The epidemiology of HIV/AIDS in women in the southern United States

"We lost a lot, but something good came out of it too:" Exploring the impact of the COVID-19 pandemic on the mental wellbeing of British Muslim Pakistani women with family responsibilities

BACKGROUND

The COVID-19 pandemic and associated restrictions caused major disruption globally, shedding light on the unprecedented strain upon the mental health and wellbeing of individuals around the world. Poor mental health in the pandemic is reported to be greater in women, with mothers being at increased risk. It is unclear whether there are differences in the impact of mental wellbeing on some ethnic groups over others. The aim of this study was to explore the experiences of British Muslim Pakistani women with family responsibilities during the COVID-19 pandemic, two years on from the first lockdown.

METHODS

Qualitative interviews with women were conducted via telephone using a semi-structured topic guide. The sample included 25 British Muslim Pakistani women with family responsibilities, both English and non-English speaking. Women lived in households that ranged in number and included extended family. Key themes were determined using thematic analysis.

RESULTS

Results were grouped under three themes. These were (1) Community, cultural and religious contributors to poor mental wellbeing, (2) religious and cultural mediators of mental distress, and (3) perceived positive impact on lifestyle. British Muslim Pakistani women were psychologically distressed by the high rates of virus transmission and deaths in their communities and at the prospect of older members of their extended family developing the virus. The impact of restrictions on fundamental religious and cultural interactions further exacerbated poor mental wellbeing in this population. Religion, community social capital and larger household structures were all effective coping strategies for British Muslim Pakistani women. Positive impacts of the pandemic included becoming closer to family and faith, and increased work/life harmony.

CONCLUSIONS

An exploration of religious and cultural coping mechanisms should be used to inform future national pandemic preparedness plans, as well as effective strategies for building and maintaining social capital. This may increase adherence to physical distancing and other protective behaviours in populations.

A Qualitative Exploration of Women's Interest in Long-Acting Injectable Antiretroviral Therapy Across Six Cities in the Women's Interagency HIV Study: Intersections with Current and Past Injectable Medication and Substance Use

Medications for antiretroviral therapy (ART) and preexposure prophylaxis (PrEP) are currently daily pill regimens, which pose barriers to long-term adherence. Long-acting injectable (LAI) modalities have been developed for ART and PrEP, but minimal LAI-focused research has occurred among women. Thus, little is known about how women's history of injection for medical or nonmedical purposes may influence their interest in LAI. We conducted 89 in-depth interviews at 6 sites (New York, NY; Chicago, IL; San Francisco, CA; Atlanta, GA; Chapel Hill, NC; Washington, DC) of the Women's Interagency HIV study. Interviews occurred with women living with HIV (n = 59) and HIV-negative women (n = 30) from November 2017 to October 2018. Interviews were recorded, transcribed, and analyzed using thematic content analysis. Women's prior experiences with injections occurred primarily through substance use, physical comorbidities, birth control, or flu vaccines. Four primary categories of women emerged; those who (1) received episodic injections and had few LAI-related concerns; (2) required frequent injections and would refuse additional injections; (3) had a history of injection drug use, of whom some feared LAI might trigger a recurrence, while others had few LAI-related concerns; and (4) were currently injecting drugs and had few LAI-related concerns. Most women with a history of injectable medication would prefer LAI, but those with other frequent injections and history of injection drug use might not. Future research needs to address injection-related concerns, and develop patient-centered approaches to help providers best identify which women could benefit from LAI use.

Examining COVID-19 and HIV: The impact of intersectional stigma on short- and long-term health outcomes among African Americans

The COVID-19 pandemic has exacerbated the health disparities and structural racism among African Americans. We examined overlaps between the COVID-19 pandemic and HIV epidemic using an intersectional stigma framework through the lens of Critical Race Theory. Intersectional stigma, medical mistrust, and decreased likelihood of referral for HIV and COVID-19 testing leads to decreased engagement in the healthcare system. Social inequities increase health disparities and lead to increased rates of chronic diseases, which increases the risk and severity of COVID-19. Solutions to mitigate impact among African Americans include increasing engagement regarding African American health, funding, and providers of color.

Racial and sex disparities in HIV screening outcomes within emergency departments of Harris County, Texas

OBJECTIVES

The emergency department provides opportunities for identifying undiagnosed HIV cases. We sought to describe the racial and sex epidemiology of HIV through ED screening in Harris County, Texas, one of the most diverse and populous metropolitan cities in the Southern United States.

METHODS

We used a descriptive secondary analysis of a universal HIV screening program (2010-2017) to quantify demographic differences in HIV incidence. We applied a validated codebook to a dataset by the local health department containing 894,387 records of ED visits with 62 variables to assess race/ethnicity and sex differences.

RESULTS

Of 885,199 (98.9%) patients screened for HIV during an ED visit, 1795 tested positive (incidence rate = 0.2%). Of those tested for HIV, most were White (66.3%), followed by racial minorities (African Americans (29.9%), Asians (3.6%), and American Indian, Alaska Native, Native Hawaiian or Pacific Islanders (natives) (0.1%). Half of those tested were Hispanic. Conversely, of patients testing positive (n = 1782, 99.3% of positive cases), most were African American (52.6%) followed by Whites (46.6%), Asians (0.7%), and natives (0.1%). Less than half (35.5%) of positives were Hispanic. A racial disparity in HIV incidence was discovered among African American females. This group represented 16.8% of the tested population; yet accounted for 65.8% of females who tested positive for HIV and 20.3% of all HIV-positive test results.

CONCLUSION

Descriptive findings of the racial and sex epidemiology of HIV revealed that African American females had the largest disparity between the population tested and those who tested positive for HIV.

Racial Discrimination, Protective Processes, and Sexual Risk Behaviors Among Black Young Males

Racial discrimination is a documented risk factor for sexual risk behaviors among young Black men. Mechanisms of effect and protective processes remain to be investigated. This study examined the mediating effect of emotional distress, self-regulation, and substance use on the association between racial discrimination and sexual risk behaviors. Sexual risk behaviors included in this study were inconsistent condom use and sexual concurrency (sexual partnerships that overlap overtime). The protective effect of protective social ties was also investigated. A sample of 505 heterosexually active men aged 19-22 years were recruited and surveyed for 3 time points. Men answered questions on racial discrimination, sexual risk behaviors, emotional distress, self-regulation, and substance use. Mediation and moderation models were tested. Racial discrimination (T1) significantly and positively predicted emotional distress (T2). Emotional distress, substance use, and self-regulation partially mediated the association between racial discrimination and sexual risk behaviors. Protective social ties attenuated the effects of emotional distress on substance use and self-regulation. Racial discrimination is an important context for sexual risk behaviors. Minority stress may translate to sexual risk behavior through psychosocial mediators, such as emotional distress, self-regulation, and substance use. Protective social ties may buffer against emotional distress to reduce substance use and increase self-regulation. The findings of this study can provide new insights through the investigation of risk and protective processes that influence sexual risk behaviors among young Black men.

Southern Women at Risk: Narratives of Familial and Social HIV Risk in Justice-Involved U.S. Women in Alabama

Justice-involved HIV-positive women, particularly those in the U.S. South, are a hidden, understudied population. Little work has explored their psychosocial histories in relation to their HIV risk. We conducted a content analysis of their life history narratives from childhood to present, via in-depth interviews with 24 such women in 2 Alabama cities. Findings included the following: (a) In childhood/adolescence, consistent HIV risk factors were present, beginning with early sexual abuse and induction into alcohol/substance use; (b) By early adulthood, HIV and incarceration risks were compounded in social settings, through cyclical substance use, revictimization, and reoffending;

The HIV Prison Paradox: Agency and HIV-Positive Women's Experiences in Jail and Prison in Alabama

Incarcerated women face significant barriers to achieve continuous HIV care. We employed a descriptive, exploratory design using qualitative methods and the theoretical construct of agency to investigate participants' self-reported experiences accessing HIV services in jail, in prison, and post-release in two Alabama cities. During January 2014, we conducted in-depth interviews with 25 formerly incarcerated HIV-positive women. Two researchers completed independent coding, producing preliminary codes from transcripts using content analysis. Themes were developed iteratively, verified, and refined. They encompassed (a) special rules for HIV-positive women: isolation, segregation, insults, food rationing, and forced disclosure; (b) absence of counseling following initial HIV diagnosis; and (c) HIV treatment impediments: delays, interruption, and denial. Participants deployed agentic strategies of accommodation, resistance, and care-seeking to navigate the social world of prison and HIV services. Findings illuminate the "HIV prison paradox": the chief opportunities that remain unexploited to engage and re-engage justice-involved women in the HIV care continuum.

Reducing Risky Sex among Rural African American Cocaine Users: A Controlled Trial

Rural African American cocaine users experience high rates of STIs/HIV. This NIDA-funded trial tested an adapted evidence-based risk reduction program versus an active control condition. Participants were 251 African American cocaine users in rural Arkansas recruited from 2009-2011. Outcomes included condom use skills and self-efficacy, sexual negotiation skills, peer norms, and self-reported risk behavior. The intervention group experienced greater increases in condom use skills and overall effectiveness in sexual negotiation skills. Both groups reported reductions in trading sex, improvements in condom use self-efficacy, and increased use of specific negotiation skills. Implications and limitations are discussed.

Understanding HIV-Related Stigma Among Women in the Southern United States: A Literature Review

Societal stigmatization of HIV/AIDS due to assumptions about transmission and associated behaviors plays a substantial role in the psychosocial well-being of people living with this chronic illness, particularly for women in traditionally conservative geographic regions. Known for social conservatism, the Southern United States (US) holds the highest incidence rate of HIV infection in the US. A systematic search of four databases was used to identify 27 relevant scientific articles pertaining to HIV-related stigma among women living with HIV/AIDS in the Southern US. These studies revealed a rudimentary understanding of stigma sources, effects, and stigma-reduction interventions in this population. Due to the cultural specificity of stigma, further differentiation of stigma in discrete sectors of the South as well as a dialogue about the moral implications of stigma is necessary to lay the groundwork for patient-centered interventions to mitigate the destructive effects of stigma experienced by women in this region.

Religiosity, spirituality, and HIV risk behaviors among African American women from four rural counties in the southeastern U.S

In a cross-sectional survey of 1,013 African American women from rural Alabama and North Carolina, we examined the relationship of (1) organizational religiosity (i.e., religious service attendance), (2) non-organizational religiosity (e.g., reading religious materials), and (3) spirituality with these outcomes: women's reports of their sexual behaviors and perceptions of their partners' risk characteristics. Women with high non-organizational religiosity, compared with low, had fewer sex partners in the past 12 months (adjusted prevalence ratio (aPR): 0.58, 95% confidence interval (CI): 0.42, 0.80) and were less likely to have concurrent partnerships (aPR: 0.47, 95% CI: 0.30, 0.73). Similar results were observed for spirituality, and protective but weaker associations were observed for organizational religiosity. Weak associations were observed between organizational religiosity, non-organizational religiosity, and spirituality with partners' risk characteristics. Further exploration of how religiosity and spirituality are associated with protective sexual behaviors is needed to promote safe sex for African American women.

Prescription opioid use, illicit drug use, and sexually transmitted infections among participants from a community engagement program in North Central Florida

INTRODUCTION

The purpose of this analysis was to determine the intersection between prescription opioid use, illicit drug use and STIs amongst Alachua County participants.

METHODS

Cross-sectional data come from 2,194 Alachua County community members interviewed by Community Health Workers (CHWs) from HealthStreet, a community engagement program of the University of Florida. Demographic characteristics, health risk factors and health conditions were obtained.

RESULTS

Among participants, 9.3% reported ever having an STI, 40% reported lifetime use of prescription opioids, and 53% reported ever using an illicit drug. Persons who reported using an illicit drug or an illicit drug plus prescription were 2.89 and 4.12 times as likely to report one or more STIs respectively, compared to those who never used these drugs. Prescription opioid use alone was not statistically related to STIs though female gender (AOR 3.75), lower education (AOR 1.45) and food insecurity (AOR 1.52) were.

DISCUSSION

Those who report a history illicit drug use with or without prescription opioid use are at increased risk for STIs and could benefit from prevention programs. Those with factors that are proxies for other disparities (lower education, food insecurity) are especially important targets for intervention among women.

Using Molecular HIV Surveillance Data to Understand Transmission Between Subpopulations in the United States

BACKGROUND

Studying HIV transmission networks provides insight into the spread of HIV and opportunities for intervention. We identified transmission dynamics among risk groups and racial/ethnic groups in the United States.

METHODS

For HIV-1 pol sequences reported to the US National HIV Surveillance System during 2001-2012, we calculated pairwise genetic distance, identified linked pairs of sequences (those with distance ≤1.5%), and examined transmission category and race/ethnicity of these potential transmission partners.

RESULTS

Of 40,950 sequences, 12,910 (32%) were linked to ≥1 other sequence. Of men who have sex with men (MSM) who were linked to ≥1 sequence, 88% were linked to other MSM and only 4% were linked to heterosexual women. Of heterosexual women for whom we identified potential transmission partners, 29% were linked to MSM, 21% to heterosexual men, and 12% to persons who inject drugs. Older and black MSM were more likely to be linked to heterosexual women. Assortative mixing was present for all racial/ethnic groups; 81% of blacks/African Americans linked to other blacks.

CONCLUSIONS

This analysis is the first use of US surveillance data to infer an HIV transmission network. Our data suggest that HIV infections among heterosexual women predominantly originate from MSM, followed by heterosexual men. Although few MSM were linked to women, suggesting that a minority of MSM are involved in transmission with heterosexual women, these transmissions represent a substantial proportion of HIV acquisitions by heterosexual women. Interventions that reduce transmissions involving MSM are likely to also reduce HIV acquisition among other risk groups.

Incarcerated Black Women in the Southern USA: A Narrative Review of STI and HIV Risk and Implications for Future Public Health Research, Practice, and Policy

Incarcerated black women in the southern USA are understudied despite the high prevalence of sexually transmitted infections (STI) and human immunodeficiency virus (HIV). These incarceration and health disparities are rooted in centuries of historically inequitable treatment. Amidst the current dialogue on mass incarceration in the south and its relationship to the health of the black community, individual and environmental risk factors for STI/HIV transmission are seldom paired with discussions of evidence-based solutions. A narrative review of the literature from January 1995 to May 2015 was conducted. This sample of the literature (n = 18) revealed that partner concurrency, inconsistent condom use, sex work, previous STI, and drug abuse augmented individual STI/HIV risk. Recommended interventions include those which promote healthier relationships, cultural competence, and gender specificity, as well as those that enhance prevention skills. Policy recommendations include improving cultural sensitivity, cultural competence, and cultural humility training for clinicians, as well as substantially increasing funding for prevention, treatment, and rehabilitative services. These recommendations are timely given the recent national attention to incarceration, STI, and HIV disparities, particularly in the southern USA.

EXPERIENCE OF FORCED SEX AND SUBSEQUENT SEXUAL, DRUG, AND MENTAL HEALTH OUTCOMES: AFRICAN AMERICAN AND HISPANIC WOMEN IN THE SOUTHEASTERN UNITED STATES

OBJECTIVES

This cross-sectional study examined African American and Hispanic women's (N = 1,509) self-reports of unwanted forced sex and its association with behavioral and mental health outcomes after the event.

METHODS

Twenty percent of the women had experienced forced sex (1st occurrence at age 15 years or younger for 10%, 1st occurrence at older than 15 years of age for 10%).

RESULTS

Regardless of when forced sex 1st occurred, women were more likely to have engaged in unprotected vaginal and anal sex, to have had multiple unprotected sex partners, to have sexually transmitted infections, to have reported binge drinking and illicit drug use, and to exhibit distress and have received mental health counseling.

CONCLUSIONS

Forced sex may have wide-ranging behavioral and mental health consequences years later.

The Epidemiology of Human Immunodeficiency Virus Infection and Care among Adult and Adolescent Females in the United States, 2008-2012

OBJECTIVE

We sought to determine epidemiological patterns in diagnoses of human immunodeficiency virus (HIV) infection and prevalence among females by age, race/ethnicity and transmission category, and essential steps in the continuum of HIV care.

METHODS

Using data from the National HIV Surveillance System, we estimated the number of females aged 13 years or older diagnosed with HIV infection in 2008 through 2012 and living with HIV at the end of 2011 in the United States. We determined percentages of females linked to care, retained in care, and virally suppressed in 18 jurisdictions with complete reporting of CD4 and viral load test results.

RESULTS

From 2008 to 2012, the estimated rate of HIV diagnoses among females decreased from 9.3 to 6.9 per 100,000 (-7.1% per year; 95% confidence interval [CI], -7.9, -6.3). In 2012, the diagnosis rate was highest among Blacks/African Americans (35.7), followed by Hispanics or Latinos (6.4), and Native Hawaiian Other Pacific Islander (5.1), and lowest among Whites (1.8). Most females diagnosed in 2012 were linked to care within 3 months of diagnosis (82.5%). About one-half (52.4%) of females living with HIV in 2011 received ongoing care in 2011 and 44.3% had a suppressed viral load. Viral suppression was lower among American Indian/Alaska Native (29.7%) and Black/African American (41.6%) compared with White females (46.5%). The percentage in care and with viral suppression was lower among younger compared with older females.

CONCLUSION

HIV diagnoses continue to decrease among females; however, disparities exist in HIV burden and viral suppression. Improvements in care and treatment outcomes are needed for all women with particular emphasis on younger women.

Disparities in viral load and CD4 count trends among HIV-infected adults in South Carolina

On a population level, trends in viral load (VL) and CD4 cell counts can provide a marker of infectivity and an indirect measure of retention in care. Thus, observing the trend of CD4/VL over time can provide useful information on disparities in populations across the HIV care continuum when stratified by demography. South Carolina (SC) maintains electronic records of all CD4 cell counts and HIV VL measurements reported to the state health department. We examined temporal trends in individual HIV VLs reported in SC between January 1, 2005 and December 31, 2012 by using mixed effects models adjusting for gender, race/ethnicity, age, baseline CD4 count, HIV risk category, and residence. Overall VL levels gradually decreased over the observation period. There were significant differences in the VL decline by gender, age groups, rural/urban residence, and HIV risk exposure group. There were significant differences in CD4 increases by race/ethnicity, age groups, and HIV risk exposure group. However, the population VL declines were slower among individuals aged 13-19 years compared to older age groups (p<0.0001), among men compared to women (p=0.002), and among people living with HIV/AIDS (PLWHA) with CD4 count ≤200 cell/mm(3) compared to those with higher CD4 counts (p<0.0001). Significant disparities were observed in VL decline by gender, age, and CD4 counts among PLWHA in SC. Population based data such as these can help streamline and better target local resources to facilitate retention in care and adherence to medications among PLWHA.

Race/ethnicity, sexual partnerships with men involved with drugs, and sexually transmitted infections among a sample of urban young adult women

In many urban neighbourhoods in the United States, drug markets borne from disadvantage have produced risk for sexually transmitted infections through altered sexual norms and partnerships. Presently, we examined the association of race, sexual partnerships with men involved with drugs, and self-reported sexually transmitted infections among 240 African American and white women aged 18-30 years. Thirty seven per cent reported ever having a sexually transmitted infection. Almost 30% of Whites reported sex with a drug user, compared to 5% of African Americans. Fifty eight per cent of African Americans compared to 31% of Whites reported sex with a drug dealer. On Step 1 of a sequential logistic regression model, race was associated with lifetime sexually transmitted infections (OR = 4.7, 95% CI = 2.61-8.34). Results from the full sequential logistic regression model indicated a significant, but smaller association of race and lifetime sexually transmitted infections (Adjusted OR = 3.5, 95% CI = 1.78-7.02) and an association of sex with a drug dealer and lifetime sexually transmitted infections (Adjusted OR = 2.9, 95% CI = 1.55-5.20). Forming sexual partnerships with drug dealers may place women at increased risk for sexually transmitted infections and explain racial disparities. More research focused on drug dealers as core transmitters is needed.

Discounting of money and sex: effects of commodity and temporal position in stimulant-dependent men and women

Research on delay discounting has contributed to the understanding of numerous addiction-related phenomena. For example, studies have shown that substance dependent individuals discount their addictive substances (e.g., cocaine) more rapidly than they do other commodities (e.g., money). Recent research has shown that substance dependent individuals discount delayed sex more rapidly than delayed money, and their discounting rates for delayed sex were higher than those of non-addicted individuals. The particular reason that delay discounting rates for sex are higher than those for money, however, are unclear. Do individuals discount delayed sex rapidly because immediate sex is particularly appealing or because delayed sex does not retain its value? Moreover, do the same factors influence men and women's choices? The current study examined delay discounting in four conditions (money now versus money later; sex now versus sex later; money now, versus sex later; sex now versus money later) in cocaine dependent men and women. The procedures used isolated the role of the immediate versus delayed commodity. For men, the higher rates of delay discounting for sex were because delayed sex did not retain its value, whereas both the immediate and delayed commodity influenced the female participants' decisions.

Concurrent partnering and condom use among rural heterosexual African-American men

Background Limited research has targeted HIV risk among heterosexual African-American men in the rural south-eastern United States.

METHODS

A cross-sectional survey was administered to 538 men to assess HIV knowledge, attitudes towards HIV testing and sexual risk behaviour.

RESULTS

Fifty-one percent reported consistent condom use in the past 3 months. Monogamous men reported more consistent condom use (t=3.47, d.f.=536, P<0.001). In concurrent partnerships, condom use was inversely related to age (adjusted odds ratio (AOR)=0.98, 95% confidence interval (CI)=0.95-0.998, P=0.03) and increased with the number of female partners (AOR=1.49, 95% CI=1.26-1.76, P<0.001).

CONCLUSIONS

African-American HIV prevention outreach should include focus on concurrent partnering in rural settings.

HIV diagnoses and prevalence in the southern region of the United States, 2007-2010

On a number of leading health indicators, including HIV disease, individuals in the southern states of the United States fare worse than those in other regions. We analyzed data on adults and adolescents diagnosed with HIV infection through December 2010, and reported to the Centers for Disease Control and Prevention (CDC) through June 2011 from 46 states with confidential name-based HIV reporting since January 2007 to describe the impact of HIV in the South. In 2010 46.0 % of all new diagnoses of HIV infection occurred in the South. Compared to other regions, a higher percentage of diagnoses in the South were among women (23.8 %), blacks/African Americans (57.2 %), and among those in the heterosexual contact category (15.0 % for males; 88.5 % for females). From 2007 to 2010 the estimated number and rate of diagnoses of HIV infection decreased significantly in the South overall (estimated annual percentage change [EAPC] = -1.5 % [95 %CI -2.3 %, -0.7 %] and -2.1 % [95 % CI -4.0 %, -0.2 %], respectively) and among most groups of women, but there was no change in the number or rate of diagnoses of HIV infection among men overall. Significant decreases in men 30-39 and 40-49 years of age were offset by increases in young men 13-19 and 20-29 years of age. A continued focus on this area of high HIV burden is needed to yield success in the fight against HIV disease.

Recent cancer incidence trends in an observational clinical cohort of HIV-infected patients in the US, 2000 to 2011

Background

In HIV-infected populations in developed countries, the most recent published cancer incidence trend analyses are only updated through 2008. We assessed changes in the distribution of cancer types and incidence trends among HIV-infected patients in North Carolina up until 2011.

Methods

We linked the University of North Carolina Center for AIDS Research HIV Clinical Cohort, an observational clinical cohort of 3141 HIV-infected patients, with the North Carolina Cancer registry. Cancer incidence rates were estimated across calendar years from 2000 to 2011. The distribution of cancer types was described. Incidence trends were assessed with linear regression.

Results

Across 15,022 person-years of follow-up, 202 cancers were identified (incidence rate per 100,000 person-years [IR]: 1345; 95% confidence interval [CI]: 1166, 1544). The majority of cancers were virus-related (61%), including Kaposi sarcoma (N = 32) (IR: 213; 95%CI: 146, 301), non-Hodgkin lymphoma (N = 34) (IR: 226; 95%CI: 157, 316), and anal cancer (N = 16) (IR: 107; 95%CI: 61, 173). Non-Hodgkin lymphoma was observed to decrease from 2000 to 2011 (decline of 15 cases per 100,000 person-years per calendar year, 95%CI: -27, -3). No other changes in incidence or changes in incidence trends were observed for other cancers (all P > 0.20).

Conclusions

We observed a substantial burden of a variety of cancers in this population in the last decade. Kaposi sarcoma and non-Hodgkin lymphoma were consistently two of the greatest contributors to cancer burden across calendar time. Cancer rates appeared stable across calendar years, except for non-Hodgkin lymphoma, which appeared to decrease throughout the study period.

A Qualitative Study of Barriers to the Utilization of HIV Testing Services Among Rural African American Cocaine Users

This qualitative study is about barriers to the utilization of HIV testing as perceived by African Americans who have recently used cocaine and who live in the rural Delta region of Arkansas. Affordability, physical accessibility, and geographic availability were not perceived as barriers to HIV testing in this sample, yet acceptability was still perceived as poor. Acceptability due to social mores and norms was a major barrier. Many said testing was unacceptable because of fear of social costs. Many were confident of being HIV-negative based on risky assumptions about testing and the notification process. Small-town social and sexual networks added to concerns about reputation and risk. System approaches may fail if they focus solely on improving access to HIV services but do not take into consideration deeply internalized experiences of rural African Americans as well as involvement of the community in developing programs and services.

Integrating condom skills into family-centered prevention: efficacy of the Strong African American Families-Teen program

PURPOSE

The Strong African American Families-Teen (SAAF-T) program, a family-centered preventive intervention that included an optional condom skills unit, was evaluated to determine whether it prevented unprotected intercourse and increased condom efficacy among rural African American adolescents. Ancillary analyses were conducted to identify factors that predicted youth attendance of the condom skills unit.

METHODS

Sixteen-year-old African American youths (N = 502) and their primary caregivers were randomly assigned to SAAF-T (n = 252) or an attention control (n = 250) intervention. SAAF-T families participated in a 5-week family skills training program that included an optional condom skills unit. All families completed in-home pretest, posttest, and long-term follow-up interviews during which adolescents reported on their sexual behavior, condom use, and condom efficacy. Because condom use was addressed only in an optional unit that required caregiver consent, we analyzed efficacy using complier average causal effect analyses.

RESULTS

Attendance in both SAAF-T and the attention control intervention averaged 4 of 5 sessions; 70% of SAAF-T youth attended the condom skills unit. Complier average causal effect models indicated that SAAF-T was efficacious in reducing unprotected intercourse and increasing condom efficacy among rural African American high school students. Exploratory analyses indicated that religious caregivers were more likely than nonreligious caregivers to have their youth attend the condom skills unit.

CONCLUSIONS

Results suggest that brief condom skills educational modules in the context of a family-centered program are feasible and reduce risk for sexually transmitted infections and unplanned pregnancies.

Preexposure prophylaxis for HIV infection: healthcare providers' knowledge, perception, and willingness to adopt future implementation in the southern US

BACKGROUND

Understanding providers' perspective on preexposure prophylaxis (PrEP) would facilitate planning for future implementation.

METHODS

A survey of care providers from sexually transmitted disease and family planning clinics in South Carolina and Mississippi was conducted to assess their knowledge, perception, and willingness to adopt PrEP. Multivariable logistic and general linear regression with inverse propensity score treatment weights were used for analyses.

RESULTS

Survey response rate was 360/480 (75%). Median age was 46.9 years and a majority were women (279 [78%]), non-Hispanic white (277 [78%]), nonphysicians (254 [71%]), and public health care providers (223 [62%]). Knowledge about PrEP was higher among physicians compared with nonphysicians (P = 0.001); nonpublic health care providers compared with public health care providers (P = 0.023), and non-Hispanic whites compared with non-Hispanic blacks (P = 0.034). The majority of the providers were concerned about the safety, efficacy, and cost of PrEP. Providers' perceptions about PrEP were significantly associated with their sociodemographic and occupational characteristics. The willingness to prescribe PrEP was more likely with higher PrEP knowledge scores (adjusted odds ratio [aOR] 14.94; 95% confidence interval [CI] 3.21-69.61), older age (aOR 1.14; 95% CI 1.01-1.29), and in those who agreed that "PrEP would empower women" (aOR 2.90; 95% CI 1.28-6.61); and was less likely for "other" race/ethnicity versus white (aOR 0.23; 95% CI 0.07-0.76) and in those who agreed that "PrEP, if not effective, could lead to higher HIV transmission" (aOR 0.45; 95% CI 0.27-0.75).

CONCLUSIONS

To improve the acceptance of PrEP among providers, there is a need to develop tailored education/training programs to alleviate their concerns about the safety and efficacy of PrEP.

Factors Related to HIV testing among an African American church-affiliated population

HIV continues to disproportionately impact communities of color, and more calls are being extended to African American churches to assist in HIV education and screening efforts. However, no studies have reported on the HIV testing practices of African American church-affiliated persons. This study examines demographic, social, and behavioral factors associated with ever receiving an HIV test and last 12-month HIV testing. Findings indicated not having insurance and condom use were predictors of ever receiving an HIV test. Predictors of HIV testing in the last 12 months included marital status (i.e., single, divorced, separated, or widowed) and intentions to get tested for HIV in the near future. These predictors should be considered when designing HIV education and screening interventions for African American church settings.

Young adult, rural, African American stimulant users: antecedents and vulnerabilities

Early initiation of substance use appears to be an alarming trend among rural minorities. This study focuses on 18- to 21-year-old African American stimulant users in the Arkansas Mississippi Delta. Most participants had no high school diploma and were unemployed; 74.5% had already been arrested. Substance use was initiated early and nearly all of the men and three-quarters of the women already met criteria for lifetime abuse or dependence. Only 18% reported that they had ever received substance abuse treatment. The results suggest that substance use interventions in rural communities will require multi-faceted strategies addressing economic, educational and healthcare disparities.

"We as drug addicts need that program": Insight from rural African American cocaine users on designing a sexual risk reduction intervention for their community

This focused ethnographic study examines data collected in 2007 from four gender- and age-specific focus groups (FGs) (N = 31) to inform the development of a sexual risk reduction intervention for African American cocaine users in rural Arkansas. A semi-structured protocol was used to guide audio-recorded FGs. Data were entered into Ethnograph and analyzed using constant comparison and content analysis. Four codes with accompanying factors emerged from the data and revealed recommendations for sexual risk reduction interventions with similar populations. Intervention design implications and challenges, study limitations, and future research are discussed. The study was supported by funds from the National Institute of Nursing Research (P20 NR009006-01) and the National Institute on Drug Abuse (1R01DA024575-01 and F31 DA026286-01).

Sexual risk behaviors among African-American and Hispanic women in five counties in the Southeastern United States: 2008-2009

PURPOSE

We examined sexual risk behaviors and unrecognized HIV infection among heterosexually active African-American and Hispanic women.

METHODS

Women not previously diagnosed with HIV infection were recruited in rural counties in North Carolina (African American) and Alabama (African American), and an urban county in southern Florida (Hispanic) using multiple methods. They completed a computer-administered questionnaire and were tested for HIV infection.

RESULTS

Between October 2008 and September 2009, 1,527 women (1,013 African American and 514 Hispanic) enrolled in the study. Median age was 35 years (range, 18-59), 33% were married or living as married, 50% had an annual household income of $12,000 or less, and 56% were employed full or part time. Two women (0.13%) tested positive for HIV. In the past 12 months, 19% had been diagnosed with a sexually transmitted infection (other than HIV), 87% engaged in unprotected vaginal intercourse (UVI), and 26% engaged in unprotected anal intercourse (UAI). In multivariate analysis, UAI was significantly (p < .05) more likely among those who reported ever being pregnant, binge drinking in the past 30 days, ever exchanging sex for things needed or wanted, engaging in UVI, or being of Hispanic ethnicity. UAI was also more likely to occur with partners with whom women had a current or past relationship as opposed to casual partners.

CONCLUSION

A high percentage of our sample of heterosexually active women of color had recently engaged in sexual risk behaviors, particularly UAI. More research is needed to elucidate the interpersonal dynamics that may promote this high-risk behavior. Educational messages that explicitly address the risks of heterosexual anal intercourse need to be developed for heterosexually active women and their male partners.

Social network characteristics and HIV sexual risk behavior among urban African American women

HIV/AIDS has emerged as a significant health threat for African American women with well-documented disparities. The purpose of this study was to assess the association between social network characteristics and high-risk sexual behaviors among a sample of urban African American women at risk of heterosexually acquired HIV/STIs. We performed a cross-sectional study of baseline data collected from the CHAT study, a randomized HIV-prevention trial targeting urban HIV-at-risk women in Baltimore, MD. Our primary outcomes were risky sexual behaviors defined as either (a) two or more sexual partners or (b) having a risky sex partner within the past 90 days. Bivariable and multivariable logistic regression examining the associations between individual and social network factors and our two outcomes of interest were conducted. The study population included 513 sexually active African American women with a mean age of 41.1 years. High levels of unemployment (89.5%), depressive symptoms (60.0%), and drug use (68.8%) were present among this high-risk urban cohort. Controlling for individual factors including participant drug use, age, and depression, having two or more sex partners within the past 90 days was associated with having a larger personal network (OR = 1.11; 95% CI, 1.06 and 1.17); more network members who pitched in to help (OR = 1.22; 95% CI, 1.04 and 1.44), provided financial support (OR = 1.33; 95% CI, 1.11 and 1.60), or used heroin or cocaine (OR = 1.26; 95% CI, 1.14 and 1.40). Having a risky sexual partner within the past 90 days was associated with having a larger social network (OR = 1.06; 95% CI, 1.00 and 1.12) and having more social networks who used heroin or cocaine (OR = 1.30; 95% CI, 1.14 and 1.49).In summary, social network characteristics are associated with HIV sexual risk behaviors among African American urban women. Social-network-based interventions that promote norms pertaining to HIV risk reduction and provide social support are needed for African American women at risk of heterosexually acquired HIV/STIs.

Challenges of a hidden epidemic: HIV prevention among women in the United States

HIV/AIDS trends in the United States depict a concentrated epidemic with hot spots that vary by location, poverty, race/ethnicity, and transmission mode. HIV/AIDS is a leading cause of death among US women of color; two-thirds of new infections among women occur in black women, despite the fact that black women account for just 14% of the US female population. The gravity of the HIV epidemic among US women is often not appreciated by those at risk and by the broader scientific community. We summarize the current epidemiology of HIV/AIDS among US women and discuss clinical, research, and public health intervention components that must be brought together in a cohesive plan to reduce new HIV infections in US women. Only by accelerating research and programmatic efforts will the hidden epidemic of HIV among US women emerge into the light and come under control.

Male injecting drug users in the Deep South: bisexual behaviour is a marker for elevated HIV risk

This study determined whether bisexual male injecting drug users (IDUs) as compared with heterosexual IDUs were more likely to engage in HIV-associated risk behaviours. Respondent-driven sampling was employed to recruit a sample of 382 male IDUs residing in the southeastern USA. Data were collected in face-to-face interviews. Weighted analyses showed that bisexual IDUs in the past 12 months were 4.6 times as likely to share needles and 3.5 times as likely to share a cooker; having multiple female sexual partners and trading money or drugs for sex with women were marginally significant. Bisexual IDUs were 10 times as likely to self-report HIV. Male IDUs, who engage in bisexual behaviour, are also engaging in HIV-associated drug and to some degree sexual-risk behaviours with women more so than heterosexual IDUs. Their higher prevalence of HIV infection coupled with their risk behaviours place themselves and other IDUs at heightened risk of both acquiring and transmitting HIV.

Two-year trajectory of stimulant use in 18- to 21-year-old rural African Americans

Little is known about stimulant use trajectories of rural African American youth. The purpose of the present study is to explore substance use over 24 months in 98 African Americans, ages 18 to 21, who used cocaine or methamphetamine 30 days prior to baseline. The majority was male, unemployed, and had not graduated from high school. At baseline, almost half of the participants met criteria for abuse/dependence of cocaine--the primary stimulant used--which decreased to 25% by the final follow-up. Similar decreases were noted in rates of alcohol and marijuana abuse/dependence, although monthly use remained high. Participants reported minimal utilization of mental health or substance abuse services, but demonstrated significant improvements on physical and mental health measures. In summary, cocaine use declined, but other substances were used at high rates, suggesting a significant need for intervention services that address multisubstance use in rural areas.

Stages of change, decisional balance, and self-efficacy in condom use among rural African-American stimulant users

This pilot study (a) examined the stages of change (SOC) for condom use with primary and casual partners among rural heterosexual African American stimulant users, (b) identified gender differences in variables associated with SOC, and (c) assessed the association of SOC with decisional balance and self-efficacy. A total of 72 participants completed the study. SOC with a primary partner were much lower than with a casual partner, indicating more consistent condom use with casual partners. Significant gender differences existed in decisional balance for condom use for both primary (p = .02) and casual partners (p =.03), with women having higher decisional balance scores than men. Women also reported higher self-efficacy scores for condom use with casual partners than men. In regression models, age, decisional balance, and self-efficacy were significantly associated with SOC for condom use with a primary partner; however, only self-efficacy was significantly associated with SOC with casual partners. The results provide support for the development of interventions that promote the advantages of and increase self-efficacy for condom use.

Anal sex is a behavioural marker for laboratory-confirmed vaginal sexually transmissible infections and HIV-associated risk among African-American female adolescents

BACKGROUND

African-American females are disproportionately affected by HIV and sexually transmissible infections (STIs). The prevalence of anal sex and its association with other sexual risk behaviours is understudied in this population.

METHODS

Participants were 715 African-American females, 15 to 21 years old, who had reported sexual activity in the previous 60 days. Data collection included an audiocomputer assisted self-interview (ACASI) and a self-collected vaginal swab specimen assayed using nucleic acid amplification tests to detect the presence of Chlamydia trachomatis and Neisseria gonorrhoeae, and real-time polymerase chain reaction assay to detect Trichomonas vaginalis.

RESULTS

Approximately 10.5% reported anal sex, at least once, during the 60 days before completing the computerised baseline assessment. The prevalence of any STI was significantly greater among adolescents reporting recent anal sex (40% tested positive for at least one of three laboratory-confirmed STIs) relative to those adolescents not reporting anal sex (27.5% STI prevalence). Of the 10 outcomes comprising the sexual risk profile, seven achieved bivariate significance, with each of the differences indicating greater risk for those recently engaging in anal sex. In multivariable controlled analyses, six of the seven measures retained statistical significance.

CONCLUSIONS

African-American adolescent females who engage in penile-anal sex may experience an elevated risk of vaginally-acquired STIs. The findings suggest that, among those having penile-anal sex, several HIV/STI-associated sexual risk behaviours are significantly more prevalent. Thus, penile-anal sex may be an important proxy of overall sexual risk behaviours and can be readily assessed during paediatrician visits as part of a sexual history.

Sexual mixing patterns and heterosexual HIV transmission among African Americans in the southeastern United States

OBJECTIVES

Heterosexually transmitted HIV infection rates are disproportionately high among African Americans. HIV transmission is influenced by sexual network characteristics, including sexual partnership mixing patterns among subpopulations with different prevalences of infection.

STUDY DESIGN

We conducted a cross-sectional analysis of previously collected data from a North Carolina population-based case-control study. Respondents were heterosexual black men and women who either had recently reported heterosexually transmitted HIV infection (cases) or were randomly selected from the general population (controls).

METHODS

Respondents reported their own and their 3 most recent sex partners' education and involvement in illicit drug use, concurrent sex partners, and incarceration. We examined sexual mixing patterns by comparing the characteristics and behaviors of respondents reported for themselves with those they reported for their partners. We estimated Newman assortativity coefficient (-1.0 to 1.0) as an aggregate quantitative assessment of mixing patterns.

RESULTS

Across the 4 strata (male and female cases, male and female controls), mixing was assortative (0.31-0.45) with respect to illicit drug use and minimally assortative with respect to having concurrent partners (0.14-0.22). Mixing patterns for incarceration were assortative for men (0.18 and 0.41) but not women (0.07 and 0.08). Mixing with respect to education was assortative primarily for male controls (0.33).

CONCLUSIONS

These sexual partnership patterns, driven in part by the social and economic context of life for African Americans, likely contribute to the heterosexually transmitted HIV epidemic.

Transmitted antiretroviral drug resistance among acute and recent HIV infections in North Carolina from 1998 to 2007

Background

Transmitted drug resistance (TDR) limits antiretroviral options and thus complicates the management of HIV-positive patients. HIV disproportionately affects the southern US, but available national estimates of TDR prevalence principally reflect large metropolitan centres outside this region.

Methods

The Duke/UNC Acute HIV Program has collected data on acute or recent HIV infections (ARHI) in North Carolina since 1998. Acute infections represent antibody-negative, RNA-positive patients. Recent infection was determined by history of HIV testing or concordance between detuned ELISA and antibody avidity assays. Genotypic sequence data from the earliest collected pretreatment plasma samples were analysed with the Stanford HIV Database and screened for surveillance drug resistance mutations (SDRMs).

Results

A total of 253 individuals with ARHI between May 1998 and May 2007 had complete genotypic sequence data for analysis; 39.5% were acute infections, 78.7% were male, 64.8% were non-White and 53.8% were men who have sex with men. The overall prevalence of TDR was 17.8%, with SDRMs for non-nucleoside/ nucleotide reverse transcriptase inhibitors (NNRTIs) in 9.5% of the cohort. Mutations for nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) were detected in 7.5% and for protease inhibitors (PIs) in 3.2%. K103N was the most common mutation (7.5%). Thymidine analogue mutations were found in 4.7% of samples; the most common PI SDRM was L90M (2.4%). Dual- or triple-class antiretroviral resistance was rare, encountered in only six (2.4%) samples.

Conclusions

The prevalence of TDR in North Carolina is similar to estimates from the US metropolitan areas. These findings have implications for initial regimen selection and secondary prevention efforts outside of large, metropolitan HIV epicentres.

Losing All the Pieces: A Qualitative Study of HIV Risk Perception and Risk Reduction among Rural African American Women Who Use Cocaine

The purpose of this study was to examine HIV-related beliefs of rural African American women who use stimulant drugs and their perceived risk for acquiring HIV. Qualitative interviews were conducted with 15 African American women living in the Mississippi Delta region of rural Arkansas. All women in the study were active users of crack and/or powder cocaine. We used the qualitative methods of content analysis and constant comparison to analyze the transcribed interviews. Four major themes emerged from the analysis: 1) Knowledge and Beliefs, 2) Don't Ask, Don't Tell, 3) Staying Safe, and 4) Surviving in the Community. Based on participants' responses, we discuss implications for framing new risk-reduction interventions tailored to the specific needs of this high-risk population at both the individual and community levels.

How caring for persons with HIV/AIDS affects rural nurses

Prior research findings about caregiving for persons with HIV/AIDS indicate that caregiving impacts nurses in three separate domains: personal self as a nurse in practice; interactions with the nurse's family members, friends, and colleagues; and interactions with persons with HIV/AIDS. However the impact caregiving for persons with HIV/AIDS has on rural nurses has not been extensively explored. A qualitative study of rural registered nurses' experiences of caring for persons with HIV/AIDS was conducted to determine how caregiving affects registered nurses in rural areas. Content analysis was used to analyze rural registered nurses' written comments about their experiences of caring for persons with HIV/AIDS. Themes identified from the nurses' accounts of instances of caregiving were the perceived risk of acquiring the virus, a lack of concern about HIV/AIDS, and a need for ongoing continued education about the care of persons with HIV/AIDS.

County-level socioeconomic status and survival after HIV diagnosis, United States

PURPOSE

To estimate relative survival (RS) after human immunodeficiency virus (HIV) diagnosis, by race/ethnicity and county-level socioeconomic status (SES).

METHODS

We estimated 5-year RS by age, race/ethnicity, transmission category, sex, diagnosis year, CD4 count, and by county-level SES variables from the U.S. Census. Data, from the national HIV/AIDS Reporting System, were for HIV-infected persons ages > or =13 years (diagnosis during 1996-2003 and follow-up through 2005). We calculated RS proportions by using a maximum likelihood algorithm and modeled the relative risk of excess death (RR) using generalized linear models, with poverty as a random effect.

RESULTS

For men, RS was worse in counties with larger proportions of people living below the 2000 U.S. poverty level (87.7% for poverty of > or =20% vs. 90.1% for poverty of <5.0%) and where unemployment was greater (87.8% where unemployment > 7.1% vs. 90.5% where unemployment < 4.0%). The effects of county-level SES on RS of women were similar. In multilevel multivariate models, RR for men and women within 5 years after an HIV diagnosis was significantly worse in counties where 10.0-19.9% (compared with <5.0%) lived below the poverty level (RR = 1.3 [95% CI 1.2-1.5] and RR = 1.8 [95% CI 1.4-2.2], respectively).

CONCLUSIONS

RS was worse in lower SES areas. To help address the impact of county-level SES, resources for HIV testing, care, and proven economic interventions should be directed to areas with concentrations of economically disadvantaged people.

Changes in hepatitis A virus seroepidemiology in HIV-infected Brazilian patients

Shifting of hepatitis A virus (HAV) epidemiology from a high towards an intermediate endemicity pattern and use of antiretroviral therapy increased the risk of HIV/HAV coinfection in developing countries. The aim of this study was to investigate the presence of HAV markers in a cohort of HIV-infected patients from 1988 to 2004. The presence of serum anti-HAV antibodies and HAV-RNA by real-time polymerase chain reaction was investigated in 581 patients. Total anti-HAV antibodies was found in 464/581 (79.8%) patients, however, a changing epidemiologic pattern of hepatitis A among HIV-infected patients from 1988 to 2004 was observed. Among patients susceptible to HAV (n = 117), 5 (4.2%) were coinfected with HAV, all of them had IgM anti-HAV antibodies and were serum HAV-RNA-positive. The high prevalence of anti-HAV antibodies in HIV-infected patients suggests that screening tests for anti-HAV antibodies should be performed before implementation of hepatitis A vaccination, especially in those patients from endemic countries.

African American women's experience of infection with HIV in the rural southeastern United States

The design of effective behavioral interventions to prevent HIV infection among African American women requires a more complete understanding of the context and circumstances that precipitate infection with the virus. A descriptive study was designed to explore African American women's experiences of infection with HIV in the rural southeastern United States. Ten women living with HIV participated in interviews. All were infected through sex with a man or men; three had engaged in high-risk activities associated with HIV infection including sex trading; seven described themselves as at low risk for infection related to serial monogamy, no injection drug use, and no history of addiction. Participants reported that desire for intimacy coupled with inaccurate risk appraisal of sex partners contributed to their infection. These results provide insight into the role of intimacy in sexual risk taking. Inquiry into how women can be assisted to protect themselves in the context of intimate relationships may improve interventions to prevent HIV.

Correlates of HIV, HBV, HCV and syphilis infections among prison inmates and officers in Ghana: A national multicenter study

Background

Prisons are known to be high-risk environments for the spread of bloodborne and sexually transmitted infections. Prison officers are considered to have an intermittent exposure potential to bloodborne infectious diseases on the job, however there has been no studies on the prevalence of these infections in prison officers in Ghana.

Methods

A national multicenter cross-sectional study was undertaken on correlates of human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and syphilis infections in sample of prison inmates and officers from eight of ten regional central prisons in Ghana. A total of 1366 inmates and 445 officers were enrolled between May 2004 and December 2005. Subjects completed personal risk-factor questionnaire and provided blood specimens for unlinked anonymous testing for presence of antibodies to HIV, HCV and Treponema pallidum; and surface antigen of HBV (HBsAg). These data were analyzed using both univariate and multivariate techniques.

Results

Almost 18% (1336) of 7652 eligible inmates and 21% (445) of 2139 eligible officers in eight study prisons took part. Median ages of inmates and officers were 36.5 years (range 16–84) and 38.1 years (range 25–59), respectively. Among inmates, HIV seroprevalence was 5.9%, syphilis seroprevalence was 16.5%, and 25.5% had HBsAg. Among officers tested, HIV seroprevalence was 4.9%, HCV seroprevalence was 18.7%, syphilis seroprevalence was 7.9%, and 11.7% had HBsAg. Independent determinants for HIV, HBV and syphilis infections among inmates were age between 17–46, being unmarried, being illiterate, female gender, being incarcerated for longer than median time served of 36 months, history of homosexuality, history of intravenous drug use, history of sharing syringes and drug paraphernalia, history of participation in paid sexual activity, and history of sexually transmitted diseases. Independent determinants for HIV, HBV, HCV and syphilis infections among officers were age between 25–46, fale gender, being unmarried, being employed in prison service for longer than median duration of employment of 10 years, and history of sexually transmitted diseases.

Conclusion

The comparably higher prevalence of HIV, HBV, HCV and syphilis in prison inmates and officers in Ghana suggests probable occupational related transmission. The implementation of infection control practices and risk reduction programs targeted at prison inmates and officers in Ghana is urgently required to address this substantial exposure risk.