except 3 included some form of microfinance. Only a minority of studies found significant intervention effects on condom use, number of sexual partners or other HIV-related behavioral outcomes; most studies showed no significant change, although some may have had inadequate statistical power. One trial showed a 55% reduction in intimate partner violence (adjusted risk ratio 0.45, 95% confidence interval 0.23-0.91). No studies measured incidence/prevalence of HIV or sexually transmitted infections among intervention recipients. The evidence that income generation interventions influence HIV-related behaviors and outcomes is inconclusive. However, these interventions may have important effects on outcomes beyond HIV prevention. Further studies examining not only HIV-related outcomes, but also causal pathways and intermediate variables, are needed. Additional studies among men are also needed.
PMCID: PMC3943565  PMID: 24107189
Income generation; microcredit; microfinance; vocational skills; livelihoods; HIV prevention
25.  HIV Testing Male Partners of Pregnant Women in Porto Alegre, Brazil: A Potential Strategy for Reduction of HIV Seroconversion during Pregnancy 
AIDS care  2013;26(6):790-794.
Pregnant women have a significantly higher risk of HIV acquisition during gestation than their non-pregnant counterparts due to behavioral and biological factors. Acute seroconversion during gestation results in increased HIV mother-to-child transmission rates and has been identified as a major public health challenge. In order to address potential HIV seroconversion in our pregnant patients, we conducted a prospective cohort study to evaluate the acceptability of offering HIV testing to sexual partners of HIV-negative pregnant women receiving antenatal care at 2 hospitals in Porto Alegre, Brazil. Over a 14 month study period, HIV-negative pregnant women at two hospital-based clinic sites were encouraged to bring their stable sexual partner for HIV voluntary counseling and testing during prenatal care. Women were re-interviewed following delivery to measure success of the intervention. Of the 1223 HIV-negative pregnant women enrolled in the study, 663 (54%) of their male sexual partners received HIV testing during antenatal care and 4 (0.6%) were diagnosed with HIV infection. Six hundred and forty five women were interviewed at the time of delivery, with 620 (97%) confirming that HIV testing was suggested to their partner. The most common reason provided by women as to why partners did not come for testing was work (69%) and lack of perceived risk (14%). Independent predictors of successful partner testing included being white (OR 1.59, 95% CI 1.18–2.12), married (OR 1.78, 95% CI 1.08–2.94), having an older age of sexual debut (OR 0.94, 95% CI 0.9–0.98), and being recruited at Hospital Conceiçao (OR 2.1, 95% CI 1.52–2.88). We conclude that HIV partner testing during prenatal care is acceptable, rendering this intervention attractive to public health programs targeting prevention of sexually transmitted infections.
PMCID: PMC4230890  PMID: 24200084
Partner testing; acute seroconversion; pregnancy; prevention of mother to child transmission

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