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1.  Preventing HIV Transmission among Partners of HIV-Positive Male Sex Workers in Mexico City: A Modeling Study 
AIDS and behavior  2015;19(9):1579-1588.
Mexico has a concentrated HIV epidemic, with male sex workers constituting a key affected population. We estimated annual HIV cumulative incidence among male sex workers’ partners, and then compared incidence under three hypothetical intervention scenarios: improving condom use; and scaling up HIV treatment as prevention, considering current viral suppression rates (CVS, 60.7%) or full viral suppression among those treated (FVS, 100%). Clinical and behavioral data to inform model parameterization were derived from a sample (n=79) of male sex workers recruited from street locations and Clínica Condesa, an HIV clinic in Mexico City. We estimated annual HIV incidence among male sex workers’ partners to be 8.0% (95% CI: 7.3–8.7). Simulation models demonstrated that increasing condom use by 10%, and scaling up HIV treatment initiation by 50% (from baseline values) would decrease the male sex workers-attributable annual incidence to 5.2%, 4.4% (CVS) and 3.2% (FVS), respectively. Scaling up the number of male sex workers on ART and implementing interventions to ensure adherence is urgently required to decrease HIV incidence among male sex workers’ partners in Mexico City.
PMCID: PMC4495010  PMID: 25307025
epidemiology; men who have sex with men; Monte Carlo simulation methods; data imputation; HIV prevention
2.  Retention to Care of HIV-Positive Postpartum Females in Kumasi, Ghana 
Despite the success of prevention of mother-to-child transmission programs, transition to care in the postpartum period is vulnerable to being lost to care.
The authors performed a 2-year retrospective study of postpartum HIV-infected patients at Komfo Anokye Teaching Hospital in Kumasi, Ghana. The outcome was classified as optimal follow-up, suboptimal follow-up, and loss to follow-up (LTFU). Univariate and multivariate analyses were used to identify factors associated with optimal retention.
Follow-up was optimal in 66%, suboptimal in 16%, and LTFU in 18% of patients. The rate of LTFU was 22% among women diagnosed at pregnancy and 13% among those with known HIV diagnosis (P = .078). Adherence counseling (odds ratio [OR] 5.0, confidence interval [CI] 1.6-15.7; P = .006) and family planning (FP; OR 2.3, CI 1.0-5.3; P = .041) were predictive of optimal follow-up.
At 1 year, only two-thirds of postpartum women remained in care. Investigating barriers to adherence counseling and FP may impact engagement in care among HIV-infected women.
PMCID: PMC4811741  PMID: 26319433
retention; postpartum; linkage to care; adherence
3.  Addressing the Increasing Burden of Sexually Transmitted Infections in Rhode Island 
The rates of sexually transmitted infections (STI) including chlamydia, gonorrhea, and syphilis, are increasing across the United States, including in Rhode Island (RI). These STIs affect many otherwise healthy adolescents and young adults, and represent a significant source of morbidity. The Centers for Disease Control and Prevention encourages states to develop strategies for addressing increasing STI rates in the setting of diminishing public health resources. The RI Department of Health (DOH) works with providers and funded community-based organizations to promote STI screening, expedited partner therapy, and partner services to reduce STI rates. The Miriam Hospital Immunology Center opened a public HIV/STI Clinic, which offers free and confidential testing for HIV, viral hepatitis, chlamydia, gonorrhea, and syphilis, as well as post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) services to prevent HIV. In collaboration with the RI DOH, the Clinic serves as a referral source across the state for complicated STI cases.
PMCID: PMC4975600  PMID: 25562058
4.  Pretreatment HIV Drug Resistance and HIV-1 Subtype C Are Independently Associated With Virologic Failure: Results From the Multinational PEARLS (ACTG A5175) Clinical Trial 
In a global clinical trial conducted in 9 countries and 4 continents, pretreatment drug resistance and HIV-1 subtype were independently associated with virologic failure, suggesting that pretreatment genotyping should be considered whenever feasible.
Background. Evaluation of pretreatment HIV genotyping is needed globally to guide treatment programs. We examined the association of pretreatment (baseline) drug resistance and subtype with virologic failure in a multinational, randomized clinical trial that evaluated 3 antiretroviral treatment (ART) regimens and included resource-limited setting sites.
Methods. Pol genotyping was performed in a nested case-cohort study including 270 randomly sampled participants (subcohort), and 218 additional participants failing ART (case group). Failure was defined as confirmed viral load (VL) >1000 copies/mL. Cox proportional hazards models estimated resistance–failure association.
Results. In the representative subcohort (261/270 participants with genotypes; 44% women; median age, 35 years; median CD4 cell count, 151 cells/µL; median VL, 5.0 log10 copies/mL; 58% non-B subtypes), baseline resistance occurred in 4.2%, evenly distributed among treatment arms and subtypes. In the subcohort and case groups combined (466/488 participants with genotypes), used to examine the association between resistance and treatment failure, baseline resistance occurred in 7.1% (9.4% with failure, 4.3% without). Baseline resistance was significantly associated with shorter time to virologic failure (hazard ratio [HR], 2.03; P = .035), and after adjusting for sex, treatment arm, sex–treatment arm interaction, pretreatment CD4 cell count, baseline VL, and subtype, was still independently associated (HR, 2.1; P = .05). Compared with subtype B, subtype C infection was associated with higher failure risk (HR, 1.57; 95% confidence interval [CI], 1.04–2.35), whereas non-B/C subtype infection was associated with longer time to failure (HR, 0.47; 95% CI, .22–.98).
Conclusions. In this global clinical trial, pretreatment resistance and HIV-1 subtype were independently associated with virologic failure. Pretreatment genotyping should be considered whenever feasible.
Clinical Trials Registration. NCT00084136.
PMCID: PMC4425827  PMID: 25681380
HIV; drug resistance; subtype; clinical trial
5.  Evaluating HIV prevention strategies for populations in key affected groups: The example of Cabo Verde 
We used an individual-based model to evaluate the effects of hypothetical prevention interventions on HIV incidence trajectories in a concentrated, mixed epidemic setting from 2011 to 2021, and using Cabo Verde as an example.
Simulations were conducted to evaluate the extent to which early HIV treatment and optimization of care, HIV testing, condom distribution, and substance abuse treatment could eliminate new infections (i.e., reduce incidence to less than 10 cases per 10,000 person-years) among non-drug users, female sex workers (FSW), and people who use drugs (PWUD).
Scaling up all four interventions resulted in the largest decreases in HIV, with estimates ranging from 1.4 (95%CI:1.36–1.44) per 10,000 person-years among non-drug users to 8.2 (95%CI:7.8–8.6) per 10,000 person-years among PWUD in 2021. Intervention scenarios targeting FWS and PWUD also resulted in HIV incidence estimates at or below 10 per 10,000 person-years by 2021 for all population sub-groups.
Our results suggest that scaling up multiple interventions among entire population is necessary to achieve elimination. However, prioritizing key populations with this combination prevention strategy may also result in a substantial decrease in total incidence.
PMCID: PMC4545645  PMID: 25838121
individual-based model; condom use; female sex workers; Monte Carlo simulation; people who use drugs; substance use
6.  Proportion and factors associated with Hepatitis B viremia in antiretroviral treatment naïve and experienced HIV co-infected Ghanaian patients 
The global burden of Hepatitis B virus (HBV) and HIV co-infection is enormous. The risk of developing cirrhosis and hepatocellular cancer is associated with HBV DNA levels. The main objective of the study was to determine proportion of Hepatitis B viremia in ART-naïve and ART-experienced co-infected Ghanaian patients and factors associated with HBV viremia after at least 36 weeks of lamivudine with or without tenofovir containing ART.
Hepatitis B and HIV co-infected patients who were ART-naïve or had received at least 9 months of lamivudine-containing ART were enrolled in a cross-sectional study at Korle-Bu Teaching Hospital. Demographic and clinical data were collected and samples obtained for Hepatitis B serology, liver function tests and HBV DNA. Factors associated with viremia were determined using univariate and multivariate logistic regression analysis.
Of 3108 HIV-infected patients screened, 257 (8.3 %) were HBsAg-positive, of which 235 enrolled. Overall, 152 (64.7 %) were ART-experienced and 83 (35.3 %) were ART-naïve. Eighty-nine-percent of ART-naïve and 42.1 % of ART-experienced patients had HBV DNA > 20 IU/mL. In multivariate analysis of all patients, being ART-naïve (OR 10.1, 95 % CI 4.6 – 21.9) and elevated ALT (OR 3.7, 95 % CI 1.8 – 7.9) were associated with Hepatitis B viremia. In treatment experienced patients, elevated ALT (OR 4.8 CI 2.0 – 12.1) and male sex (OR 2.1, 95 % CI 1.0 – 4.2) were associated with Hepatitis B viremia.
Majority of ART-naïve (89 %) and 42 % of ART-experienced patients had detectable hepatitis B viremia > 20 IU/mL. An abnormal serum ALT was significantly associated with hepatitis B viremia in HBV and HIV co-infected patients irrespective of treatment status. Baseline and on-treatment ALT may be a useful non-invasive predictor of Hepatitis B viremia in resource-constrained countries in sub-Saharan Africa where infection is endemic and viral load tests are not widely available.
PMCID: PMC4710995  PMID: 26759172
ART; HIV and HBV co-infection; Viremia; Sub-Saharan Africa
7.  Characterizing the burden of hepatitis C infection among entrants to Pennsylvania state prisons, 2004–2012 
Although hepatitis C infection (HCV) is common among prisoners, relatively few undergo evaluation for treatment. This study reports the prevalence of chronic infection and the genotype distribution among an incarcerated population. HCV antibody testing was provided to adults entering Pennsylvania prisons; confirmatory and genotype testing were offered to those eligible for treatment. Antibody prevalence among 101,727 individuals was 18.1%. Among 7,633 individuals who underwent confirmatory testing, 69.3% had detectable RNA. Among 3,247 individuals who underwent genotype testing, genotype 1 was the most common (76.6%). The rate of chronic infection after HCV exposure is similar to that reported in the community, as is genotype distribution. Correctional facilities provide access to a population with a high disease burden, creating a public health opportunity for evaluation and treatment.
PMCID: PMC4683408  PMID: 26672118
correctional health; chronic hepatitis c infection; hepatitis c genotype distribution; prevalence
8.  Delayed entry to care by men with HIV infection in Kumasi, Ghana 
In resource-limited settings, men may face considerable barriers to accessing HIV care as early interventions tend to focus on antenatal care settings.
We performed a retrospective chart review of all adult patients referred to Komfo Anokye Teaching Hospital HIV clinic in Kumasi, Ghana in 2011 to identify the differences in clinical and demographic variables by gender at presentation to care using two-sample t tests with adjusted variance and Wilcox rank sum tests for continuous variables and Pearson chi-squared tests for categorical variables. We also compared differences in clinical and demographic variables among men stratified by CD4 count at initiation of care in order to identify variables associated with later entry to care.
Demographically, men were more likely to be older (men age 42 vs. 37, p<0.01), have a greater number of dependent children (1.8 v. 1.5, p = 0.04), to be living with or married to their partner (65.4% vs. 49.0%, p<0.01), and to have a higher level of education (tertiary education, 45.8% vs. 25.4%, p<0.01) than women. Clinically, men were more likely to have a lower CD4 count at entry to care (260 v. 311 cells/µL, p<0.01), to report clinical symptoms to the nurse during intake (p<0.01), and to have any history of alcohol use (p<0.01).
Men in Ghana are accessing treatment at a later stage of their disease than women. Efforts to test and link men to care early should be intensified.
PMCID: PMC4732647  PMID: 26848354
Gender disparities; men; HIV; Ghana; access to care; entry to care
9.  Abnormal vibrissa-related behavior and loss of barrel field inhibitory neurons in 5xFAD transgenics 
Genes, brain, and behavior  2014;13(5):488-500.
A recent study reported lower anxiety in the 5xFAD transgenic mouse model of Alzheimer's disease, as measured by reduced time on the open arms of an elevated plus maze. This is important because all behaviors in experimental animals must be interpreted in light of basal anxiety and response to novel environments. We conducted a comprehensive anxiety battery in the 5xFAD transgenics and replicated the plus-maze phenotype. However, we found that it did not reflect reduced anxiety, but rather abnormal avoidance of the closed arms on the part of transgenics and within-session habituation to the closed arms on the part of wild-type controls. We noticed that the 5xFAD transgenics did not engage in the whisker-barbering behavior typical of mice of this background strain. This is suggestive of abnormal social behavior, and we suspected it might be related to their avoidance of the closed arms on the plus maze. Indeed, transgenic mice exhibited excessive home-cage social behavior and impaired social recognition, and did not permit barbering by wild-type mice when pair-housed. When their whiskers were snipped the 5xFAD transgenics no longer avoided the closed arms on the plus maze. Examination of parvalbumin (PV) staining showed a 28.9% reduction in PV+ inhibitory interneurons in the in barrel fields of 5xFAD mice, and loss of PV+ fibers in layers IV and V. This loss of vibrissal inhibition suggests a putatively aversive overstimulation that may be responsible for the transgenics’ avoidance of the closed arms in the plus maze.
PMCID: PMC4170055  PMID: 24655396
anxiety; cognition; memory; behavior; Alzheimer's disease; transgenic mice; neurodegeneration; subiculum; hippocampus; neocortex
10.  Renal Function Recovery and HIV Viral Suppression Following Tenofovir Discontinuation for Renal Impairment 
Tenofovir associated nephrotoxicity (TDFN) is well recognized. This study describes the trend of renal function recovery and virologic consequences after cessation of tenofovir (TDF) for suspected TDFN.
This was a retrospective chart review of 241 patients who underwent HLA-B*5701 allele testing between January 2007-December 2010. Demographics and clinical characteristics were compared at baseline, 3, 6, and 12 month between patients that continued and discontinued TDF. Factors associated with renal function recovery were assessed by multivariable logistic regression.
Eighty patients were identified with TDFN; 84% male, 74% African American (AA) with a median age of 55 years, and median length of TDF use for 122 weeks. Renal recovery at 12 months differed in those who stopped versus (vs.) continued TDF (83% vs. 57% p=0.03). In a crude analysis, baseline chronic kidney disease was negatively associated with renal recovery (p=0.01). An adjusted analysis showed that those who stopped TDF had 3.76 higher odds of renal recovery compared to those who did not stop TDF (95% CI: 1.26-11.27, p=0.02). There were no significant differences in virologic response after switching TDF to an alternative agent.
In this mostly AA male population with suspected TDFN, discontinuation of TDF was strongly associated with renal function recovery without affecting viral suppression.
PMCID: PMC4469471  PMID: 26097776
Tenofovir; Nephrotoxicity; Renal failure
11.  Acceptance of HIV Antibody Testing Among Women in Domestic Violence Shelters 
The purpose of this study was to examine which factors derived from an adapted version of the Health Belief Model are associated with HIV testing among women at domestic violence shelters in the rural south (N = 112). Participants were administered self-report questionnaires to assess for test acceptance and were offered private and free HIV rapid testing. A logistic regression analysis was performed. Results indicated that higher perceived susceptibility and higher PTSD symptoms predicted a greater likelihood of HIV test acceptance. The most common reason given for not testing was a lack of time. Implications are discussed.
PMCID: PMC4467823  PMID: 26085820
Rapid HIV testing; domestic violence; intimate partner violence; HIV and IPV
12.  Geographic variability in HIV and injection drug use in Ukraine: Implications for integration and expansion of drug treatment and HIV care 
Ukraine has the highest HIV burden of any European country with much of the current HIV epidemic concentrated among people who inject drugs (PWIDs) and their sexual partners. Opiate substitution therapy (OST) is limited in Ukraine and expansion of OST is urgently needed to help stem the tide of the HIV epidemic.
We accessed publicly available data in Ukraine in order to explore geographic variability with respect to prevalence of HIV, PWIDs and OST programmes.
The regions of Ukraine with the largest number of opioid dependent persons (the south and eastern portions of the country) correspond to the regions with the highest HIV prevalence and HIV incidence. The number of opioid PWIDs per 100,000 population as well as the number of all OST treatment slots per 100,000 varied significantly across the three HIV prevalence categories. Overall, the proportion of individuals receiving either methadone maintenance therapy (MMT) or buprenorphine maintenance therapy (BMT) was quite low: average across categories: 7.3% and 0.4%, respectively. Additionally, less than half of OST patients receiving MMT or BMT were HIV positive patients.
There is significant geographic variability in both numbers of HIV positive individuals and numbers of PWIDs across Ukraine, however, there may be a more concentrated epidemic among PWIDs in many regions of the country. Scale up of addiction treatment for PWID, especially OST, can have a significant impact on preventing injection related morbidity, such as HIV and HCV infection. Ukraine can learn from the mistakes other nations have made in denying critical treatment opportunities to PWID.
PMCID: PMC4465255  PMID: 25304049
Ukraine; People who inject drugs (PWID); HIV; Opiate substitution therapy (OST)
13.  Missed Opportunities for HIV Screening in Pharmacies and Retail Clinics 
In the wake of new recommendations to offer HIV screening to everyone aged 13–64 years and to start all people living with HIV/AIDS on highly active antiretroviral therapy (HAART) regardless of CD4 count, the need to generate widespread, scalable HIV screening programs is greater than ever. Nearly 50,000 new HIV infections occur in the United States each year, and the Centers for Disease Control and Prevention estimates that approximately half of these new infections are transmitted by individuals who are unaware of their HIV serostatus. Numerous barriers to screening exist, including the lack of primary care for many at-risk patients, expense of screening in traditional settings, and need for repeat testing in high-risk populations. With their relative accessibility and affordability, community pharmacies and retail clinics within those pharmacies are practical and appealing venues for expanded HIV screening. For widespread pharmacy-based testing to become a reality, policymakers and corporate pharmacy leadership would need to develop innovative solutions to the existing time pressures of pharmacists’ behind-the-counter functions and absence of reimbursement for direct patient care services. Pharmacists nationwide should also receive training to assist with risk reduction counseling and linkage to care for customers purchasing the new over-the-counter HIV test.
PMCID: PMC4465258  PMID: 24684638
14.  Love, Lust, and the Emotional Context of Concurrent Sexual Partnerships among Young Swazi Adults 
Men and women in Swaziland who are engaged in multiple or concurrent sexual partnerships, or who have sexual partners with concurrent partners, face a very high risk of HIV infection. Ninety-four in-depth interviews were conducted with 28 Swazi men and women (14 of each sex) between the ages of 20 and 39 in order to explore participants’ sexual partnership histories, including motivations for sexual relationships which carried high HIV risk. Concurrency was normative, with most men and women having had at least one concurrent sexual partnership, and all women reporting having had at least one partner who had a concurrent partner. Men distinguished sexual partnerships that were just for sex from those that were considered to be “real relationships”, while women represented the majority of their relationships, even those which included significant financial support, as being based on love. Besides being motivated by love, concurrent sexual partnerships were described as motivated by a lack of sexual satisfaction, a desire for emotional support and/or as a means to exact revenge against a cheating partner. Social and structural factors were also found to play a role in creating an enabling environment for high-risk sexual partnerships, and these factors included social pressure and norms, a lack of social trust, poverty and a desire for material goods, and geographical separation of partners.
PMCID: PMC4201849  PMID: 25174630
couple relationships; HIV/AIDS; HIV prevention; multiple and concurrent sexual partnerships; transactional sex
15.  The Feasibility of Implementing the HIV Seek, Test, and Treat Strategy in Jails 
AIDS Patient Care and STDs  2014;28(4):183-187.
To successfully implement the Seek, Test, and Treat (STT) strategy to curb the HIV epidemic, the criminal justice system must be a key partner. Increasing HIV testing and treatment among incarcerated persons has the potential to decrease HIV transmission in the broader community, but whether it is feasible to consider the implementation of the STT within jail facilities is not known. We conducted a retrospective review of Rhode Island Department of Corrections (RIDOC) medical records to assess whether persons newly diagnosed in the jail were able to start ART and be linked to community HIV care after release. From 2001 to 2007, 64 RIDOC detainees were newly diagnosed with HIV. During their index incarcerations, 64% were informed of positive confirmatory HIV test results, 50% completed baseline evaluations, and 9% began ART. Linkage to community care was confirmed for 58% of subjects. Subjects incarcerated for >14 days were significantly more likely to receive HIV test results and complete baseline evaluation (p<0.001). A similar association was not observed for ART initiation until incarceration length reached 60 days (p<0.001). There was no association between incarceration length and linkage to care. This comprehensive analysis demonstrates that length of incarceration impacts HIV test result delivery, baseline evaluation, and ART initiation in the RIDOC. Jails are an important venue to “Seek” and “Test”; however, completing the “Treat” part of the STT strategy is hindered by the transient nature of this criminal justice population and may require new strategies to improve linkage to care.
PMCID: PMC3985510  PMID: 24617960
17.  Care at the Crossroads: Navigating the HIV, HCV, and Substance Abuse Syndemic 
For patients with both HIV/HCV coinfection and substance addiction, multidisciplinary teams can facilitate coordination of care and improve clinical outcomes. Such teams should include HIV/HCV treatment providers, mental health specialists, case managers, social workers, and substance abuse counselors.
PMCID: PMC4266471  PMID: 25520548
18.  Sex differences in perceived risk and testing experience of HIV in an urban fishing setting in Ghana 
Understanding sex differences in willingness to test and testing experience could aid the design of focus interventions to enhance uptake and engagement with care, treatment and support services. This study determined differences in perceived risk of acquiring HIV, willingness to test and HIV testing experience in an urban fishing community.
A cross-sectional community survey was conducted in 2013 among men and women in two fishing communities (Chorkor and James Town) in Accra. In all, 554 subjects (≥18 years) were involved, 264 in Chorkor and 290 in James Town. Data on demographic characteristics, perceived risk for HIV and willingness to test for HIV and testing experience were collected with a structured questionnaire. Descriptive statistics and Chi square test were used for the analysis at 95% significant level, using SPSS version 21.
Of 554 subjects, 329 (59.4%) were females, and median age was 32 years. Overall, only 91(40.4%) men and 118(35.9%) women perceived themselves to be at risk of acquiring HIV. A significant proportion of women were willing to test for HIV compared to men (86.3% vs. 80.0%, P = 0.048). Women were more likely to have ever tested for HIV compared to men (42.2% vs. 28.6%, P = 0.001) and more women had tested within 12 months prior to survey than men (49.6% vs. 40.6%, P = 0.230). Of the number who had tested for HIV infection, a higher proportion of men tested voluntarily 42(65.6%), while a higher proportion of women tested as part of healthcare service received 96(69.1%); (P = 0.001; indicating women vs. men).
Sex differences in risk perception and willingness to test need more focused public education and behaviour change communication strategies to achieve high coverage. Community-based strategies could improve HIV testing among men whilst more access to testing in health settings should be available to women in these communities.
PMCID: PMC4234896  PMID: 25398271
HIV testing; Sex differences; Perceived risks; Urban community; Ghana
19.  Buprenorphine for Human Immunodeficiency Virus/Hepatitis C Virus–coinfected Patients 
Journal of addiction medicine  2012;6(3):179-185.
Buprenorphine is associated with enhanced human immunodeficiency virus (HIV) treatment outcomes including increased antiretroviral therapy initiation rates, adherence, and CD4+ cell counts among HIV-infected opioid-dependent individuals. Buprenorphine facilitates hepatitis C virus (HCV) treatment in opioid-dependent patients with HCV monoinfection. Less is known about buprenorphine’s role in HIV/HCV coinfection.
We conducted a retrospective chart review to evaluate HCV care for HIV-infected buprenorphine patients in the first 4 years of buprenorphine’s integration into a Rhode Island HIV clinic.
Sixty-one patients initiated buprenorphine. All had HCV antibody testing; 57 (93%) were antibody-positive. All antibody-positive patients underwent HCV RNA testing; 48 (84%) were RNA-positive. Of these, 15 (31%) were not referred to HCV care. Among chronically infected patients, 3 received HCV treatment after buprenorphine; all had cirrhosis and none achieved viral eradication. At buprenorphine induction, most patients had inadequately controlled HIV infection, with detectable HIV RNA (59%) or CD4+ cell count less than or equal to 350/µL (38%).
Buprenorphine has shown limited success to date as a bridge to HCV treatment within an HIV clinic. Buprenorphine’s stabilization of opioid dependence and HIV disease may permit the use of HCV therapy over time.
PMCID: PMC4209296  PMID: 22614935
buprenorphine; hepatitis C virus (HCV); HIV/HCV coinfection; HCV treatment; opioid replacement therapy
20.  African American Patient Experiences with a Rapid HIV Testing Program in an Urban Public Clinic 
Of 1,174 new HIV cases diagnosed in Philadelphia in 2008, 771 (66%) were among African Americans. In 2007, Philadelphia introduced a citywide rapid HIV testing program in public clinics.
We conducted a prospective qualitative study among 60 African Americans undergoing rapid HIV testing in one of Philadelphia’s public clinics located in a zipcode with high HIV incidence. Employing grounded theory, we used semi-structured interviews to assess patients’ motivations, perceptions and clinical experiences with rapid HIV testing. Interviews were transcribed and coded; 20% were double coded to enhance reliability.
Primary motivations for undergoing rapid HIV testing included: testing during routine clinical care, presenting for care with symptomatic STIs or opportunistic infections, knowing someone living with HIV/AIDS, and perceiving oneself at risk for HIV. Most patients reported positive experiences with rapid testing and preferred it to conventional testing because it eliminated the need for return visits and decreased anxiety; however, many expressed concerns about accuracy of rapid HIV testing. Barriers to HIV testing among this population included low self-perceived risk, HIV stigma and reported homophobia in respondents’ communities.
This rapid testing program was acceptable, convenient, and preferred over conventional HIV testing. Providing educational information about rapid and confirmatory HIV testing may further enhance acceptability of rapid HIV testing in this population. Nationwide expansion of rapid HIV testing in public health centers is an important and acceptable means of achieving President Obama’s National AIDS Strategy goals of reducing racial disparities in HIV infection and HIV/AIDS treatment services.
PMCID: PMC4203368  PMID: 22708242
Rapid HIV testing; African American; HIV/AIDS
21.  Jails: The New Frontier. HIV Testing, Treatment, and Linkage to Care After Release 
AIDS and behavior  2013;17(0 2):10.1007/s10461-013-0552-7.
PMCID: PMC3876465  PMID: 23975472
22.  Adherence to HIV treatment and care among previously homeless jail detainees 
AIDS and behavior  2013;17(8):2654-2666.
HIV-infected persons entering the criminal justice system (CJS) often experience suboptimal healthcare system engagement and social instability, including homelessness. We evaluated surveys from a multisite study of 743 HIV-infected jail detainees prescribed or eligible for antiretroviral therapy (ART) to understand correlates of healthcare engagement prior to incarceration, focusing on differences by housing status. Dependent variables of healthcare engagement were: 1) having an HIV provider, 2) taking ART, and 3) being adherent (>95% of prescribed doses) to ART during the week before incarceration. Homeless subjects, compared to their housed counterparts, were significantly less likely to be engaged in healthcare using any measure. Despite Ryan White funding availability, insurance coverage remains insufficient among those entering jails, and having health insurance was the most significant factor correlated with having an HIV provider and taking ART. Individuals interfacing with the CJS, especially those unstably housed, need innovative interventions to facilitate healthcare access and retention.
PMCID: PMC3325326  PMID: 22065234
HIV; AIDS; Homelessness; jail; incarceration; substance abuse; alcohol; insurance; Adherence; healthcare access
23.  Changes in HIV-1 Subtypes B and C Genital Tract RNA in Women and Men After Initiation of Antiretroviral Therapy 
Fiscus, Susan A. | Cu-Uvin, Susan | Eshete, Abel Tilahun | Hughes, Michael D. | Bao, Yajing | Hosseinipour, Mina | Grinsztejn, Beatriz | Badal-Faesen, Sharlaa | Dragavon, Joan | Coombs, Robert W. | Braun, Ken | Moran, Laura | Hakim, James | Flanigan, Timothy | Kumarasamy, N. | Campbell, Thomas B. | Klingman, Karin L. | Nair, Apsara | Walawander, Ann | Smeaton, Laura M. | De Gruttola, Victor | Martinez, Ana I. | Swann, Edith | Barnett, Ronald L. | Brizz, Barbara | Delph, Yvette | Gettinger, Nikki | Mitsuyasu, Ronald T. | Eshleman, Susan | Safren, Steven | Andrade, Adriana | Haas, David W. | Amod, Farida | Berthaud, Vladimir | Bollinger, Robert C. | Bryson, Yvonne | Celentano, David | Chilongozi, David | Cohen, Myron | Collier, Ann C. | Currier, Judith Silverstein | Eron, Joseph | Firnhaber, Cynthia | Flexner, Charles | Gallant, Joel E. | Gulick, Roy M. | Hammer, Scott M. | Hoffman, Irving | Kazembe, Peter | Kumwenda, Johnstone | Kumwenda, Newton | Lama, Javier R. | Lawrence, Jody | Maponga, Chiedza | Martinson, Francis | Mayer, Kenneth | Nielsen, Karin | Pendame, Richard B. | Ramratnam, Bharat | Rooney, James F. | Sanchez, Jorge | Sanne, Ian | Schooley, Robert T. | Snowden, Wendy | Solomon, Suniti | Tabet, Steve | Taha, Taha | Uy, Jonathan | van der Horst, Charles | Wanke, Christine | Gormley, Joan | Marcus, Cheryl J. | Putnam, Beverly | Ntshele, Smanga | Loeliger, Edde | Pappa, Keith A. | Webb, Nancy | Shugarts, David L. | Winters, Mark A. | Descallar, Renard S. | Sharma, Jabin | Poongulali, S. | Cardoso, Sandra Wagner | Faria, Deise Lucia | Berendes, Sima | Burke, Kelly | Kanyama, Cecelia | Kayoyo, Virginia | Samaneka, Wadzanai P. | Chisada, Anthony | Santos, Breno | La Rosa, Alberto | Infante, Rosa | Balfour, Henry H. | Mullan, Beth | Kim, Ge-Youl | Klebert, Michael K. | Mildvan, Donna | Revuelta, Manuel | Jan Geiseler, P. | Santos, Bartolo | Daar, Eric S. | Lopez, Ruben | Frarey, Laurie | Currin, David | Haas, David H. | Bailey, Vicki L. | Tebas, Pablo | Zifchak, Larisa | Sha, Beverly E. | Fritsche, Janice M.
Women with human immunodeficiency virus (HIV)–1 subtype C had significantly higher genital tract viral loads compared to women with HIV-1 subtype B and men with HIV-1 subtype C or B. Women in general were significantly less likely to have genital tract viral load below the lower limit of quantification compared to men.
Background. Combination antiretroviral therapy (cART) reduces genital tract human immunodeficiency virus type 1 (HIV-1) load and reduces the risk of sexual transmission, but little is known about the efficacy of cART for decreasing genital tract viral load (GTVL) and differences in sex or HIV-1 subtype.
Methods. HIV-1 RNA from blood plasma, seminal plasma, or cervical wicks was quantified at baseline and at weeks 48 and 96 after entry in a randomized clinical trial of 3 cART regimens.
Results. One hundred fifty-eight men and 170 women from 7 countries were studied (men: 55% subtype B and 45% subtype C; women: 24% subtype B and 76% subtype C). Despite similar baseline CD4+ cell counts and blood plasma viral loads, women with subtype C had the highest GTVL (median, 5.1 log10 copies/mL) compared to women with subtype B and men with subtype C or B (4.0, 4.0, and 3.8 log10 copies/mL, respectively; P < .001). The proportion of participants with a GTVL below the lower limit of quantification (LLQ) at week 48 (90%) and week 96 (90%) was increased compared to baseline (16%; P < .001 at both times). Women were significantly less likely to have GTVL below the LLQ compared to men (84% vs 94% at week 48, P = .006; 84% vs 97% at week 96, P = .002), despite a more sensitive assay for seminal plasma than for cervical wicks. No difference in GTVL response across the 3 cART regimens was detected.
Conclusions. The female genital tract may serve as a reservoir of persistent HIV-1 replication during cART and affect the use of cART to prevent sexual and perinatal transmission of HIV-1.
PMCID: PMC3689341  PMID: 23532477
HIV-1 genital tract RNA; HIV-1 subtypes B and C; antiretroviral drugs
24.  What’s God got to do with it? Engaging African American faith-based institutions in HIV prevention 
Global public health  2013;8(3):258-269.
African Americans are disproportionately infected and affected by HIV/AIDS. Although faith-based institutions play critical leadership roles in the African American community, the faith-based response to HIV/AIDS has historically been lacking. We explore recent successful strategies of a citywide HIV/AIDS awareness and testing campaign developed in partnership with 40 African American faith-based institutions in Philadelphia, Pennsylvania, a city with some of the United State’s highest HIV infection rates. Drawing on important lessons from the campaign and subsequent efforts to sustain the campaign’s momentum with a citywide HIV testing, treatment and awareness program, we provide a roadmap for engaging African American faith communities in HIV prevention that include partnering with faith leaders; engaging the media to raise awareness, destigmatising HIV/AIDS and encouraging HIV testing; and conducting educational and HIV testing events at houses of worship. African American faith based institutions have a critical role to play in raising awareness about the HIV/AIDS epidemic and for reducing racial disparities in HIV infection.
PMCID: PMC3601577  PMID: 23379422
African Americans; HIV/AIDS; health disparities; faith community; clergy; pastors
25.  Short Communication: New HIV Infections at Southern New England Academic Institutions: Implications for Prevention 
New HIV infections among younger men who have sex with men (MSM) in the United States are escalating. Data on HIV infections in college students are limited. In 2010, three MSM college students presented to our clinic with primary HIV infection (PHI) in a single month. To determine the number of college students among new HIV diagnoses, we reviewed clinical characteristics and molecular epidemiology of HIV-diagnosed individuals from January to December 2010 at the largest HIV clinic in Southern New England. PHI was defined as acute HIV infection or seroconversion within the last 6 months. Of 66 individuals diagnosed with HIV in 2010, 62% were MSM and 17% were academic students (12% college or university, 5% other). Seventy-three percent of students were MSM. Compared to nonstudents, students were more likely to be younger (24 versus 39 years), born in the United States (91% versus 56%), have another sexually transmitted disease (45% versus 11%), and present with PHI (73% versus 16%, all p-values<0.05). Thirty percent of individuals formed eight transmission clusters including four students. MSM were more likely to be part of clusters. Department of Health contact tracing of cluster participants allowed further identification of epidemiological linkages. Given these high rates of PHI in recently diagnosed students, institutions of higher education should be aware of acute HIV presentation and the need for rapid diagnosis. Prevention strategies should focus on younger MSM, specifically college-age students who may be at increased risk of HIV infection.
PMCID: PMC3537304  PMID: 22724920

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