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1.  Social and behavioral characteristics of gharwalis who operate brothels in the Ganga-Jamuna area of Nagpur, India 
AIDS care  2012;25(4):438-442.
Nagpur is an industrial hub in Maharashtra, a state in Central India that has the second highest HIV prevalence in the country. Approximately 3000 brothel-based female sex workers (FSWs) are estimated to be working in Nagpur’s Ganga-Jamuna red light district. The extent to which brothel madams, known as gharwalis, support HIV/STI prevention for FSWs has not been examined. The present study sought to identify personal, social, and behavioral characteristics of gharwalis in Nagpur as well as enhance our understanding of the gharwali’s role in shaping the sexual practices of brothel-based FSWs. Thirty gharwalis participated in a survey that covered personal, social, behavioral, and environmental characteristics. Respondents ranged in age from 29 to 50 years (M = 38.9) and had worked as a gharwali for an average of 5.3 years; 80% had no formal education, 43% had never married and 30% were divorced or separated, and 93% earned money from their own sex work. Gharwalis managed an average of 4.2 FSWs (range 2 to 10). Overall, gharwalis reported positive attitudes toward condoms, promoted use of condoms by their FSWs with clients, taught FSWs how to use condoms, knew where to obtain condoms for free, and required HIV testing for their FSWs; however, levels of HIV prevention knowledge were low. Gharwalis also reported providing a range of support services to FSWs who lived in their brothels, including shelter, protection from drunk and aggressive clients and police, emotional support, caring and love, and health care. These data suggest the feasibility of involving gharwalis in brothel-based HIV prevention programs.
doi:10.1080/09540121.2012.712663
PMCID: PMC3502656  PMID: 22877415
2.  Situating HIV risk in the lives of formerly trafficked female sex workers on the Mexico-US border 
AIDS care  2012;25(4):459-465.
Due to stigma and the psychosocial repercussions of past trauma and abuse, survivors of sex trafficking may experience increased susceptibility to violence, revictimization, and various harmful health outcomes, including HIV infection. Given the paucity of research characterizing the experiences of formerly trafficked female sex workers (FSWs), we set out to describe and contextualize perceptions of HIV risk among women who have experienced past episodes of sex trafficking and who are currently engaged in sex work in Tijuana, Mexico. Based on semi-structured interviews and ethnographic fieldwork, we describe the following interrelated themes as influencing formerly trafficked FSWs' perceptions and experiences of HIV risk: economic vulnerability; susceptibility to violence; and psychological trauma. Our findings highlight the need for HIV prevention efforts to incorporate broader structural and social interventions aimed at reducing vulnerability to violence and human rights abuses among this population and improving their general economic, psychological, and social well-being.
doi:10.1080/09540121.2012.720361
PMCID: PMC3521850  PMID: 22963518
Sex trafficking; HIV; sex work; violence; Mexico border
3.  Chronic illness burden and quality of life in an aging HIV population 
AIDS care  2012;25(4):451-458.
The population of persons living with HIV (PLWH) is growing older and more prone to developing other chronic health conditions. Disease progression has been shown to be related to quality of life. However, descriptions of chronic comorbid illnesses and the unique quality of life challenges of older adults living with HIV are not well understood and have not been examined in multiple geographic locations. 452 PLWH aged 50 years or older were recruited from AIDS Service Organizations in 9 states. Participants completed a telephone survey that included measures of other chronic health conditions, perceived stress, depression and health related quality of life. 94% of the sample reported a chronic health condition in addition to HIV (mode = 2). The highest reported conditions were hypertension, chronic pain, hepatitis, and arthritis. Despite relatively high rates of depression, overall quality of life was moderately high for the sample. Physical functioning was most impacted by the addition of other chronic health problems. Social functioning, mental health functioning, stress and depression were also strongly associated with chronic disease burden. Additional chronic health problems are the norm for PLWH aged 50 years and older. Quality of life is significantly related to the addition of chronic health problems. As increasing numbers of PLWH reach older age, this raises challenges for providing comprehensive healthcare to older PLWH with multiple chronic conditions.
doi:10.1080/09540121.2012.712669
PMCID: PMC3535557  PMID: 22894702
HIV; Older Adults; Chronic Illness; Quality of Life
4.  Intimate partner violence and HIV risk factors among African American and African Caribbean women in clinic-based settings 
AIDS care  2012;25(4):472-480.
Despite progress against intimate partner violence (IPV) and HIV/AIDS in the past two decades, both epidemics remain major public health problems, particularly among women of color. The objective of this study was to assess the relationship between recent IPV and HIV risk factors (sexual and drug risk behaviors, STIs, condom use and negotiation) among women of African descent. We conducted a comparative case-control study in women’s health clinics in Baltimore, Maryland and St. Thomas and St. Croix, US Virgin Islands (USVI). Women aged 18–55 years who experienced physical and/or sexual IPV in the past two years (Baltimore, n=107; USVI, n=235) were compared to women who never experienced any form of abuse (Baltimore, n=207; USVI, n=119). Logistic regression identified correlates of recent IPV by site. In both sites, having a partner with concurrent sex partners was independently associated with a history of recent IPV (Baltimore, AOR: 3.91, 95% CI:1.79–8.55 and USVI, AOR: 2.25, 95% CI:1.11–4.56). In Baltimore, factors independently associated with recent IPV were lifetime casual sex partners (AOR: 1.99, 95% CI: 1.11–3.57), exchange sex partners (AOR: 5.26, 95% CI:1.92–14.42), infrequent condom use during vaginal sex (AOR: 0.24, 95% CI:0.08–0.72), and infrequent condom use during anal sex (AOR: 0.29, 95% CI:0.09–0.93). In contrast, in the USVI, having a concurrent sex partner (AOR: 3.33, 95% CI:1.46–7.60), frequent condom use during vaginal sex (AOR: 1.97, 95% CI:1.06–3.65), frequent condom use during anal sex (AOR: 6.29, 95% CI:1.57–25.23), drug use (AOR: 3.16, 95% CI:1.00–10.06), and a past-year STI (AOR: 2.68, 95% CI:1.25–5.72) were associated with recent IPV history. The divergent results by site warrant further investigation into the potential influence of culture, norms, and intentions on the relationships examined. Nonetheless, study findings support a critical need to continue the development and implementation of culturally tailored screening for IPV within HIV prevention and treatment programs.
doi:10.1080/09540121.2012.722602
PMCID: PMC3556174  PMID: 23006050
HIV/AIDS; intimate partner violence; Caribbean; African descent; women
5.  A Randomized Controlled Trial of an HIV/AIDS Symptom Management Manual for Depressive Symptoms 
AIDS care  2012;25(4):391-399.
Depressive symptoms are highly prevalent, underdiagnosed and undertreated in people living with HIV/AIDS (PLWH), and are associated with poorer health outcomes. This randomized controlled trial examined the effects of the HIV/AIDS Symptom Management Manual self-care symptom management strategies compared to a nutrition manual on depressive symptoms in an international sample of PLWH. The sample consisted of a sub-group (N=222) of participants in a larger study symptom management study who reported depressive symptoms. Depressive symptoms of the intervention (n=124) and control (n=98) groups were compared over three months: baseline, one-month and two-months. Use and effectiveness of specific strategies were examined. Depressive symptom frequency at baseline varied significantly by country (χ2 12.9; p=0.04). Within the intervention group there were significant differences across time in depressive symptom frequency [F(2, 207) = 3.27, p=0.05], intensity [F(2, 91) = 4.6, p=0.01] and impact [F(2, 252) = 2.92, p= 0.05), and these were significantly lower at one-month but not at two-months, suggesting that self-care strategies are effective in reducing depressive symptoms, however effects may be short-term. Most used and most effective self-care strategies were distraction techniques and prayer. This study suggests the people living with HIV can be taught and will employ self-care strategies for management of depressive symptoms, and that they are effective in reducing these symptoms. Self-care strategies are non-invasive, have no side-effects and can be readily taught as an adjunct to other forms of treatment. Studies are needed to identify the most effective self-care strategies and quantify optimum dose and frequency of use as a basis for evidence-based practice.
doi:10.1080/09540121.2012.712662
PMCID: PMC3561506  PMID: 22880943
depressive symptoms; HIV disease; self-management; symptom management; randomized controlled trial
6.  HIV-related symptoms and patient clusters among Chileans living with HIV 
AIDS care  2012;25(4):488-495.
Identifying both HIV-related and co-morbid symptoms experienced by people living with HIV (PLWH) who are receiving antiretroviral therapy treatment (ART) is a major challenge for health care providers globally. Yet little research to date has examined the symptoms of illness experienced by PLWH including patients living in Central and South American. To address this gap, this study was designed to identify symptoms of HIV by socio-demographic and/or clinical characteristics among Chilean patients living with the virus. A convenience sample of 209 Chilean PLWH was recruited from an outpatient clinic in Santiago, Chile. A structured interview was used to elicit socio-demographic information and HIV symptoms status. Additional clinical information was obtained through a review of the participants’ medical records. Results show that patients’ most commonly reported HIV-related symptoms were fear/worries (66%), anxiety (52%), gas/bloating (50%), and thirst (50%). Multivariate analysis revealed a positive association between the number of reported HIV-related symptoms and number of years living with HIV. Having completed college was negatively associated with number of symptoms. Latent class analysis indicated that PLWH in the sample who had completed college were two times more likely to experience a mild intensity of HIV-related symptoms than their lesser educated counterparts. Similarly, logistic regression revealed that college-educated PLWH were twice as likely to be classified in the subgroup reporting mild intensity of symptoms than those who lacked a college degree. Overall, the study’s results reveal that many Chilean PLWH, even those with high CD4 counts and low or undetectable viral loads, are not symptom free. The findings point to the need for clinicians to tailor a plan of care for individuals living with HIV that is based on their symptomatology.
doi:10.1080/09540121.2012.714457
PMCID: PMC3563858  PMID: 22909386
Symptoms; HIV infections; people living with HIV; clusters analysis; quantitative method
7.  Unprotected sex with their clients among low-paying female sex workers in southwest China 
AIDS care  2012;25(4):503-506.
Background
China has been experiencing a rapid increase in the HIV epidemic for decades. Commercial sex plays a critical role in heterosexual transmission of HIV. Limited studies suggested that low-paying female sex workers (FSWs) faced a higher risk of HIV infection. Low-paying FSWs are women who usually encounter their clients on the street or small establishments in rural or less-developed areas, or who charge low fees for each sexual service.
Methods
A total of 720 low-paying FSWs from 130 commercial sex venues/locations in southwest China were included in the data analysis. Multivariate regression models were employed to examine the associations of unprotected sex with a number of exploratory variables among the study sample.
Results
About 33.9% and 61.5% of low-paying FSWs reported unprotected sex with clients in the last sex act and in the last month, respectively. After controlling for confounders, women’s HIV knowledge, risk perception, experience of police arrest, and venue types were significantly associated with unprotected sex among low-paying FSWs.
Discussion
Low-paying FSWs are at an alarmingly high risk of HIV infection. HIV prevention programs are urgently needed to address risk factors posit in both individual and contextual levels among this most-at-risk population in order to curb the HIV epidemic in China.
doi:10.1080/09540121.2012.726345
PMCID: PMC3594428  PMID: 23062062
Low-paying FSWs; HIV risks; Unprotected sex; China
8.  The importance of HIV prevention messaging for orphaned youth in Zimbabwe 
AIDS care  2012;24(7):877-885.
The AIDS epidemic has contributed to a drastic increase in the number of orphans in Zimbabwe. Female adolescent orphans are particularly in jeopardy of contracting HIV due to disadvantages including extreme poverty, low education, and the absent of parental oversight which can lead to higher risk-taking sexual behaviors. By understanding where girls receive education about HIV and who they rely on for information, organizations can effectively modify existing programs to better target this at-risk population. For this study a household survey was conducted which included 216 orphans and 324 non-orphans (n=540), aged 12–17 years old, in the resource-poor setting of Hwange District, Zimbabwe. The aims of this paper were to examine the differences between orphans and non-orphans in HIV prevention message exposure, level of motivation for learning about HIV, and communication with caregivers about safe sex. The household survey revealed that younger orphans, aged 12–15 years old, were more motivated to learn about HIV and had greater HIV messaging exposure in school than non-orphans. These exposure and differences in the levels of motivation between groups dissipated at older ages. Our research also discovered less caregiver communication among orphans than non-orphans. Our findings suggest that HIV programs targeting orphans need to do a better job at keeping older orphans interested in HIV prevention at a time when it matters most. Furthermore, intervention strategies that provide caregiver support are instrumental in effectively delivering prevention messages to girls at home.
doi:10.1080/09540121.2011.648162
PMCID: PMC3966070  PMID: 22293040
orphans; AIDS; parent communication; HIV prevention programs; Zimbabwe; adolescents
9.  Gender Equality and Education: Increasing the Uptake of HIV Testing among Married Women in Kenya, Zambia and Zimbabwe 
AIDS care  2013;25(11):1452-1461.
Gender equality and education are being promoted as strategies to combat the HIV epidemic in Africa, but few studies have looked at the role of gender equality and education in the uptake of a vital service - HIV testing. This study looks at associations between education (a key input needed for gender equality) and key gender equality measures (financial decision-making and attitudes towards violence) with ever tested for HIV and tested for HIV in the past year. The study focused on currently married women ages 15–24 and 25–34 in three countries - Kenya, Zambia and Zimbabwe. The data came from the Demographic and Health Surveys (DHS). Logistic regression was used to study the role of gender equality and education on the HIV testing outcomes after controlling for both social and biological factors. Results indicated that education had a consistent positive relationship with testing for both age groups, and the associations were always significant for young women 15–24 (p<0.01). The belief that gender-based violence is unacceptable was positively associated with testing for women 25–34 in all three countries though the associations were only significant in Kenya (among women reporting ever being tested: OR 1.58, p<0.00; among women reporting being tested in the past year: OR 1.34, p<0.05) and Zambia (among women reporting ever being tested: OR 1.24, p<0.10; among women reporting being tested in the past year: OR 1.29, p< 0.05). High financial decision-making was associated with testing for women 25–34 in Zimbabwe only (among women reporting ever being tested: OR 1.66, p< 0.01). Overall the findings indicate that education and the promotion of gender equality are important strategies for increasing uptake of a vital HIV service, and thus are important tools for protecting girls and young women against HIV.
doi:10.1080/09540121.2013.774311
PMCID: PMC3966089  PMID: 23438082
empowerment; financial decision-making; gender equality; gender-based violence; HIV; voluntary counseling and test (VCT)
10.  Mediators of antiretroviral adherence: a multisite international study 
AIDS care  2012;25(3):364-377.
The purpose of this study was to investigate the effects of stressful life events (SLE on medication adherence (3 day, 30 day) as mediated by sense of coherence (SOC), self-compassion (SCS), and engagement with the health care provider (eHCP) and whether this differed by international site. Data were obtained from a cross-sectional sample of 2082 HIV positive adults between September 2009 and January 2011 from sites in Canada, China, Namibia, Puerto Rico, Thailand and the U.S. Statistical tests to explore the effects of stressful life events on antiretroviral medication adherence included descriptive statistics, multivariate analysis of variance (MANOVA), analysis of variance (ANOVA) with Bonferroni post-hoc analysis, and path analysis. An examination by international site of the relationships between SLE, SCS, SOC and eHCP with adherence (3 day, 30 day) indicated these combined variables were related to adherence whether 3 day or 30 day to different degrees at the various sites. SLE, SCS, SOC, and eHCP were significant predictors of adherence past 3 days for the U.S (p= <.001), Canada (p= .006), and Namibia (p= .019). The combined independent variables were significant predictors of adherence past 30 days only in the U.S. and Canada.
Engagement with the provider was a significant correlate for antiretroviral adherence in most, but not all, of these countries. Thus the importance of eHCP cannot be overstated. Nonetheless, our findings need to be accompanied by the caveat that research on variables of interest while enriched by a sample obtained from international sites, may not have the same relationships in each country. Mediators of antiretroviral adherence: a multisite international study
doi:10.1080/09540121.2012.701723
PMCID: PMC3491166  PMID: 22774796
adherence; stressful life events; sense of coherence; self compassion; engagement with the provider; HIV/AIDS
11.  Theoretical Models of Parental HIV Disclosure: A Critical Review 
AIDS care  2012;25(3):326-336.
This review critically examined three major theoretical models related to parental HIV disclosure (i.e., the Four-Phase Model, the Disclosure Decision Making Model, and the Disclosure Process Model), and the existing studies that could provide empirical support to these models or their components. For each model, we briefly reviewed its theoretical background, described its components and or mechanisms, and discussed its strengths and limitations. The existing empirical studies supported most theoretical components in these models. However, hypotheses related to the mechanisms proposed in the models have not yet tested due to a lack of empirical evidence. This review also synthesized alternative theoretical perspectives and new issues in disclosure research and clinical practice that may challenge the existing models. The current review underscores the importance of including components related to social and cultural contexts in theoretical frameworks, and calls for more adequately designed empirical studies in order to test and refine existing theories and to develop new ones.
doi:10.1080/09540121.2012.712658
PMCID: PMC3508317  PMID: 22866903
Parental HIV infection; HIV disclosure; Parental HIV disclosure; Literature review; Theoretical model
12.  Delayed initiation of antiretroviral therapy among HIV-discordant couples in Kenya 
AIDS care  2012;25(3):265-272.
Timely initiation of antiretroviral therapy (ART) is particularly important for HIV-discordant couples because viral suppression greatly reduces the risk of transmission to the uninfected partner. To identify issues and concerns related to ART initiation among HIV-discordant couples, we recruited a subset of discordant couples participating in a longitudinal study in Nairobi to participate in in-depth interviews and focus group discussions about ART. Our results suggest that partners in HIV-discordant relationships discuss starting ART, yet most are not aware that ART can decrease the risk of HIV transmission. Additionally, their concerns about ART initiation include side effects, sustaining an appropriate level of drug treatment, HIV/AIDS related stigma, medical/biological issues, psychological barriers, misconceptions about the medications, the inconvenience of being on therapy, and lack of social support. Understanding and addressing these barriers to ART initiation among discordant couples is critical to advancing the HIV “treatment as prevention” agenda.
doi:10.1080/09540121.2012.712660
PMCID: PMC3523215  PMID: 22866934
HIV/AIDS; serodiscordant couples; serodiscordant; antiretroviral therapy; Africa
13.  Positive parenting for positive parents: HIV/AIDS, poverty, caregiver depression, child behavior and parenting in South Africa 
AIDS care  2013;26(3):304-313.
Families affected by HIV/AIDS in the developing world experience higher risks of psychosocial problems than non-affected families. Positive parenting behavior may buffer against the negative impact of child AIDS-orphanhood and caregiver AIDS-sickness on child wellbeing. Although there is substantial literature regarding the predictors of parenting behavior in Western populations, there is insufficient evidence on HIV/AIDS as a risk factor for poor parenting in low- and middle-income countries. This paper examines the relationship between HIV/AIDS and positive parenting by comparing HIV/AIDS-affected and non-affected caregiver-child dyads (n = 2,477) from a cross-sectional survey in KwaZulu-Natal, South Africa (27.7% AIDS-ill caregivers; 7.4% child AIDS-orphanhood). Multiple mediation analyses tested an ecological model with poverty, caregiver depression, perceived social support, and child behavior problems as potential mediators of the association of HIV/AIDS with positive parenting. Results indicate that familial HIV/AIDS’s association to reduced positive parenting was consistent with mediation by poverty, caregiver depression and child behavior problems. Parenting interventions that situate positive parenting within a wider ecological framework by improving child behavior problems and caregiver depression may buffer against risks for poor child mental and physical health outcomes in families affected by HIV/AIDS and poverty.
doi:10.1080/09540121.2013.825368
PMCID: PMC3922642  PMID: 23930647
Parenting; depression; social support; poverty; child behavior, HIV/AIDS; orphan; caregiver
14.  A Qualitative Study of Barriers to Consistent Condom Use among HIV-1 Serodiscordant Couples in Kenya 
AIDS care  2011;24(4):509-516.
This study explored barriers to consistent condom use among heterosexual HIV-1 serodiscordant couples who were aware of the HIV-1 serodiscordant status and had been informed about condom use as a risk reduction strategy. We conducted 28 in-depth interviews and 9 focus group discussions among purposively-selected heterosexual HIV-1 serodiscordant couples from Thika and Nairobi districts in Kenya. We analyzed the transcribed data with a grounded theory approach. The most common barriers to consistent condom use included male partners’ reluctance to use condoms regardless of HIV-1 status coupled with female partners’ inability to negotiate condom use, misconceptions about HIV-1 serodiscordance, and desire for children. Specific areas of focus should include development of skills for women to effectively negotiate condom use, ongoing information on HIV-1 serodiscordance and education on safer conception practices that minimize risk of HIV-1 transmission.
doi:10.1080/09540121.2011.613911
PMCID: PMC3932299  PMID: 22085306
HIV-1; Serodiscordant; Condom use; Kenya
15.  Adolescent Response to Having an HIV-infected Mother 
AIDS care  2013;25(6):10.1080/09540121.2013.769495.
In this study, late adolescents/early adults whose mothers were living with HIV (MLH) were interviewed in order to explore their perceptions of what it had been like for them to grow up under the shadow of their mothers’ illness. Adolescents were asked to describe what the difficult aspects of growing up with an HIV-positive mother were as well as what, if any, were the more rewarding aspects. Interviews were conducted in 2009 - 2010 with a random sample of 40 adolescents being followed in a longitudinal assessment study. All study participants were English or Spanish speaking. Mean age was 18.9 (SD = 1.9) years; 67.5% were Latino; 27.5% African American; and 5% other/multi-racial. Results revealed that growing up with an HIV-positive mother had both challenges as well as rewards. On the challenge side, adolescents mentioned six main issues: (1) disappointment regarding mothers’ missing of childhood activities and events; (2) worry about mothers’ health; (3) worry about the possibility of mothers’ death; (4) increased burden of adult responsibilities/caregiving; (5) feelings of secrecy/stigma associated with HIV/AIDS; and (6) need to self-monitor behavior and communication to avoid maternal stress. On the positive side, adolescents mentioned three main rewarding aspects of growing up with an HIV-positive mother: increased closeness in the mother-child relationship; fostering of positive personality traits (e.g., resilience, gratitude, open-mindedness); and “perks” accorded to HIV-affected families.
doi:10.1080/09540121.2013.769495
PMCID: PMC3832195  PMID: 23414445
HIV+ Mothers; Family Functioning; Chronic Illness; Qualitative Interviews; Longitudinal Study
16.  Community environments shaping transactional sex among sexually active men in Malawi, Nigeria, and Tanzania 
AIDS care  2012;25(6):784-792.
Transactional sex, or the exchange of sex for material goods or money, is a risky sexual behavior that has been linked to HIV/AIDS and gender-based violence. Throughout sub-Saharan Africa, transactional sex remains a common practice, putting men and women at risk of HIV. However, little is known of how community environments shape men’s participation in risky transactional sex. This analysis examines community-level influences on participation in risky transactional sex among sexually active men in three African countries (Malawi, Tanzania, and Nigeria). The analysis uses Demographic and Health Survey (DHS) data to examine the association between men’s report of risky transactional sex and community characteristics including economic, gender norms, HIV behavior and knowledge, and demographic factors. The results show that men residing in communities with more female education and later age of first birth are less likely to report risky transactional sex, while men who live in communities where men report higher number of sexual partners are more likely to report risky transactional sex. While programmatic interventions should continue to improve women’s status individually and relative to men, such efforts should be extended to recognize that many community and cultural influences also affect men’s sexual behavior. Programs that understand, discuss, and challenge community factors that influence men’s sexual behavior may be able to provide a more effective intervention resulting in opportunities for communities to initiate behavioral change.
doi:10.1080/09540121.2012.748161
PMCID: PMC3914300  PMID: 23215551
transactional sex; contextual factors; community; Africa; men
17.  Socio-cultural and Economic Antecedents of Adolescent Sexual Decision-Making and HIV-Risk in Rural Uganda 
AIDS care  2012;25(2):258-264.
With more than half of new infections occurring among youth, HIV/AIDS remains a major contributor to morbidity and mortality in Uganda. Semi-structured interviews were performed with 48 adolescents and 15 adult key informants in a rural Ugandan community to identify influences on adolescent sexual decision-making. Inductive data analytic methods revealed five thematic influences: 1) social pressure, 2) decline of the Senga (a familial figure who traditionally taught female adolescents about how to run a household), 3) cultural barriers to condom use, 4) knowledge of HIV transmission and modes of prevention, and 5) a moral injunction against sex before marriage. Influences were classified as HIV/AIDS risk and protective factors and organized to form an explanatory framework of adolescent sexual risk-taking. Risk factors pull youth toward risky behavior, while protective factors push them away. Predominance of risk over protective influences explains persistent sexual risk-taking by Ugandan youth. HIV prevention programs designed for Ugandan adolescents should take competing factors and socio-cultural and economic influences into account.
doi:10.1080/09540121.2012.701718
PMCID: PMC3488357  PMID: 22835224
HIV prevention; adolescents; Uganda; sexual risk-taking
18.  Socio-demographic and Behavioral Correlates for HIV and Syphilis Infections among Migrant Men Who Have Sex With Men in Beijing, China 
AIDS care  2012;25(2):249-257.
Migrant men who have sex with men (MSM) may be particularly vulnerable to sexually transmitted infections (STIs) including HIV. This study examines the rates of HIV and syphilis infections and associated socio-demographic and behavioral factors among migrant MSM in China. Data from 307 migrant MSM were collected in Beijing, China. Blood specimens were collected to test for HIV and syphilis infections. HIV and syphilis rates were 5.9% and 20.2%, respectively. Multivariate logistic regression analyses showed that having ever been married, living a longer period in Beijing, having more sexual partners, and having a foreign MSM friend were significantly associated with HIV infection. Migrating from a rural area, experiencing one’s sexual debut at an older age, having a male as first sexual partner, having more sexual partners, and being recruited from peer outreach and social network were associated with syphilis infection. Migrant MSM in China are at high risk for HIV and syphilis infections. HIV prevention programs targeting rural migrant MSM who have been married are needed.
doi:10.1080/09540121.2012.701714
PMCID: PMC3563352  PMID: 22788859
China; men who have sex with men; HIV; syphilis; unprotected anal intercourse; sexual partners
19.  Managing identity impacts associated with disclosure of HIV status: a qualitative investigation 
AIDS care  2009;21(8):1071-1078.
Disclosure of HIV status to potential and current sex partners by HIV-positive people (HIVPP) is a complex issue that has received a significant amount of attention. Research has found that disclosure depends upon the evaluation by HIVPP of potential benefits and risks, especially of the risks stemming from the profound social stigma of HIV and AIDS. Drawing on concepts from Goffman’s classic stigma theory and Anderson’s more recently developed cultural-identity theory of drug abuse, we analyzed data from in-depth, post-intervention qualitative interviews with 116 heterosexually active, HIV-positive injection drug users enrolled in a randomized trial of a behavioral intervention to prevent HIV transmission. We explored how disclosure experiences lead to “identity impacts” defined as: (1) identity challenges (i.e. interactions that challenge an individual’s self-concept as a “normal” or non-deviant individual); and (2) identity transformations (i.e. processes whereby an individual comes to embrace a new identity and reject behaviors and values of an old one, resulting in the conscious adoption of a social and/or public identity as an HIV-positive individual). Participants engaged in several strategies to manage the identity impacts associated with disclosure. Implications of these findings for research and prevention programming are discussed.
doi:10.1080/09540120802657514
PMCID: PMC3903159  PMID: 20024764
HIV disclosure; injection drug use; social identity; HIV prevention
20.  “They give us hope”: HIV-positive caregivers’ perspectives on the role of social support for health 
AIDS care  2013;25(10):1203-1209.
A number of studies indicate that social support is associated with better health outcomes among HIV-positive caregivers of children, suggesting its potential importance for interventions aimed at safeguarding the wellbeing of this population. However, there is very little published literature assessing the support-health relationship or evaluating applied social support interventions with HIV-positive populations in HIV-endemic contexts of the developing world. The global literature on social support and health suggests that, in order to refine theory and improve interventions, greater attention should be paid to specific dimensions of support, such as types and sources, as well as the processes through which support may be affecting health outcomes. This article presents and discusses data from in-depth interviews with twelve HIV-positive primary caregivers of children living in an HIV-endemic, low-resourced, urban South African community. The primary aim of this qualitative work was to provide further insight into survey findings of a positive relationship between social support and self-reported general health and functioning, by exploring caregivers’ personal experiences of being supported within their community, and their perceptions on how this ‘informal’ support may be influencing their health. Our qualitative data highlight the importance of instrumental and emotional support for this population, the relevance of support provider characteristics and some of the processes or pathways that are likely explaining the support-health link. These processes include psychological factors such as mastery and hope, coping strategies and positive health behaviours. We provide recommendations for future research to further this work, and discuss implications for health interventions.
doi:10.1080/09540121.2013.763893
PMCID: PMC3892909  PMID: 23356672
21.  BARRIERS TO ADHERENCE TO ANTIRETROVIRAL MEDICATIONS AMONG PATIENTS LIVING WITH HIV IN SOUTHERN CHINA: A QUALITATIVE STUDY 
AIDS care  2008;20(10):1242-1250.
Although China’s government is rapidly expanding access to antiretroviral therapy, little is known about barriers to adherence among Chinese HIV-infected patients, particularly among injection drug users (IDUs). To better understand barriers to antiretroviral treatment adherence, we conducted a qualitative research study, using both focus group and key informant methods, among 36 HIV-positive men and women in Dali, in southwestern China. All interviews utilized semi-structured question guides and were conducted in Mandarin, audio-recorded, and translated into English for analysis. The most commonly cited adherence challenges were stigma, including secondary stigma experienced by family members; mental health issues; and economic concerns, particularly related to finding and maintaining employment. Distinctive gender differences emerged, partly due to previous heroin use among male respondents. Optimizing adherence may require that antiretroviral therapy programs be linked to other services, including drug addiction treatment, mental health services, and vocational treatment and support. HIV care and service providers, and policy makers in China responsible for HIV treatment, should be aware of these important barriers to adherence.
doi:10.1080/09540120801918651
PMCID: PMC3888993  PMID: 19012083
HIV; AIDS; antiretroviral therapy; adherence; injection drug users; qualitative research; China; mental health; stigma; vocational support
22.  Identifying self-perceived HIV-related stigma in a population accessing antiretroviral therapy 
AIDS care  2012;25(1):10.1080/09540121.2012.687809.
This study identifies factors associated with self-perceived HIV-related stigma (stigma) among a cohort of individuals accessing antiretroviral therapy (ART) in British Columbia, Canada. Data were drawn from the Longitudinal Investigations into Supportive and Ancillary Health Services study, which collects social, clinical, and quality of life (QoL) information through an interviewer-administered survey. Clinical variables (i.e. CD4 count) were obtained through linkages with the British Columbia HIV/AIDS Drug Treatment Program. Multivariable linear regression was performed to determine the independent predictors of stigma. Our results indicate that among participants with high school education or greater the outcome stigma, was associated with a 3.05 stigma unit decrease (95% CI: −5.16, −0.93). Having higher relative standard of living and perceiving greater neighborhood cohesion were also associated with a decrease in stigma (−5.30 95% CI: −8.16, −2.44; −0.80 95% CI: −1.39, −0.21, respectively). Lower levels of stigma were found to be associated with better QoL measures, including perceiving better overall function (−0.90 95% CI: −1.47, −0.34), having fewer health worries (−2.11 95% CI: −2.65, −1.57), having fewer financial worries (−0.67 95% CI: −1.12, −0.23), and having less HIV disclosure concerns (−4.12 95% CI: −4.63, −3.62). The results of this study show that participants with higher education level, better QoL measures, and higher self-reported standards of living are less likely to perceive HIV-related stigma.
doi:10.1080/09540121.2012.687809
PMCID: PMC3879041  PMID: 22672228
stigma; ART; quality of life; HIV
23.  Evaluation of the effectiveness of an outreach clinical mentoring programme in support of paediatric HIV care scale-up in Botswana 
AIDS care  2012;25(1):11-19.
Clinical mentoring by providers skilled in HIV management has been identified as a cornerstone of scaling-up antiretroviral treatment in Africa, particularly in settings where expertise is limited. However, little data exist on its effectiveness and impact on improving the quality-of-care and clinical outcomes, especially for HIV-infected children. Since 2008, the Botswana-Baylor Children’s Clinical Centre of Excellence (COE) has operated an outreach mentoring programme at clinical sites around Botswana. This study is a retrospective review of 374 paediatric charts at four outreach mentoring sites (Mochudi, Phutadikobo, Molepolole, Thamaga) evaluating the effectiveness of the programme as reflected in a number of clinically-relevant areas. Charts from one visit prior to initiation of mentoring and from one visit after approximately one year of mentoring were assessed for statistically-significant differences (p<0.05) in the documentation of clinically-relevant indicators. Mochudi showed notable improvements in all indicators analyzed, with particular improvements in documentation of pill count, viral load (VL) results, correct laboratory monitoring and correct antiretroviral therapy (ART) dosing (p<0.0001, p<0.0001, p<0.0001 and p<0.0001, respectively). Broad and substantial improvements were also seen in Molepolole, with the most improvement in disclosure documentation of all four sites. At Thamaga, improvements were restricted to CD4 documentation(p<0.001), recent VL and documented pill count (p<0.05 and p<0.05, respectively). Phuthadikobo showed the least amount of improvement across indicators, with only VL documentation and correct ART dosing showing statistically-significant improvements (p<0.05 and p<0.0001, respectively). These findings suggest that clinical mentoring may assist improvements in a number of important areas, including ART dosing and monitoring; adherence assessment and assurance; and disclosure. Clinical mentoring may be a valuable tool in scale-up of quality paediatric HIV care-and-treatment outside specialized centres. Further study will help refine approaches to clinical mentoring, including assuring mentoring translates into improved clinical outcomes for HIV-infected children.
doi:10.1080/09540121.2012.674096
PMCID: PMC3426665  PMID: 22533352
24.  Active cocaine use is associated with lack of HIV-1 virologic suppression independent of non-adherence to antiretroviral therapy: use of a rapid screening tool during routine clinic visits 
AIDS care  2012;25(1):109-117.
Clarifying the relationship between illicit drug use and HIV-1 virologic suppression requires characterization of both illicit drug use activity and adherence to antiretroviral therapy (ART). We developed a rapid clinical questionnaire to assess prior 7-day illicit drug use and ART adherence in a cross-sectional study among 1,777 HIV-infected persons in care. Of these, 76% were male, 35% were African-American, and 8% reported injection drug use as their probable route of HIV-1 infection. Questionnaire-reported frequencies of cocaine and marijuana use within the previous 7 days were 3.3% and 12.1%, respectively. Over three quarters (77.8%) of participants were on ART, of whom 69.7% had HIV-1 virologic suppression (HIV-1 RNA<48 copies/mL). Univariate analyses revealed that compared to no use, cocaine and marijuana use were both associated with missed ART doses (P<0.01). Multivariable logistic regression analysis adjusting for non-adherence demonstrated that cocaine use was independently associated with failing to achieve virologic suppression (adjusted odds ratio (aOR), 0.46; 95% confidence interval (CI), 0.22–0.98) but marijuana use was not (aOR, 1.08; 95% CI, 0.72–1.62). This result strengthens the evidence of a direct effect of cocaine on virologic control, independent of non-adherence to ART.
doi:10.1080/09540121.2012.687814
PMCID: PMC3443534  PMID: 22670566
Drug use; cocaine; marijuana; antiretroviral therapy; HIV-1 virologic suppression
25.  Reliability and Validity of the Functional Assessment of Human Immunodeficiency Virus Infection (FAHI) in patients with drug and alcohol use disorders 
AIDS care  2012;25(1):118-125.
HIV and substance use disorders can both significantly impact a patient’s quality of life (QOL), and it is therefore important to assess QOL throughout treatments for these chronic conditions. This study evaluated the psychometric properties of the Functional Assessment of Human Immunodeficiency Virus (HIV) Infection (FAHI) in 170 HIV-positive patients who participated in a substance abuse treatment study. Internal consistency of the FAHI was good. Convergent and discriminant validity were generally supported with comparisons to other patient-reported measures. FAHI scores were not significantly associated with viral loads or CD4 counts, and they were similar in patients with and without AIDS. Patients who achieved longer durations of drug and alcohol abstinence during treatment reported better quality of life post-treatment. The FAHI appears to be a reliable and valid measure for assessing quality of life in HIV-positive patients with concurrent drug and alcohol use disorders.
doi:10.1080/09540121.2012.687811
PMCID: PMC3478433  PMID: 22646736
HIV; quality of life; FAHI; substance use

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