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Talebi-Tamijani Z, Lotfi R, Kabir K. Tele-counseling based on motivational interviewing to change sexual behavior of women living with HIV: a randomized controlled clinical trial. AIDS Behav 2022; 26:3506-3515. [PMID: 35467228 DOI: 10.1007/s10461-022-03678-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2022] [Indexed: 11/28/2022]
Abstract
Sexual transmission accounts for the majority of new HIV infections in Iran. More than 80% of HIV-positive persons are sexually active, and nearly 68% reported never using a condom. The present RCT study was conducted on a group of HIV-positive women using internet-based motivational interviewing. The participants, including 100 HIV-positive women, were randomly assigned to an intervention or control group. The intervention group received five weekly internet-based group motivational interviewing sessions focused on reducing risky behaviors, and the control group received routine care. Follow-ups occurred one month and three months after the end of the intervention. The participants completed demographic information, sexual behaviors, HIV knowledge, condom negotiation skills, and HIV-specific perceived social support scales before, one month, and three months after the intervention. Motivational interviewing was effective in improving knowledge about HIV/AIDS, condom negotiation skills, and HIV-specific perceived social support in the intervention group compared to controls. The intervention significantly increased using condoms in vaginal or anal intercourse in the last three months. Still, it was not effective at consistent condom use in all vaginal and anal sex. Further investigation or a larger RCT needs to confirm the using tele-counseling for women living with HIV.
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Affiliation(s)
| | - Razieh Lotfi
- Social Determinants of Health Research Center, Alborz University of Medical Sciences, Karaj, Iran.
- Department of Midwifery and Reproductive Health, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran.
| | - Kourosh Kabir
- Social Determinants of Health Research Center, Alborz University of Medical Sciences, Karaj, Iran
- Department of Community Medicine, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
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Dangerfield DT, Ober AJ, Anderson JN, Gorbach P, Bluthenthal RN. Observational "go-alongs" of follow-up HIV care visits of two virally suppressed Black sexual minority men. Public Health Nurs 2022; 39:153-160. [PMID: 34403517 PMCID: PMC8766864 DOI: 10.1111/phn.12960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 07/29/2021] [Accepted: 07/31/2021] [Indexed: 01/03/2023]
Abstract
PURPOSE This study explored potentially underreported healthcare contexts, clinical experiences, and motivations for adherence in care among virally suppressed Black sexual minority men (BSMM) living with HIV (LWHIV) in Baltimore, MD. METHODS Go-alongs with two virally suppressed BSMM LWHIV supplemented 27 in-depth interviews of a larger qualitative study guided by Positive Deviance and Life Course Theory. The go-alongs involved accompanying participants' follow-up HIV care visit to obtain a better account of contextual healthcare factors. Observations focused on (1) clinic location and resources, (2) sources of HIV and sexuality stigma or support in the clinic, and (3) patient-provider interactions. RESULTS We found that facilitators and barriers to viral suppression for BSMM LWHIV included structural factors (i.e., healthcare setting, facility, and services), quality of patient-provider interactions, and personal motivations to achieve viral suppression. CONCLUSION Clinic accessibility, co-located clinical services, and rapport with clinicians and healthcare staff could be key contextual conditions that facilitate retention in care among BSMM LWHIV.
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Affiliation(s)
| | - Allison J. Ober
- Policy and Behavioral Science Researcher, RAND Corporation, Los Angeles, CA, USA
| | - Janeane N. Anderson
- Assitant Professor, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Pamina Gorbach
- Professor, University of California Los Angeles, Los Angeles, CA, USA
| | - Ricky N. Bluthenthal
- Professor, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
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Noiman A, Macalino G, Won SH, Byrne M, Deiss R, Haw NJ, Ganesan A, Okulicz JF, Schofield C, Lalani T, Maves RC, Wang X, Agan BK, Achatz E, Bradley W, Merritt S, Merritt T, Olsen C, Rhodes C, Sjoberg T, Baker C, Chambers S, Colombo R, Ferguson T, Kunz A, Powers J, Tramont E, Banks S, Illinik L, Kronmann K, Tant R, Cammarata S, Curry J, Kirkland N, Utz G, Price M, Aronson N, Burgess T, Chu X, Estupigan C, Hsieh, Parmelee E, Tribble D, Won S, Ake J, Crowell T, Peel S, Barahona I, Blaylock J, Decker C, Ressner R. Sexual Risk Behaviors Associated with Sexually Transmitted Infections in a US Military Population Living with HIV After the Repeal of "Don't Ask, Don't Tell". AIDS Patient Care STDS 2020; 34:523-533. [PMID: 33296270 DOI: 10.1089/apc.2020.0095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Risk behaviors associated with sexually transmitted infections (STIs) among people living with HIV (PLWH) have not been well characterized in the US military. We identified risk behaviors associated with a new STI in this population after the repeal of "Don't Ask, Don't Tell." US Military HIV Natural History Study participants who completed the risk behavior questionnaire (RBQ) between 2014 and 2017 and had at least 1 year of follow-up were included (n = 1589). Logistic regression identified behaviors associated with incident STI in the year following RBQ completion. Overall, 18.9% acquired an STI and 52.7% reported condom use at last sexual encounter. Compared with those with no new sex partners, participants with between one and four or five or more new partners were 1.71 [1.25-2.35] and 6.12 [3.47-10.79] times more likely to get an STI, respectively. Individuals reporting low or medium/high perceived risk of STI were 1.83 [1.23-2.72] and 2.65 [1.70-4.15] times more likely to acquire a new STI than those reporting no perceived risk, respectively. Participants who preferred not to answer about sexual preference, number of new partners, or perceived STI risk were also more likely to acquire a new STI. Our study illustrates that despite regular access to health care and accurate perceptions of risk, rates of STI among PLWH remain high in the US military setting, as in others. Given the potential individual and public health consequences of STI coinfection after HIV, more work is needed to assess interventions aimed at sexual behavior change for PLWH.
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Affiliation(s)
- Adi Noiman
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | | | - Seung Hyun Won
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Morgan Byrne
- Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, District of Columbia, USA
| | - Robert Deiss
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | | | - Anuradha Ganesan
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
- Division of Infectious Diseases, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Jason F. Okulicz
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Infectious Disease Service, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Christina Schofield
- Division of Infectious Diseases, Madigan Army Medical Center, Joint Base Lewis McChord, Washington, District of Columbia, USA
| | - Tahaniyat Lalani
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
- Division of Infectious Diseases, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - Ryan C. Maves
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Division of Infectious Diseases, Naval Medical Center San Diego, San Diego, California, USA
| | - Xun Wang
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Brian K. Agan
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
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Racial and Ethnic Differences in Viral Suppression Among HIV-Positive Women in Care. J Acquir Immune Defic Syndr 2019; 79:e56-e68. [PMID: 30212433 DOI: 10.1097/qai.0000000000001779] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Women with HIV diagnoses are less likely to be virally suppressed than men. Women of different racial/ethnic groups may be differentially affected by sociodemographic factors. We examined differences in viral suppression among women by race/ethnicity and associated variables to inform prevention interventions. METHODS We used data from the 2010-2014 cycles of the Medical Monitoring Project, a cross-sectional survey of HIV-positive adults in care. We limited analyses to black, Hispanic, and white women. We calculated weighted prevalences of recent viral suppression (undetectable or <200 copies/mL) and sustained viral suppression (consistent viral suppression during the past 12 months) among women by race/ethnicity. We computed adjusted prevalence differences (aPDs) and 95% confidence intervals (CIs) for viral suppression by racial/ethnic group, controlling for selected variables, including available social determinants of health variables. RESULTS Among women, 62.9% were black, 19.8% Hispanic, and 17.3% white. Overall, 74.3% had recent viral suppression, and 62.3% had sustained viral suppression. Compared with white women (79.7%, CI: 77.2 to 82.2), black (72.5%, CI: 70.3 to 74.7; PD: 7.2) and Hispanic (75.4%, CI: 72.6 to 78.3; PD: 4.3) women were less likely to have recent viral suppression. In multivariable analyses, after adjusting for antiretroviral therapy adherence, HIV disease stage, age, homelessness, and education, black-white aPDs remained significant for recent (aPD: 4.8, CI: 1.6 to 8.1) and sustained (aPD: 5.0, CI: 1.1 to 9.0) viral suppression. CONCLUSION Viral suppression was suboptimal for all women, but more for black and Hispanic women. Differences between black, Hispanic, and white women may be partially due to antiretroviral therapy adherence, HIV disease stage, and social determinants of health factors.
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HIV Screening and Early Referral in the Trauma Population: The Experience of a Large Safety Net Hospital. J Surg Res 2019; 245:360-366. [PMID: 31425876 DOI: 10.1016/j.jss.2019.07.071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 06/21/2019] [Accepted: 07/19/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND While the prevalence of HIV infection in the population is 0.5%, it is higher among trauma patients as are rates of unknown seropositivity. Routine HIV screening for all trauma evaluations was implemented at our urban level I center in 2009. We aimed to evaluate use and results of the program in our trauma population. METHODS This was a retrospective analysis of all trauma evaluations between July 2015 and February 2018. After passage of legislation rescinding the requirement for consent to perform HIV testing, our trauma service instituted an order set which automatically tested for HIV unless the ordering physician opted out. Patients found to be infected with HIV were to be counseled and referred to specialty care. RESULTS Of 6175 consecutive trauma evaluations during the study period, 449 (7.3%) patients had been screened within the prior year and were excluded. Of the remaining cohort, 2024 (35.3%) patients were screened with 27 (1.3%) testing positive. Among those testing positive for infection, 100% were male, 77% white, 63% non-Hispanic, and 70% lacked insurance. Twenty-five (92.6%) patients received counseling and 19 were referred to specialty care. Age, gender, race, ethnicity, Injury Severity Score, trauma activation level, and payor type were not significant predictors for positive HIV screen on logistic regression analysis. CONCLUSIONS Despite a significantly higher rate of HIV in the trauma population, only a third of patients are screened. Such high infection rates justify the existence of this screening program but steps must be taken to increase screening rate. LEVEL OF EVIDENCE Level 3.
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de Voux A, Bernstein KT, Bradley H, Kirkcaldy RD, Tie Y, Shouse RL. Syphilis Testing Among Sexually Active Men Who Have Sex With Men and Who Are Receiving Medical Care for Human Immunodeficiency Virus in the United States: Medical Monitoring Project, 2013-2014. Clin Infect Dis 2019; 68:934-939. [PMID: 29985985 PMCID: PMC6563935 DOI: 10.1093/cid/ciy571] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 07/06/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Guidelines recommend that sexually active men who have sex with men (MSM) including human immunodeficiency virus (HIV)-positive MSM be tested at least annually for syphilis, with testing every 3-6 months for MSM at elevated risk. We examined the proportion of HIV-positive MSM tested for syphilis in the past 3, 6, and 12 months by their HIV care provider during 2013-2014. METHODS Using data from the Medical Monitoring Project, a population-based HIV surveillance system, we evaluated the proportion of MSM who had documentation of being tested for syphilis by their HIV care provider in the past 3, 6, and 12 months. RESULTS During 2013-2014, 71% (95% confidence interval [CI]: 69%-73%) of sexually active HIV-positive MSM were tested for syphilis in the past year. This proportion was higher among MSM reporting condomless sex: (75%; 95% CI: 72%-78%), and among MSM reporting ≥ 2 sex partners (77%; 95% CI: 74%-79%), in the past 12 months. Among MSM reporting condomless sex, 49% (95% CI: 45%-53%) were tested in the past 6 months, and 26% (95% CI: 22%-30%) in the past 3 months. Among MSM reporting ≥ 2 sex partners, 49% (95% CI: 44%-54%) were tested in the past 6 months and 26% (95% CI: 22%-29%) in the past 3 months. CONCLUSIONS Nearly one-third of sexually active HIV-positive MSM were not tested annually, and many at increased risk were not tested at recommended frequencies. Efforts to improve compliance with screening guidelines for high-risk HIV-positive MSM are warranted.
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Affiliation(s)
- Alex de Voux
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kyle T Bernstein
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Heather Bradley
- Division HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Robert D Kirkcaldy
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Yunfeng Tie
- Division HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - R Luke Shouse
- Division HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
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Byrd KK, Hardnett F, Clay PG, Delpino A, Hazen R, Shankle MD, Camp NM, Suzuki S, Weidle PJ, Aguirre M, Akinbosoye O, Bamberger DM, Bluml B, Bullock K, Burrell DC, Bush T, Bush C, Cadwell C, Cardarelli R, Clark T, Crim A, Cure A, Darin K, Dean T, DeMayo M, Elrod S, Eschmann AL, Farmer D, Farnan R, Free H, Gudzelak A, Halbur A, Hardnett F, Hazen R, Hilker H, Hou J, Hujdich B, Johnson L, Kirkham H, Lecounte J, Lio S, Lo G, Middleton S, Mills B, Nguyen CM, Ortiz L, Pietrandoni G, Scarsi K, Schommer J, Shrestha R, Smith D, Taitel MS, Teferi GN, Tomer V, Terres L, Whitfield C, Willman JE. Retention in HIV Care Among Participants in the Patient-Centered HIV Care Model: A Collaboration Between Community-Based Pharmacists and Primary Medical Providers. AIDS Patient Care STDS 2019; 33:58-66. [PMID: 30648888 DOI: 10.1089/apc.2018.0216] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Poor retention in HIV care is associated with higher morbidity and mortality and greater risk of HIV transmission. The Patient-Centered HIV Care Model (PCHCM) integrated community-based pharmacists with medical providers. The model required sharing of patient clinical information and collaborative therapy-related action planning. The proportion of persons retained in care (≥1 medical visit in each 6-month period of a 12-month measurement period with ≥60 days between visits), pre- and post-PCHCM implementation, was modeled using log binomial regression. Factors associated with post-implementation retention were determined using multi-variable regression. Of 765 enrolled persons, the plurality were male (n = 555) and non-Hispanic black (n = 331), with a median age of 48 years (interquartile range = 38-55); 680 and 625 persons were included in the pre- and post-implementation analyses, respectively. Overall, retention improved 12.9% (60.7-68.5%, p = 0.002). The largest improvement was seen among non-Hispanic black persons, 22.6% increase (59.7-73.2%, p < 0.001). Persons who were non-Hispanic black [adjusted risk ratio (ARR) 1.27, 95% confidence interval (CI) 1.08-1.48] received one or more pharmacist-clinic developed action plan (ARR 1.51, 95% CI 1.18-1.93), had three or more pharmacist encounters (ARR 1.17, 95% CI 1.05-1.30), were more likely to be retained post-implementation. In the final multi-variable models, only race/ethnicity [non-Hispanic black (ARR 1.27, 95% CI 1.09-1.48) and "other or unknown" race/ethnicity (ARR 1.36, 95% CI 1.14-1.63)] showed an association with post-implementation retention. PCHCM demonstrated how collaborations between community-based pharmacists and primary medical providers can improve retention in HIV care. This care model may be particularly useful for non-Hispanic black persons who often are less likely to be retained in care.
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Affiliation(s)
- Kathy K. Byrd
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Felicia Hardnett
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Patrick G. Clay
- University of North Texas Health Science System College of Pharmacy, Fort Worth, Texas
| | | | | | | | | | - Sumihiro Suzuki
- Department of Biostatistics and Epidemiology, University of North Texas Health Science Center, Fort Worth, Texas
| | - Paul J. Weidle
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
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8
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Cook CL, Staras SAS, Zhou Z, Chichetto N, Cook RL. Disclosure of HIV serostatus and condomless sex among men living with HIV/AIDS in Florida. PLoS One 2018; 13:e0207838. [PMID: 30557362 PMCID: PMC6296664 DOI: 10.1371/journal.pone.0207838] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 11/07/2018] [Indexed: 11/18/2022] Open
Abstract
Despite campaigns to increase safer sex practices, there are people living with HIV/AIDS (PLWH) who do not disclose their HIV status to sexual partners and engage in condomless sex. The purpose of this research was to: 1) describe factors associated with disclosure of HIV status to sexual partners; and 2) determine if disclosure and/or receipt of prevention counseling are independently associated with condomless sex. We used the Florida Medical Monitoring Project to analyze data from 376 HIV positive men with more than one sexual partner. Results indicated that 55% consistently disclosed their HIV status to sexual partners, 30% inconsistently disclosed, 15% did not disclose, and 48% reported any condomless sex. The odds of having condomless sex was 3.3 (CI = 1.5, 7.3) times greater in men who disclosed to all partners. Results suggest that men who disclose are also those who are more likely to have condomless sex. More research is needed to better understand the complex nature of disclosure and sexual risk behaviors and how disclosure impacts sexual risk.
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Affiliation(s)
- Christa L. Cook
- Department of Nursing Systems, College of Nursing, University of Central Florida, Orlando, FL, United States of America
| | - Stephanie A. S. Staras
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Zhi Zhou
- Department of Epidemiology, College of Medicine and College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States of America
| | - Natalie Chichetto
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Robert L. Cook
- Department of Epidemiology, College of Medicine and College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States of America
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Costa M, Montague BT, Solomon L, Sammartino C, Gutman R, Zibman C, Rosen D, Rich JD. Assessing the Effect of Recent Incarceration in Prison on HIV Care Retention and Viral Suppression in Two States. J Urban Health 2018; 95:499-507. [PMID: 29717402 PMCID: PMC6095755 DOI: 10.1007/s11524-018-0255-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The prevalence of HIV among people in correctional facilities remains much higher than that of the general population. Numerous studies have demonstrated the effectiveness and acceptability of HIV treatment for individuals incarcerated in US prisons and jails. However, the period following incarceration is characterized by significant disruptions in HIV care. These disruptions include failure to link in a timely manner (or at all) to community care post-release, as well as not being retained in care after linking. We used a retrospective, propensity-matched cohort design to compare retention in care between HIV-positive individuals recently released from prison (releasees) who linked to care in Ryan White HIV/AIDS Program (RWHAP) clinics and RWHAP patients without a recent incarceration history (community controls). We also performed analyses comparing viral load suppression of those retained in both groups. This study shows that even for those who do successfully link to care after prison, they are 24 to 29 percentage points less likely to be retained in care than those already in community care. However, we found that for those who did retain in care, there was no disparity in rates of viral suppression. These findings provide valuable insight regarding how best to address challenges associated with ensuring that HIV-positive individuals leaving prison successfully move through the HIV care continuum to become virally suppressed.
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Affiliation(s)
| | - Brian T Montague
- School of Public Health, and Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | | | - Cara Sammartino
- School of Public Health, and Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Roee Gutman
- School of Public Health, and Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | | | - David Rosen
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Josiah D Rich
- School of Public Health, and Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
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Friedman EE, Dean HD, Duffus WA. Incorporation of Social Determinants of Health in the Peer-Reviewed Literature: A Systematic Review of Articles Authored by the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Public Health Rep 2018; 133:392-412. [PMID: 29874147 DOI: 10.1177/0033354918774788] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Social determinants of health (SDHs) are the complex, structural, and societal factors that are responsible for most health inequities. Since 2003, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) has researched how SDHs place communities at risk for communicable diseases and poor adolescent health. We described the frequency and types of SDHs discussed in articles authored by NCHHSTP. METHODS We used the MEDLINE/PubMed search engine to systematically review the frequency and type of SDHs that appeared in peer-reviewed publications available in PubMed from January 1, 2009, through December 31, 2014, with a NCHHSTP affiliation. We chose search terms to identify articles with a focus on the following SDH categories: income and employment, housing and homelessness, education and schooling, stigma or discrimination, social or community context, health and health care, and neighborhood or built environment. We classified articles based on the depth of topic coverage as "substantial" (ie, one of ≤3 foci of the article) or "minimal" (ie, one of ≥4 foci of the article). RESULTS Of 862 articles authored by NCHHSTP, 366 (42%) addressed the SDH factors of interest. Some articles addressed >1 SDH factor (366 articles appeared 568 times across the 7 categories examined), and we examined them for each category that they addressed. Most articles that addressed SDHs (449/568 articles; 79%) had a minimal SDH focus. SDH categories that were most represented in the literature were health and health care (190/568 articles; 33%) and education and schooling (118/568 articles; 21%). CONCLUSIONS This assessment serves as a baseline measurement of inclusion of SDH topics from NCHHSTP authors in the literature and creates a methodology that can be used in future assessments of this topic.
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Affiliation(s)
- Eleanor E Friedman
- 1 Association of Schools and Programs of Public Health/CDC Public Health Fellowship Program, Atlanta, GA, USA.,2 Office of Health Equity, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA.,3 Chicago Center for HIV Elimination and University of Chicago Department of Medicine, Chicago, IL, USA
| | - Hazel D Dean
- 4 Office of the Director, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Wayne A Duffus
- 2 Office of Health Equity, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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11
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McKinstry LA, Zerbe A, Hanscom B, Farrior J, Kurth AE, Stanton J, Li M, Elion R, Leider J, Branson B, El-Sadr WM. A Randomized-Controlled Trial of Computer-based Prevention Counseling for HIV-Positive Persons (HPTN 065). ACTA ACUST UNITED AC 2017; 8. [PMID: 28966842 PMCID: PMC5619875 DOI: 10.4172/2155-6113.1000714] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Decreasing the risk of HIV transmission from HIV-positive individuals is an important public health priority. We evaluated the effectiveness of a computer-based sexual risk reduction counseling intervention (CARE+) among HIV-positive persons enrolled in care. METHODS HIV-positive eligible participants (N=1075) were enrolled from 11 care sites in the Bronx, NY and Washington, DC and randomized 1:1 to either a tablet-based self-administered CARE+ intervention or standard of care (SOC). The primary outcome was the proportion of participants reporting any unprotected vaginal/anal sex at last sex, among all partners, HIV-negative or HIV-unknown-status partners and for primary and non-primary partners. RESULTS At baseline, 7% of participants in both arms reported unprotected sex with an HIV-negative or HIV-unknown-status partner, while 13% in the CARE+ arm and 17% in the SOC arm reported unprotected sex with any partner. Most participants (88%) were on antiretroviral therapy (ART) at baseline. There was no significant difference in changes over time in unprotected vaginal/anal sex between the CARE+ and SOC arms for any partners (p=0.67) or either HIV-negative or HIV-unknown-status partners (p=0.40). At the Month 12 visit, most participants (85%) either strongly agreed or agreed that computer counseling would be a good addition to in-person counseling by a provider. CONCLUSION The CARE+ intervention was not effective at reducing sexual risk behaviors among HIV-positive patients in care, most of whom were on ART. Further research may be warranted around the utility of computer-based counseling for HIV prevention.
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Affiliation(s)
- Laura A McKinstry
- Statistical Center for AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, USA
| | - Allison Zerbe
- ICAP at Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Brett Hanscom
- Statistical Center for AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, USA
| | | | | | | | - Maoji Li
- Statistical Center for AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, USA
| | - Rick Elion
- District of Columbia District of Health STD/HIV Research Program, Washington, USA
| | - Jason Leider
- North Bronx Health Care Network, New York, NY, USA
| | | | - Wafaa M El-Sadr
- ICAP at Columbia University, Mailman School of Public Health, New York, NY, USA
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Sacamano PL, Farley JE. Behavioral and Other Characteristics Associated with HIV Viral Load in an Outpatient Clinic. PLoS One 2016; 11:e0166016. [PMID: 27806109 PMCID: PMC5091742 DOI: 10.1371/journal.pone.0166016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 10/21/2016] [Indexed: 11/18/2022] Open
Abstract
Persons living with HIV (PLWH) who are engaged in care, yet not virally suppressed, represent a risk for transmission and opportunity for risk reduction interventions. This study describes characteristics of an outpatient clinic cohort of PLWH by laboratory confirmed viral suppression status and examines associations with demographics and sexual and drug use behaviors gathered through questionnaire. From a sample of 500 clinic patients, 438 were prescribed antiretroviral treatment (ART) and 62 were not. Among the 438 on ART, 72 (16.4%) were not virally suppressed at the most recent lab draw. Compared to individuals with a suppressed viral load, those that were unsuppressed were more likely to: be black (79.2% vs. 64.2%; p = 0.014); earn below $25,000/year (88.9% vs. 65.0%; p < 0.001); be of a younger age (47.8 vs. 50.0 mean years; p = 0.009); be on opiate substitution (14.1% vs. 6.3%; p = 0.023); and acknowledge poly-substance (38.9% vs. 24.4%; p = 0.012) and excessive alcohol use (13.9% vs. 6.0%; p = 0.019). Conversely, a smaller proportion of those with an unsuppressed viral load had multiple sex partners in the previous 30 days (39.8% vs. 58.5%; p = 0.003). In multivariable regression of those on ART, the prevalence of an unsuppressed viral load was 3% lower with each increasing year of age (aPR: 0.97; 95% CI: 0.95, 0.99) and 47% lower with income over $25,000/year (aPR: 0.33; 95% CI: 0.16, 0.70). In a separate analysis of all 500 subjects, ART was less frequently prescribed to blacks compared to whites, heterosexuals, those with lower education and income, and persons with active substance use. Findings confirm that a large proportion of PLWH and engaged in care were not virally suppressed and continued behaviors that risk transmission, indicating the need for screening, prevention counseling and access to ancillary services to lower the incidence of HIV infections.
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Affiliation(s)
- Paul L. Sacamano
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- * E-mail:
| | - Jason E. Farley
- Department of Community and Public Health, Johns Hopkins University School of Nursing, Baltimore, Maryland, United States of America
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Beer L, Weiser J, West BT, Duke C, Gremel G, Skarbinski J. Delivery of HIV Transmission Risk-Reduction Services by HIV Care Providers in the United States-2013. J Int Assoc Provid AIDS Care 2016; 15:494-504. [PMID: 26497751 PMCID: PMC4842168 DOI: 10.1177/2325957415612128] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Evidence-based guidelines have long recommended that HIV care providers deliver HIV transmission risk-reduction (RR) services, but recent data are needed to assess their adoption. METHODS The authors surveyed a probability sample of 1234 US HIV care providers on delivery of 9 sexual behavior- and 7 substance use-related HIV transmission RR services and created an indicator of "adequate" delivery of services in each area, defined as performing approximately 70% or more of applicable services. RESULTS Providers were most likely to encourage patients to disclose HIV status to all partners since HIV diagnosis (81%) and least likely to ask about disclosure to new sex and drug injection partners at follow-up visits (both 41%). Adequate delivery of sexual behavior- and substance use-related RR services was low (37% and 43%, respectively). CONCLUSION The majority of US HIV care providers may need additional support to improve delivery of comprehensive HIV transmission RR services.
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Affiliation(s)
- Linda Beer
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - John Weiser
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Brady T West
- Survey Research Center, University of Michigan, Ann Arbor, MI, USA
| | | | | | - Jacek Skarbinski
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Crepaz N, Tang T, Marks G, Mugavero MJ, Espinoza L, Hall HI. Durable Viral Suppression and Transmission Risk Potential Among Persons With Diagnosed HIV Infection: United States, 2012-2013. Clin Infect Dis 2016; 63:976-83. [PMID: 27358354 DOI: 10.1093/cid/ciw418] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 06/14/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND We examined durable viral suppression, cumulative viral load (VL) burden, and transmission risk potential among human immunodeficiency virus (HIV)-diagnosed persons in care. METHODS Using data from the National HIV Surveillance System from 17 jurisdictions with complete reporting of VL test results, we determined the percentage of persons in HIV care who achieved durable viral suppression (all VL results <200 copies/mL) and examined viremia copy-years and time spent above VL levels that increase the risk of HIV transmission during 2012-2013. RESULTS Of 265 264 persons in HIV care in 2011, 238 641 had at least 2 VLs in 2012-2013. The median number of VLs per individual during the 2-year period was 5. Approximately 62% had durable viral suppression. The remaining 38% had high VL burden (geometric mean of viremia copy-years, 7261) and spent an average of 438 days, 316 days, and 215 days (60%, 43.2%, and 29.5% of the 2-year period) above 200, 1500, and 10 000 copies/mL. Women, blacks/African Americans, Hispanics/Latinos, persons with HIV infection attributed to transmission other than male-to-male sexual contact, younger age groups, and persons with gaps in care had higher viral burden and transmission risk potential. CONCLUSIONS Two-thirds of persons in HIV care had durable viral suppression during a 2-year period. One-third had high VL burden and spent substantial time above VL levels with increased risk of onward transmission. More intervention efforts are needed to improve retention in care and medication adherence so that more persons in HIV care achieve durable viral suppression.
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Affiliation(s)
- Nicole Crepaz
- Division of HIV/AIDS Prevention, US Centers for Disease Control and Prevention
| | | | - Gary Marks
- Division of HIV/AIDS Prevention, US Centers for Disease Control and Prevention
| | - Michael J Mugavero
- Department of Medicine, Division of Infectious Diseases, University of Alabama, Birmingham
| | - Lorena Espinoza
- Division of HIV/AIDS Prevention, US Centers for Disease Control and Prevention
| | - H Irene Hall
- Division of HIV/AIDS Prevention, US Centers for Disease Control and Prevention
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15
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Social self-value intervention for empowerment of HIV infected people using antiretroviral treatment: a randomized controlled trial. BMC Infect Dis 2016; 16:272. [PMID: 27287712 PMCID: PMC4902994 DOI: 10.1186/s12879-016-1634-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 06/07/2016] [Indexed: 01/02/2023] Open
Abstract
Background Prevention and antiretroviral therapy (ART) management for human immunodeficiency virus (HIV) infected people need to have long-term health care. An empowerment focused intervention is a procedure by which HIV infected people obtain combined possession of programs to attain mainly cost-effective HIV outcomes and deal with social and structural difficulties related to their universal health access and human rights. Empowerment is a key approach for addressing HIV related issues that focuses on addressing a broader context. However, the practices of empowerment based approaches are sparse. We assessed the effect of an intervention to empower HIV infected people receiving ART. Methods In this open-label randomized controlled trial, HIV infected people from Nepal who were using ART from 6 to 24 months and were aged 18 years and above were randomly assigned to receive either the intervention or routine care. The intervention was led by two counselors for a period lasting six weeks. Participants were followed up at three and six months after the baseline. The primary outcome was change in empowerment scores, analyzed by using Difference-in-Difference (DiD). Results Between September and November 2014, 1447 HIV infected people were screened, of whom 132 were randomly assigned to the intervention (n = 66) or control (n = 66) group. All the participants completed the 3- and 6- months follow up. A significant difference in mean empowerment score was found between the groups at 3- (46.77, p-value <0.001) and 6- (49.71, p-value <0.001) months follow up. The average treatment effect (after matching intervention and control individuals) showed that the participants who received the intervention increased their mean empowerment scores from baseline by 47.05 (p-value <0.001, at three months) and 49.87 (p-value <0.001, at six months) than those who did not receive the intervention. No adverse events were reported. Conclusion Social self-value intervention provided to HIV infected people during ART increased their empowerment. This intervention can be expanded to be utilized in routine services. Trial registration Thai Clinical Trials Registry, number TCTR20140814002.
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16
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Bacterial sexually transmitted infections among HIV-infected patients in the United States: estimates from the Medical Monitoring Project. Sex Transm Dis 2015; 42:171-9. [PMID: 25763669 DOI: 10.1097/olq.0000000000000260] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Bacterial sexually transmitted infections may facilitate HIV transmission. Bacterial sexually transmitted infection testing is recommended for sexually active HIV-infected patients annually and more frequently for those at elevated sexual risk. We estimated percentages of HIV-infected patients in the United States receiving at least one syphilis, gonorrhea, or chlamydia test, and repeat (≥2 tests, ≥3 months apart) tests for any of these sexually transmitted infections from mid-2008 through mid-2010. DESIGN The Medical Monitoring Project collects behavioral and clinical characteristics of HIV-infected adults receiving medical care in the United States using nationally representative sampling. METHODS Sexual activity included self-reported oral, vaginal, or anal sex in the past 12 months. Participants reporting more than 1 sexual partner or illicit drug use before/during sex in the past year were classified as having elevated sexual risk. Among participants with only 1 sex partner and no drug use before/during sex, those reporting consistent condom use were classified as low risk; those reporting sex without a condom (or for whom this was unknown) were classified as at elevated sexual risk only if they considered their sex partner to be a casual partner, or if their partner was HIV-negative or partner HIV status was unknown. Bacterial sexually transmitted infection testing was ascertained through medical record abstraction. RESULTS Among sexually active patients, 55% were tested at least once in 12 months for syphilis, whereas 23% and 24% received at least one gonorrhea and chlamydia test, respectively. Syphilis testing did not vary by sex/sexual orientation. Receipt of at least 3 CD4+ T-lymphocyte cell counts and/or HIV viral load tests in 12 months was associated with syphilis testing in men who have sex with men (MSM), men who have sex with women only, and women. Chlamydia testing was significantly higher in sexually active women (30%) compared with men who have sex with women only (19%), but not compared with MSM (22%). Forty-six percent of MSM were at elevated sexual risk; 26% of these MSM received repeat syphilis testing, whereas repeat testing for gonorrhea and chlamydia was only 7% for each infection. CONCLUSIONS Bacterial sexually transmitted infection testing among sexually active HIV-infected patients was low, particularly for those at elevated sexual risk. Patient encounters in which CD4+ T-lymphocyte cell counts and/or HIV viral load testing occurs present opportunities for increased bacterial sexually transmitted infection testing.
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Frimpong JA, Guerrero EG, Kong Y, Tsai G. Correlates of HIV testing and receipt of test results in addiction health services in Los Angeles County. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2015; 10:31. [PMID: 26245281 PMCID: PMC4527120 DOI: 10.1186/s13011-015-0026-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 07/17/2015] [Indexed: 11/13/2022]
Abstract
Background HIV testing and receipt of HIV test results among individuals with substance use disorders is less than optimal. We examined rates and correlates of HIV testing and receipt of test results in one of the largest public addiction health services systems in the United States. Methods The study included 139,516 adult clients in treatment between 2006 and 2011. We used logistic regression models to examine associations between predisposing, enabling, and need factors and two dependent variables, HIV testing rates and receipt of test results. Associations were considered statistically significance at p < .01. Results We found that 64 % of clients reported being tested for HIV, of whom 85 % reported receiving their test results. Likelihood of being tested was positively associated with being female, a minority, homeless, employed, having prior treatment episodes, comorbidities, injection drug use, or a history of mental illness. It was negatively associated with alcohol or marijuana as primary drug. Receipt of test results was more likely among clients on medication (methadone or buprenorphine) or whose method of drug use was smoking, inhalation, or injecting; it was less likely among older clients and those with more outpatient psychiatric visits. Conclusions Findings from this study may inform strategies and targeting of population groups to improve HIV testing practices and ultimately increase awareness of infection status among clients of addiction health services.
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Affiliation(s)
- Jemima A Frimpong
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY, 10032, USA.
| | - Erick G Guerrero
- School of Social Work, University of Southern California, 655 West 34th Street, Los Angeles, CA, 90089, USA.
| | - Yinfei Kong
- School of Social Work, University of Southern California, 655 West 34th Street, Los Angeles, CA, 90089, USA.
| | - Gary Tsai
- Los Angeles County Department of Public Health, Substance Abuse Prevention and Control, 1000 South Fremont Avenue, Building A-9 East, Alhambra, CA, 91803, USA.
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18
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Mgbere O, Rodriguez-Barradas MC, Bell TK, Khuwaja S, Arafat R, Essien EJ, Singh M, Simmons P, Aguilar J. Frequency and Determinants of Preventive Care Counseling by HIV Medical Care Providers during Encounters with Newly Diagnosed and Established HIV-Infected Patients. J Int Assoc Provid AIDS Care 2014; 15:215-27. [PMID: 25361557 DOI: 10.1177/2325957414556352] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This study evaluates the frequency and determinants of preventive care counseling by HIV medical care providers (HMCPs) during encounters with newly diagnosed and established HIV-infected patients. Data used were from a probability sample of HMCPs in Houston/Harris County, Texas, surveyed in 2009. Overall, HMCPs offered more preventive care counseling to newly diagnosed than the established patients (adjusted odds ratio [AOR] = 7.28; 95% confidence interval [CI] = 2.86-16.80). They were more likely to counsel newly diagnosed patients than the established ones on medication and adherence (AOR = 14.70; 95% CI = 1.24-24.94), HIV risk reduction (AOR = 5.91; 95% CI = 0.48-7.13), and disease screening (AOR = 7.20; 95% CI = 0.72-11.81). HIV medical care providers who were less than 45 years of age, infectious disease specialists, and had less than 30 minutes of encounter time were less likely to counsel patients regardless of the status. Our findings suggest the need for HMCPs to improve their preventive care counseling efforts, in order to help patients build skills for adopting and maintaining safe behavior that could assist in reducing the risk of HIV transmission.
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Affiliation(s)
- Osaro Mgbere
- Bureau of Epidemiology, Office of Surveillance and Public Health Preparedness, Houston Department of Health and Human Services, Houston, TX, USA Institute of Community Health, University of Houston College of Pharmacy, Texas Medical Center, Houston, TX, USA
| | - Maria C Rodriguez-Barradas
- Infectious Diseases Section, Michael E. DeBakey VA Medical Center, Houston, TX, USA Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Tanvir K Bell
- Department of Internal Medicine, Division of Infectious Diseases, University of Texas Health Science Center, Houston, TX, USA
| | - Salma Khuwaja
- Bureau of Epidemiology, Office of Surveillance and Public Health Preparedness, Houston Department of Health and Human Services, Houston, TX, USA
| | - Raouf Arafat
- Bureau of Epidemiology, Office of Surveillance and Public Health Preparedness, Houston Department of Health and Human Services, Houston, TX, USA
| | - Ekere J Essien
- Institute of Community Health, University of Houston College of Pharmacy, Texas Medical Center, Houston, TX, USA
| | - Mamta Singh
- Bureau of Epidemiology, Office of Surveillance and Public Health Preparedness, Houston Department of Health and Human Services, Houston, TX, USA
| | - Paul Simmons
- Legacy Community Health Services, Montrose Campus, Houston, TX, USA
| | - Jonathan Aguilar
- Bureau of Epidemiology, Office of Surveillance and Public Health Preparedness, Houston Department of Health and Human Services, Houston, TX, USA
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