Prevention interventions with persons living with HIV/AIDS: state of the science and future directions

Association of Condom Use Advocacy with Perceived Condom Use Among Social Network Members: The Mediating Role of Advocates' Internalized HIV Stigma and Own Condom Use

We examined the association of HIV prevention advocacy with social network members (alters) on alter condom use behavior, and factors that may mediate and moderate this relationship, among people living with HIV (PLWH) in Uganda. Ninety PLWH completed all assessments (baseline and 5- and 8-month follow-ups). Internalized HIV stigma, HIV disclosure self-efficacy, positive living behavior (i.e., condom use), and advocacy self-efficacy were examined as mediators (at 5-month follow-up) of the association between condom use advocacy and perceived alter condom use. Individual socio-demographic and social network characteristics at baseline were examined as moderators. Among alters who received condom use advocacy in the months prior to both baseline and 5-month follow-up, 69.9% (51/73) were perceived to mostly/always use condoms at either the 5- or 8-month follow-up, which was significantly higher than the 36.4% (235/645) of alters who received none or less advocacy. Participants' internalized HIV stigma and consistent condom use mediated the association of advocacy and perceived consistent condom use among alters; the participant having any secondary education and the alter being male were associated with increased magnitude of the associations between advocacy and alter condom use. These findings highlight the importance of sustained advocacy to promote consistent condom use, and the value of anti-stigma and positive living interventions as mechanisms for enhancing effective advocacy.

Examination of Mediators and Moderators to Understand How and in What Context Game Changers Increases HIV Prevention Advocacy Among Persons Living With HIV in Uganda

BACKGROUND

Our randomized controlled trial (RCT) of the group-based Game Changers intervention demonstrated effects on the primary goal of increased HIV-protective behaviors among social network members (alters), via the mechanism of increased participant engagement in HIV prevention advocacy with alters. We sought to understand how and in what context the intervention has its effects by examining specific mediators and moderators of the intervention's effect on increased prevention advocacy.

METHODS

The RCT was conducted with 98 adult PLWH in Uganda. Intervention content targeted internalized HIV stigma, HIV disclosure, positive living behaviors, and self-efficacy for advocacy; these constructs were examined as intervention mediators (at the 5-month follow-up) of advocacy effects reported at the 8-month follow-up. Baseline sample characteristics were explored as moderators.

RESULTS

Internalized HIV stigma and HIV disclosure mediated intervention effects on prevention advocacy, but not antiretroviral adherence or self-efficacy for advocacy. Moderators of the intervention effect included several network characteristics (trust in, support from, stigma from, and connectedness among network members), but not respondent socio-demographics or HIV disease characteristics. The intervention was associated with greater prevention advocacy when trust in, support from, and connectedness among alters were high, and stigma from alters was low.

CONCLUSIONS

These findings highlight the importance of helping PLWH cope with self-stigma and gain comfort with disclosure, as well as the potential influence of network support, trustworthiness, connectedness, and stigmatization on engagement in prevention advocacy.

Peripheral CB1R as a modulator of metabolic inflammation

Obesity is associated with chronic inflammation in insulin-sensitive tissues, including liver and adipose tissue, and causes hormonal/metabolic complications, such as insulin resistance. There is growing evidence that peripheral cannabinoid-type 1 receptor (CB1R) is a crucial participant in obesity-induced pro-inflammatory responses in insulin-target tissues, and its selective targeting could be a novel therapeutic strategy to break the link between insulin resistance and metabolic inflammation. In this review, we introduce the role of peripheral CB1R in metabolic inflammation and as a mediator of hormonal/metabolic complications that underlie metabolic syndrome, including fatty liver, insulin resistance, and dyslipidemia. We also discuss the therapeutic potential of second- and third-generation peripherally restricted CB1R antagonists for treating obesity-induced metabolic inflammation without eliciting central CB1R-mediated neurobehavioral effects, predictive of neuropsychiatric side effects, in humans.

Culturally-Based Challenges to and Recommendations for Delivering Adherence Counseling in a Multicultural Biomedical HIV Prevention Trial in Four African Countries

Research is needed to identify how to effectively tailor evidence-based interventions across cultures with limited resources, particularly for behavioral components in large HIV prevention trials. Through surveys and interviews with counselors of sub-Saharan African women during an open-label microbicide trial (MTN-025), we examined language, education, and cultural barriers in delivering a motivational interviewing-based adherence counseling intervention (i.e., Options Counseling). Counselors encountered an array of barriers, most prominently that participants struggled to comprehend culturally incongruent pictorial guides, such as traffic light images, and to uphold product use when primary partners disapproved. Overwhelmingly, counselors cited the intervention's inherent flexibility as an asset; it encouraged them to tailor language and examples to be more culturally relevant to participants. Future resource-conscious researchers may preemptively offset similar barriers by consulting with communities during intervention development. Similarly, affording counselors flexibility while delivering the chosen intervention may enable them to troubleshoot barriers that arise on the ground.

Changes in Clinician Ability to Assess Risk and Help Patients Determine the Need for Hiv Testing

An estimated one of four people with HIV in the United States do not know they have the infection. The Centers for Disease Control and Prevention encourages HIV testing in clinical settings, but there is evidence that this is not done on a regular basis. The purposes of this study were to (a) compare two less traditional teaching methods with a classroom method to determine whether the less traditional methods resulted in greater improvement of clinician knowledge, skill, and willingness to perform HIV risk assessment as the basis for recommending HIV testing; and (b) find out whether there were significant differences in convenience, cost, learner preference, or learner acceptance that would make one method more desirable than the others. Findings from participants in the standardized patient interaction with facilitator feedback (FB) and the case-based self-study module (SSM) were not different from those of participants in the interactive classroom education method (CL). Generally, there were positive changes in knowledge, attitudes, and behaviors over time. Participants preferred standardized patient interaction (FB) and interactive classes (CL) to self-study modules (SSM).

The 'Fears' of Disclosing HIV Status to Sexual Partners: A Mixed Methods Study in a Counseling Setting in Ghana

Encouraging disclosure within a trusting and supportive environment is imperative in dealing with HIV/AIDS related stigma. However, disclosure rates and the factors that influence it are vaguely understood in African societies. This study aimed at determining the disclosure rate and factors that influence disclosure in Cape Coast, Ghana. In-depth interviews of 15 peer educators and a survey of 510 PLHIV were used in a mixed methods study design. Majority of the study participants (78.6 %) had disclosed their HIV positive status to their sexual partners. Although peer educators in this study portrayed the overall outcome of disclosure to be negative, 84.0 % of disclosers were accepted by their partners without negative consequences after disclosure. This study suggests that the existing support services ill prepares newly diagnosed HIV positive clients and hampers disclosure initiatives. Providing comprehensive support services and re-training peer educators may be crucial in creating a safe disclosure environment in Ghana.

Understanding the socio-structural context of high HIV transmission in kasensero fishing community, South Western Uganda

BACKGROUND

In Kasensero fishing community, home of the first recorded case of HIV in Uganda, HIV transmission remains high with an incidence of 4.3 and 3.1 per 100 person-years in women and men, respectively, and an HIV prevalence of 44 %, reaching up to 74 % among female sex workers. We explored the social contextual factors for the high HIV transmission at Kasensero to inform future policy and preventive interventions.

METHODS

We conducted 20 in-depth interviews, including both HIV positive and HIV negative respondents, and 12 focus-group discussions involving a total of 92 respondents from the Kasensero fishing community from April-September 2014. Content analysis was performed to identify recurrent themes.

RESULTS

Our findings suggest that the high HIV transmission in Kasensero is a complex function of eight themes including; positive/negative attitudes about HIV and combination HIV prevention such as the demand for services versus ART/circumcision disinhibition; HIV depository; Multiple partners; Frequent unprotected sex; Clothing; Parental behaviors; Pressure within the sex industry; and Cross generational sex.

CONCLUSIONS

The current combination HIV prevention services by the RHSP need to be enhanced with more government involvement including ensuring sustainable supply of ART and circumcision services since they are reportedly highly demanded. Community involvement through the engagement of popular peers could also help in the campaign to change the HIV predisposing culture, misconceptions and risky social norms of the population. Social Context HIV Transmission Fishing Community.

Risk Denial and Socio-Economic Factors Related to High HIV Transmission in a Fishing Community in Rakai, Uganda: A Qualitative Study

Background

In Kasensero fishing community, home of the first recorded case of HIV in Uganda, HIV transmission is still very high with an incidence of 4.3 and 3.1 per 100 person-years in women and men, respectively, and an HIV prevalence of 44%, reaching up to 74% among female sex workers. We explored drivers for the high HIV transmission at Kasensero from the perspective of fishermen and other community members to inform future policy and preventive interventions.

Methods

20 in-depth interviews including both HIV positive and HIV negative respondents, and 12 focus-group discussions involving a total of 92 respondents from the Kasensero fishing community were conducted during April-September 2014. Content analysis was performed to identify recurrent themes.

Results

The socio-economic risk factors for high HIV transmission in Kasensero fishing community cited were multiple and cross-cutting and categorized into the following themes: power of money, risk denial, environmental triggers and a predisposing lifestyle and alcoholism and drug abuse. Others were: peer pressure, poor housing and the search for financial support for both the men and women which made them vulnerable to HIV exposure and or risk behavior.

Conclusions

There is a need for context specific combination prevention interventions in Kasensero that includes the fisher folk and other influential community leaders. Such groups could be empowered with the knowledge and social mobilization skills to fight the negative and risky behaviors, perceptions, beliefs, misconceptions and submission attitudes to fate that exposes the community to high HIV transmission. There is also need for government/partners to ensure effective policy implementation, life jackets for all fishermen, improve the poor housing at the community so as to reduce overcrowding and other housing related predispositions to high HIV rates at the community. Work place AIDS-competence teams have been successfully used to address high HIV transmission in similar settings.

Qualitative evaluation of a Positive Prevention training for health care providers in Mozambique

The rapid scale-up of HIV care and treatment in Mozambique has provided an opportunity to reach people living with HIV (PLHIV) with prevention interventions in HIV care and treatment settings. A three-day Positive Prevention (PP) training intervention for health care providers that focused on pressing issues for PLHIV in Mozambique was adapted and delivered at sites in three provinces. In-depth interviews were conducted with 31 providers trained in the PP curriculum. Qualitative data were used to assess the appropriateness of the training materials and approach, which lessons providers learned and were able to implement and which PP messages were still difficult to deliver. Providers reported gaining numerous insights from the training, including how to conduct a risk assessment and client-centered counseling, negotiating disclosure, partner testing, condom use, PMTCT, treatment adherence and approaches for positive living. Training topics not commonly mentioned included discordance counseling, STIs, family planning, alcohol and drug use, and frank sexual risk discussions. While areas for improvement exist, the PP training was useful in transferring skills to providers and is a viable component of HIV care. This evaluation helps identify areas where future PP trainings and specific strategies and messages can be refined for the Mozambican context.

Major Depression and Risky Sexual Behavior among Substance Dependent Patients: The Moderating Roles of Distress Tolerance and Gender

The goal of the present study was to examine the main and interactive effects of major depressive disorder (MDD), distress tolerance (DT), and gender on multiple indices of risky sexual behavior (RSB) within a sample of 185 substance dependent patients in residential substance abuse treatment. Participants were interviewed to establish current MDD (as well as other Axis I and II diagnoses) and completed a behavioral measure of DT, the Paced Auditory Serial Addition Task - Computerized Version. Results provided evidence of a MDD × DT interaction for number of different past year commercial and casual sexual partners with which penetrative sex occurred. Post-hoc analyses demonstrated that participants with current MDD and low DT reported the greatest number of commercial and casual sexual partners. Results highlight one psychological vulnerability (DT) that may improve our understanding of the complex relationship between depression and RSB. Treatment implications of findings are discussed.

The association between religious affiliation and frequency of attendance at religious services on HIV risky behaviors among people living with HIV/AIDS

The purpose of this study was to examine if religious affiliation and frequency of attendance at religious services were associated with HIV risky behaviors among people living with HIV/AIDS (PLWHA). The participants are HIV positive clients of a community based HIV/AIDS outreach facility (CBHAOF) located in Montgomery, Alabama, USA. The participants completed the questionnaire during their medical visits to the clinic at their own convenience and that of the facility's staff. A total of 341 questionnaires were distributed to PLWHA and 326 (96%) were fully completed and returned. There were more male than female participants (56 versus 42%). The majority of the respondents (67%) were between 30 and 49 years of age. Nearly two thirds of the participants (64%) were African Americans whilst 36% were other races combined (White = 29%, Hispanic = 3% and other races = 4%). A chi-square test was used to examine the association between selected variables. Findings show substantial variations of selected HIV risky behaviors according to religious affiliation and frequency of attendance at religious services (p < 0.05). The study findings suggest the importance of religious affiliation and frequency of attendance at religious services in reducing HIV risky behaviors among PLWHA. The findings have implications for HIV/AIDS prevention and we recommend that it is important to incorporate Faith-based organizations in the global fight against HIV/AIDS.

Secondary HIV prevention: novel intervention approaches to impact populations most at risk

This paper reviews recent secondary prevention interventions designed to reduce sexual risk behaviors among people living with HIV/AIDS (PLWHA). A summary of findings from previous meta-analyses and narrative reviews of interventions is provided. Next, novel HIV prevention approaches for PLWHA are reviewed. The review reports on the efficacy of interventions delivered in primary care settings or by technology-formats, interventions that also address mental health difficulties, and programs to address particular at-risk populations (eg, men who have sex with men). A critique of recent interventions for people living with HIV/AIDS is provided as well as suggestions for future research.

An exploratory study of HIV-prevention advocacy by persons in HIV care in Uganda

To explore how people living with HIV (PLHIV) and in care encourage others to adopt HIV-protective behaviours, we conducted in-depth interviews with a purposive sample of 40 HIV clinic patients in Kampala, Uganda. Content analysis was used to examine the message content, trigger events, and outcomes of HIV-prevention advocacy events initiated by the HIV clients with members of their social networks. The content themes included encouraging specific behaviours, such as HIV testing and treatment, condom use and non-promiscuity, as well as more general cautionary messages about protecting oneself from HIV infection. Common triggers for bringing up HIV-prevention advocacy information in a discussion or conversation included: wanting to prevent the targeted person from 'falling into the same problems,' wanting to benefit oneself with regard to avoiding re-infection, out of concern that the target would engage in higher-risk behaviour, due to observed changes in the target's health, and to convey information after receiving treatment at the clinic. The participants mostly reported positive or neutral responses to these advocacy events; negative responses were rare. Interventions to empower PLHIV to be agents of change could represent a new frontier for HIV prevention.

HIV serosorting among HIV-positive men who have sex with men is associated with increased self-reported incidence of bacterial sexually transmissible infections

BACKGROUND

We aimed to quantify the frequency of HIV serosorting among men who have sex with men (MSM) in Germany, and evaluate the association of serosorting with other sexual risk management approaches (RMA) and with the frequency of bacterial sexually transmissible infections (STI).

METHODS

An anonymous, self-administered questionnaire was distributed through German online sexual networking sites and medical practices in 2006. The analysis was based on 2985 respondents who reported an HIV test result. Based on two questions on RMA, serosorting was classified as tactical (an event-based decision) or strategic (a premeditated search for a seroconcordant partner). The analysis was stratified by HIV serostatus and seroconcordant partnership status.

RESULTS

HIV serosorting patterns were different for HIV-positive and HIV-negative participants. Tactical serosorting ranked second after RMA based on condom use (HIV-positive: 55.1%, HIV-negative: 45.1%; P < 0.001). While the overlap of strategic and tactical HIV serosorting among HIV-positive MSM was substantial (58.0%), HIV-negative strategic and tactical serosorting were more distinct (18.1% overlap). Among HIV-positive and HIV-negative respondents, tactical serosorting was associated with reduced condom use. Compared with respondents using RMA other than serosorting, HIV-positive men reporting serosorting had a three-fold increased risk for bacterial STI (strategic: odds ratio (OR) = 2.62; 95% confidence interval (CI): 1.76-3.89; tactical: OR = 3.19; 95% CI: 2.14-4.75; both for respondents without HIV seroconcordant partners).

CONCLUSIONS

HIV serosorting has emerged as a common RMA among MSM. For HIV-positive MSM, it may contribute to high rates of bacterial STI that may lead to elevated per-contact risks for HIV transmission.

Adapting an Evidence-Based Intervention Targeting HIV-Infected Prisoners in Malaysia

HIV-infected prisoners in Malaysia represent a critical target population for secondary HIV risk reduction interventions and care. We report on the process and outcome of our formative research aimed at systematically selecting and adapting an EBI designed to reduce secondary HIV risk and improve adherence to antiretroviral therapy among soon-to-be-released HIV-infected prisoners. Our formative work involved a critical examination of established EBIs and associated published reports complemented by data elicited through structured interviews and focus groups with key stakeholders, members of the target population, and their family members. Based on all information, we adapted the Holistic Health Recovery Program targeting people living with HIV (HHRP+), an EBI, to consist of eight 2-hour sessions that cover a range of specified topics so that participants may individually apply intervention content as needed to accommodate their particular substance abuse, HIV risk, and antiretroviral adherence issues. This study provides a complete example of the process of selecting and adapting an EBI-taking into account both empirical evidence and input from target organization stakeholders and target population members and their families-for use in real world prison settings where high-risk populations are concentrated.

Four-year treatment outcomes of adult patients enrolled in Mozambique's rapidly expanding antiretroviral therapy program

Background

In Mozambique during 2004–2007 numbers of adult patients (≥15 years old) enrolled on antiretroviral therapy (ART) increased about 16-fold, from <5,000 to 79,500. All ART patients were eligible for co-trimoxazole. ART program outcomes, and determinants of outcomes, have not yet been reported.

Methodology/Principal Findings

In a retrospective cohort study, we investigated rates of mortality, attrition (death, loss to follow-up, or treatment cessation), immunologic treatment failure, and regimen-switch, as well as determinants of selected outcomes, among a nationally representative sample of 2,596 adults initiating ART during 2004–2007. At ART initiation, median age of patients was 34 and 62% were female. Malnutrition and advanced disease were common; 18% of patients weighed <45 kilograms, and 15% were WHO stage IV. Median baseline CD4⁺ T-cell count was 153/µL and was lower for males than females (139/µL vs. 159/µL, p<0.01). Stavudine, lamivudine, and nevirapine or efavirenz were prescribed to 88% of patients; only 31% were prescribed co-trimoxazole. Mortality and attrition rates were 3.4 deaths and 19.8 attritions per 100 patient-years overall, and 12.9 deaths and 57.2 attritions per 100 patient-years in the first 90 days. Predictors of attrition included male sex [adjusted hazard ratio (AHR) 1.5; 95% confidence interval (CI), 1.3–1.8], weight <45 kg (AHR 2.1; 95% CI, 1.6–2.9, reference group >60 kg), WHO stage IV (AHR 1.7; 95% CI, 1.3–2.4, reference group WHO stage I/II), lack of co-trimoxazole prescription (AHR 1.4; 95% CI, 1.0–1.8), and later calendar year of ART initiation (AHR 1.5; 95% CI, 1.2–1.8). Rates of immunologic treatment failure and regimen-switch were 14.0 and 0.6 events per 100-patient years, respectively.

Conclusions

ART initiation at earlier disease stages and scale-up of co-trimoxazole among ART patients could improve outcomes. Research to determine reasons for low regimen-switch rates and increasing rates of attrition during program expansion is needed.

Challenges Faced by People Living with HIV/AIDS in Cape Town, South Africa: Issues for Group Risk Reduction Interventions

This paper presents the findings of an exploratory study to investigate the challenges faced by people living with HIV/AIDS (PLWHA) in communities in Cape Town, South Africa. The primary goal of the study was to gather data to inform the adaptation of a group risk reduction intervention to the South African context. Qualitative methods were used to examine the experiences of PLWHA. Eight focus group discussions (FGDs) were conducted with 83 HIV-positive participants and 14 key informants (KIs) involved in work with PLWHA were interviewed. Findings revealed that AIDS-related stigma was still pervasive in local communities. This was associated with the difficulty of disclosure of their status for fear of rejection. Also notable was the role of risky behaviours such as lack of condom use and that PLWHA considered their HIV/AIDS status as secondary to daily life stressors like poverty, unemployment, and gender-based violence. These findings have implications for the adaptation or development of behavioural risk reduction interventions for PLWHA.

Prevention of HIV infection among injection drug users in resource-limited settings

Injection drug use contributes to considerable global morbidity and mortality associated with human immunodeficiency virus (HIV) infection and AIDS and other infections due to blood-borne pathogens through the direct sharing of needles, syringes, and other injection equipment. Of approximately 16 million injection drug users (IDUs) worldwide, an estimated 3 million are HIV infected. The prevalence of HIV infection among IDUs is high in many countries in Asia and eastern Europe and could exacerbate the HIV epidemic in sub-Saharan Africa. This review summarizes important components of a comprehensive program for prevention of HIV infection in IDUs, including unrestricted legal access to sterile syringes through needle exchange programs and enhanced pharmacy services, treatment for opioid dependence (ie, methadone and buprenorphine treatment), behavioral interventions, and identification and treatment of noninjection drug and alcohol use, which accounts for increased sexual transmission of HIV. Evidence supports the effectiveness of harm-reduction programs over punitive drug-control policies.

Factor structure of Leigh's (1990) alcohol sex expectancies scale in individuals in treatment for HIV disease

The purpose of this study was to validate the use of Leigh's (1990) alcohol sex expectancies scale among HIV-infected individuals presenting for treatment as a way to facilitate research on sexual risk reduction among individuals in that population. The participants were 944 men who presented for treatment at infectious disease or general medicine clinics across 8 different VA Medical Center sites. A total of 534 of these men were HIV-positive and 410 were HIV-negative. The total sample was randomly divided in half within each HIV group to form exploratory (Sample 1) and confirmatory (Sample 2) subsamples. A principal components factor analysis with oblique rotation of the original 13-item Leigh scale within each HIV group in Sample 1 revealed a 2-factor (7 and 4 items, respectively) solution that was consistent across both HIV groups. These factors were named "More Open to Sexual Pleasure" (Factor 1) and "Reduced Inhibitions about Sex (Factor 2)." A confirmatory factor analysis of the 11-item, 2-factor solution on the full Sample 2 showed a modest fit to the data, excellent internal consistency reliability of both factors, a high correlation between the factors, and strong evidence for construct validity. These results were interpreted as supporting the use of the 11-item, 2-factor version of Leigh's scale in studies of clinical samples of HIV-positive adults, and directions for research on further scale refinement are discussed.

Prevalence and contexts of inconsistent condom use among heterosexual men and women living with HIV in India: implications for prevention

This investigation examined sexual behaviors among heterosexual persons living with HIV (PLHIV) in India. Study participants (mostly married) were interviewed during August to November 2006 in five Indian states using a quantitative survey (n = 100 men and 100 women), eight focus groups (n = 58 participants), and in-depth interviews (n = 31). One third of men and one fourth of women reported inconsistent condom use with regular sexual partners. Facilitators of condom use with regular partners included a feeling of personal responsibility to protect the health of the partner, desire to prevent acquisition and/or transmission of sexually transmitted infections, and the belief that condoms are needed for antiretroviral therapy to be effective. Barriers to consistent condom use with regular partners included the belief that condoms are unnecessary in HIV-positive seroconcordant relationships; lack of sexual satisfaction with condoms; the desire to have a child; husband's alcohol use, depression, and anxiety; fear that disclosure of HIV status will bring marital discord and family shame; and inadequate counseling by health care providers. Positive prevention programs should include counseling about benefits of safer sex in HIV-positive seroconcordant relationships, counseling about integrating condom use with sexual satisfaction and intimacy, condom use self-efficacy and negotiation skills-building, family planning counseling, mental health and alcohol dependence treatment, and counseling and skills-building about disclosure. Health care providers must be trained to provide these services. Furthermore, efforts are needed to promote tolerance for family planning choices made by couples and to counter the stigma associated with HIV/AIDS and condoms in the broader society.

HIV risk behavior in opioid dependent adults seeking detoxification treatment: an exploratory comparison of heroin and oxycodone users

Heroin users are at high risk for HIV infection, but little is known about HIV risk in oxycodone users. This study examined HIV risk behaviors in heroin (n = 27) and oxycodone (n = 23) users seeking inpatient detoxification at a private psychiatric hospital. Drug use histories were similar, except oxycodone users used marijuana more frequently. Injection drug risk occurred exclusively among heroin users. The rates of sexual activity (66%), unprotected intercourse (69%), sex while intoxicated (74%), and sex with strangers (24%) were similar, but more oxycodone users had multiple partners (39% vs. 6%, p < .05). HIV prevention efforts should target both heroin and oxycodone users.

An exploratory study on the social and genotypic clustering of HIV infection in men having sex with men

OBJECTIVE

To explore the clustering of HIV infected men having sex with men (MSM) using social network approach in conjunction with the phylogenetic relationship of the virus strains.

DESIGN

An exploratory study incorporating social network and phylogenetic analysis.

METHODS

Recently diagnosed HIV-infected MSM attending one major HIV specialist clinic in Hong Kong were recruited in the study involving the administration of a self-administered questionnaire on behaviours and partnership patterns using a Likert Scale, the results of which were assessed using social network analysis and in context of the phylogenetic analysis from sequencing the HIV-1 pol gene, as part of the clinical investigation for genotypic resistance. Clusters were defined using social and molecular methods.

RESULTS

An 'Internet-centred' cluster and 'Sauna-centred' cluster could be delineated using correspondence analysis and network diagrams. The main distinguishing features of MSM in the 'Internet-centred' social cluster were: younger age, higher education level, and multiple partner types. Three genetic clusters could be identified in the phylogenetic tree, two of which associated with Internet use and one with sauna for sex partnership. There were partial overlaps between social and genetic clusters. Characteristically, the virus strains in sauna users were more disperse compared with the closely knit configuration of those using Internet.

CONCLUSION

The principle of the duality of place and person can be strategically applied in epidemiologic investigation. The characterization of MSM cluster using anonymized network data provides a potentially powerful tool for informing public health intervention.

Sexual risk behavior and behavior change among persons newly diagnosed with HIV: the impact of targeted outreach interventions among hard-to-reach populations

The secondary effect of a national, targeted, outreach initiative in reducing sexual risk behavior among newly diagnosed persons living with HIV/AIDS (PLWHA) was examined in the present study. The findings propose an optimal number of outreach program contacts associated with a change in sexual risk behavior. The primary goal of the initiative was to implement and evaluate strategies to engage and retain underserved populations (PLWHA) in HIV primary medical care. Participants from 10 sites nationwide were enrolled in outreach interventions from 2004 to 2005 that were designed to engage and retain hard-to-reach PLWH in care. The study population in the subanalysis performed was predominantly male, people of color, sexual minorities; mean age of 32, and 31% reported no visits to an HIV health provider since testing positive. The study design was prospective and nonrandomized; 116 newly diagnosed individuals reported on unprotected sex at baseline, 6-, and 12-month interviews. The proportion of individuals reporting unprotected sex postintervention was reduced significantly compared to baseline. Postbaseline, individuals were 80% less likely to report unprotected sex. Additionally, individuals with 1-3 program contacts per month were 80 times less likely to report risky sexual behavior compared to those with 2 or less contacts (adjusted odds ratio [AOR] = 0.20). Substantial risk exists for secondary HIV transmission; this study shows the promise of a supplemental intervention to ensure access to HIV care, retention in care, and risk reduction for positives.

From prenatal HIV testing of the mother to prevention of sexual HIV transmission within the couple

The first step in preventing mother-to-child HIV transmission (PMTCT) programmes is offering HIV counselling and testing to pregnant women. In developing countries where HIV testing remains rare, it represents a unique opportunity for many women to learn their HIV status. This prenatal HIV testing is not only the entry point to prevention of mother-to-child HIV transmission, but also an occasion for women to sensitize their male partner to sexual risks. Here we explore if these women, HIV-tested as mothers, apply the prevention recommendations they also receive as women. In the Ditrame Plus PMTCT program in Abidjan, Côte d'Ivoire, two cohorts of women (475 HIV-infected women and 400 HIV-negative women) were followed up two years after the pregnancy when they were offered prenatal HIV testing. In each cohort, we compared the proportion of women who communicated with their regular partner on sexual risks, prior to and after prenatal HIV testing. We analysed socio-demographic factors related to this communication. We measured two potential conjugal outcomes of women HIV testing: the level of condom use at sex resumption after delivery and the risk of union break-up. Prenatal HIV testing increased conjugal communication regarding sexual risks, whatever the woman's serostatus. This communication was less frequent for women in a polygamous union or not residing with their partner. Around 30% of women systematically used condoms at sex resumption. Among HIV infected ones, conjugal talk on sexual risks was related to improved condom use. After HIV testing, more HIV-infected women separated from their partners than HIV-uninfected women, despite very few negative reactions from the notified partners. In conclusion, offering prenatal HIV counselling and testing is an efficient tool for sensitizing women and their partners to HIV prevention. But sexual prevention in a conjugal context remains difficult and need to be specifically addressed.

Prevalence and Significance of G6PD Deficiency in Patients of an Urban HIV Clinic

The rationale to screen for glucose-6-phosphate dehydrogenase (G6PD) deficiency in HIV-infected individuals is their increased likelihood to receive oxidant drugs and subsequent potential of hemolytic events. However, current guidelines regarding who should be screened are conflicting. The authors examined the prevalence of G6PD deficiency and the frequency of hemolytic events in an urban HIV clinic. They used data from a military database as a comparison. In both cohorts, a relatively high number of black females were found to be G6PD deficient (10% and 13%), which was similar to the rate in men (15% and 12%). No white females were G6PD deficient. The authors identified 8 drug-related hemolytic events in HIV clinic patients. Two patients necessitated blood transfusions; both were triggered by trimethoprim/sulfamethoxazole (TMP/SMX). Although G6PD screening prior to the use of TMP/SMX is not often considered by clinicians, the authors' finding of 2 hemolytic events requiring transfusion suggests this would be beneficial.

Ongoing risk behavior among persons with HIV in medical care

We surveyed randomly selected patients in the largest HIV clinic in Seattle, WA in 2005 and 2006. A total of 397 patients completed usable surveys. Twenty-seven percent of men who have sex with men (MSM) and 22% of women or heterosexual men reported having non-concordant unprotected anal or vaginal intercourse in the preceding year. Compared to 2005, more MSM in 2006 reported meeting a sex partner via the Internet (15% vs. 33%), and fewer met partners in bathhouses (23% vs. 13%). Twenty-four percent of MSM reported deciding not to have sex with a potential partner because he was HIV negative, and 31% of MSM reported that another man had decided not to have sex with them because they were HIV positive. Among all participants, 22% had told a sex partner they were HIV negative since their HIV diagnosis. These findings demonstrate the persistence of high-risk behavior among persons with HIV, a rapid increase in the use of the Internet among MSM to find sex partners, and provide direct evidence for serosorting among MSM.

Culturally specific adaptation of a prevention intervention: an international collaborative research project

This study adapted a U.S. drug use prevention program for use with Russian at-risk adolescents, and explored directions for further development of programs addressing prevention of substance abuse and other health risk behaviors including risk of HIV infection. The adaptation process was conducted in phases, initially carried out in Seattle with 23 bilingual (English-Russian) youth and then further adapted in two Moscow schools with 44 "typical" youth. In the final phase, program adaptation for the Russian at-risk adolescents was achieved by conducting a pilot test of the adapted program lessons with Moscow at-risk adolescents (n=10), who met criteria of poor school performance and/or truancy. Observations and experience were used throughout to adapt and refine the program for at-risk youth. Modifications were made to represent more accurately colloquial Russian and to capture teen experiences common to Russian culture. Both U.S. and Russian youth characterized the lessons as engaging and valuable. They also expressed a need to learn about sexuality, drug use, and health; peer and romantic relationships; and problem-solving strategies.

The status of national HIV case surveillance, United States 2006

Since the height of HIV incidence in the mid-1980s, advances in treatment have delayed progression of HIV infection. As a result, surveillance of AIDS cases alone is no longer sufficient to monitor the current status of the HIV epidemic. At the national level, new HIV diagnoses and progression of these cases to AIDS are used to describe the epidemic. The capacity to monitor the national HIV epidemic has consistently improved over the last several years. An increasing number of states report diagnosed HIV cases to the national surveillance system, allowing data from this system to better represent the national picture. Monitoring the national HIV epidemic depends on a nationwide system using standardized methods of data collection, and establishing such a comprehensive system remains one of the highest priorities for national HIV case surveillance.

Religiosity, denominational affiliation and sexual behaviors among people with HIV in the United States

This study sought to describe religiosity and denominational affiliation among the U.S. population living with HIV and to test whether either is associated with HIV-related sexual risk behaviors. A nationally representative sample of 1,421 people in care for HIV, 932 of whom reported recent sexual activity, was utilized. Religiosity was associated with fewer sexual partners and a lower likelihood of engaging in unprotected sex and in high-risk sex. Catholics were less likely to report unprotected sex than were other Christians, adherents of non-Christian religions, and those reporting no religious affiliation. Catholics were also less likely than other Christians to report high-risk sex and reported fewer sexual partners compared to those of non-Christian religions. We did not observe a difference between Catholics and Evangelicals in the three sexual behaviors investigated. Results suggest that religiosity and some religious teachings may promote safer sex among people with HIV.

Responsibility for HIV prevention: patterns of attribution among HIV-seropositive gay and bisexual men

The Seroconversion Narratives for AIDS Prevention (SNAP) study elicited narratives from recently infected seropositive gay and bisexual men that described the circumstances of their own seroconversion. This analysis of the narratives explored participants' attributions of responsibility for HIV prevention before and after they became infected. Before becoming infected with HIV, responsibility for prevention was often attributed to HIV-negative individuals themselves. These retrospective attributions revealed themes that included feelings of negligence, a sense of consequences, followed by regret. After seroconversion, responsibility for HIV prevention was primarily attributed to HIV-positive individuals themselves. Themes within these attributions included pledges to avoid HIV transmission, a strong sense of burden related to the possibility of infecting someone, and risk reduction strategies that they implemented in an attempt to avoid HIV transmission. Greater understanding of ideas related to responsibility has the potential to increase the effectiveness of HIV prevention interventions.

Prevention with HIV-infected men: recommendations for practice and research

In the United States in 2004, 74% of the new AIDS cases and 70% of the new HIV cases were in men; in addition, 75% of the cases of HIV in women were classified as heterosexually acquired. These numbers make it clear that expanded prevention efforts for men who are infected with HIV would make a large contribution to containing the epidemic. This report explores epidemiologic and psychosocial issues related to prevention in men with HIV and compares how those variables relate to prevention efforts. The report ends with a discussion of a method to approach HIV risk reduction in clinical care settings.

Adapting efficacious interventions: advancing translational research in HIV prevention

The Human Immunodeficiency Virus (HIV) has infected approximately 1.5 million people in the United States. Type 1 translation research (basic research, methods development, and efficacy trials) has yielded multiple efficacious behavioral HIV prevention programs. Type 2 translation research (dissemination and effectiveness studies) has been less prevalent or successful. Adaptation of efficacious interventions for culturally diverse populations has received increasing researcher attention, and empirical validation of adaptation procedures promises to help bridge the gap between Type 1 and Type 2 studies. In this article, the authors briefly discuss the development, testing, and dissemination of efficacious HIV prevention programs and then focus on research-based principles and processes that can guide researchers'adaptation efforts and steps that researchers can take to help empower practitioners to conduct science-based adaptation. Greater collaboration between researchers and service providers to test adaptation frameworks promises to benefit both research and practice.

Do prevention interventions reduce HIV risk behaviours among people living with HIV? A meta-analytic review of controlled trials

OBJECTIVE

To conduct a meta-analytic review of HIV interventions for people living with HIV (PLWH) to determine their overall efficacy in reducing HIV risk behaviours and identify intervention characteristics associated with efficacy.

METHODS

Comprehensive searches included electronic databases from 1988 to 2004, hand searches of journals, reference lists of articles, and contacts with researchers. Twelve trials met the stringent selection criteria: randomization or assignment with minimal bias, use of statistical analysis, and assessment of HIV-related behavioural or biologic outcomes at least 3 months after the intervention. Random-effects models were used to aggregate data.

RESULTS

Interventions significantly reduced unprotected sex [odds ratio (OR), 0.57; 95% confidence interval (CI) 0.40-0.82] and decreased acquisition of sexually transmitted diseases (OR, 0.20; 95% CI, 0.05-0.73). Non-significant intervention effects were observed for needle sharing (OR, 0.47, 95% CI, 0.13-1.71). As a whole, interventions with the following characteristics significantly reduced sexual risk behaviours: (1) based on behavioural theory; (2) designed to change specifically HIV transmission risk behaviours; (3) delivered by health-care providers or counsellors; (4) delivered to individuals; (5) delivered in an intensive manner; (6) delivered in settings where PLWH receive routine services or medical care; (7) provided skills building, or (8) addressed a myriad of issues related to mental health, medication adherence, and HIV risk behaviour.

CONCLUSION

Interventions targeting PWLH are efficacious in reducing unprotected sex and acquisition of sexually transmitted diseases. Efficacious strategies identified in this review should be incorporated into community HIV prevention efforts and further evaluated for effectiveness.

Integrating HIV prevention activities into the HIV medical care setting: a report from the NYC HIV Centers Consortium

With the maturing of the HIV epidemic and availability of potent antiretroviral therapies in the US, priorities for HIV prevention have shifted from general population approaches to case finding, treatment, risk reduction and relapse prevention activities among those at greatest risk for acquiring or transmitting HIV infection. The challenges of this approach include ensuring access and adherence to HIV care and treatment and appropriate prevention activities to ensure adequate and sustained sexual and drug use risk reduction across diverse populations. Experience with approaches to address these issues, particularly in the context of primary care, has been limited. An agenda for future research and practice includes continued development and evaluation of interventions that can address this next generation of health care issues.

Behavior change and health-related interventions for heterosexual risk reduction among drug users

Prevention of heterosexual transmission of HIV between and from drug users is important for controlling the local and global HIV heterosexual epidemic. Sex risk reduction interventions and health-related interventions are important for reducing the sex risk behaviors of drug users. Sex risk reduction interventions address individual-level, peer-level, and structural-level determinants of risk reduction. Health-related interventions include HIV counseling and testing, prevention and treatment of sexually transmitted diseases, and delivery of highly active antiretroviral therapy. It is important to adapt effective interventions implemented in resource-rich countries to the realities of the resource-constrained settings and to address relevant contextual factors.

Age shift in patterns of injection drug use among the HIV/AIDS population in Miami-Dade County, Florida

Analysis of HIV exposure category for 20,034 persons in three age groups (13-29, 30-49, 50 and over) who were alive through 2003 and had been reported to the Florida Department of Health with HIV or AIDS in Miami-Dade County, Florida, found that having a history of injection drug use increases with increasing age (p < .001). Consideration of age-specific HIV risk profiles has implications for primary and secondary HIV prevention interventions, planning, and policy.

Using economic threshold analysis to determine the intensity of HIV prevention services for HIV-seropositive persons

OBJECTIVE

Studies of the effectiveness of HIV prevention interventions for persons living with HIV have examined interventions with very wide variation in intensity (from single session interventions to those offered twice-weekly for 6 months); this raises questions about cost-effectiveness. Herein the question is asked: at varied (but specified) levels of HIV transmission rates and intervention effectiveness, how much money can be spent per HIV-seropositive client on HIV prevention services and still be considered cost-saving to society (in the United States)?

DESIGN AND METHODS

Standard methods of economic evaluation (threshold analysis, in particular) were used. Per-client HIV transmission rates and intervention effectiveness were specified and then allowed to vary widely. The threshold for intervention cost (as well as number of sessions per client) that could be justified on the basis of societal cost savings was then calculated.

RESULTS

If HIV transmissions are permanently prevented and lifetime medical costs are avoided in an HIV-seronegative partner, then monthly counseling sessions, even after high quality pre- and post-test counseling, and even at moderate levels of effectiveness, may be cost-saving to society (and at higher transmission rates and effectiveness, dozens of sessions per client could be cost-saving). If these interventions delay (but do not permanently prevent) HIV infection among HIV-seronegative partners, then the cost and number of session thresholds are substantially lower.

CONCLUSIONS

Even with considerable uncertainty in input parameters, an economic evaluation threshold analysis framework can yield useful insights for guiding the selection of intensity of HIV prevention services for persons living with HIV.