HIV-related risk behaviors, perceptions of risk, HIV testing, and exposure to prevention messages and methods among urban American Indians and Alaska Natives

Perceived versus actual HIV risk among PrEP indicated persons with criminal legal involvement

Individuals involved with community supervision experience multi-level obstacles impacting health outcomes. This is a high-risk period for HIV acquisition due to potential reengagement in unprotected sex and/or unsafe injection drug practices. This study aimed to assess the congruence between actual and perceived HIV risk and the degree to which individual, social, and behavioral factors impact risk perception among individuals on community supervision. While all participants were clinically indicated for PrEP, most participants (81.5%) did not consider themselves at risk for HIV (69.5%) or were not sure of their risk (12.0%). Among those with no or unsure perceived risk, 94% engaged in sexual behaviors that put them at-risk of HIV. Perceived HIV risk was associated with sharing injection equipment (aPR = 1.8, 95% CI [1.02, 3.3]), identifying as a sexual minority (aPR = 2.3, 95% CI [1.3, 3.9]), and having sex with a partner living with HIV (aPR = 2.4, 95% CI [1.3, 4.3]). Having sex with a partner living with HIV was the only sexual risk behavior associated with a perceived risk of HIV. These findings indicate a substantial discrepancy between actual and perceived HIV risk, highlighting the need for targeted interventions to improve risk perception accuracy and enhance risk prevention among individuals on community supervision.

Community-Identified Implementation Strategies for Promoting the Adoption of HIV Self-Testing in a Southern California American Indian community: A Rapid Qualitative Analysis

HIV incidence increased by 18% between 2015 and 2019 among American Indians (AIs) despite declining rates in other racial/ethnic groups. Culturally-appropriate implementation of prevention programs is needed to address the intersectional conditions contributing to HIV vulnerabilities experienced by AIs. The objectives of this study were to understand factors influencing HIV testing decisions and identify implementation strategies to promote the acceptability of HIV self-testing (HIVST) in a southern California AI community. A total of 15 semi-structured interviews were completed with adult community members of a southern California AI reservation. Analysis used a rapid analytic approach that was guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework and expert recommendations for implementing change (ERIC) compilation. Two team members applied a standardized summary template to elucidate implementation determinants and implementation strategies for adopting HIVST. Barriers to HIV testing identified by community members included HIV-related stigma and privacy concerns within their community. Community members expressed positive perceptions of the acceptability of HIVST, with many identifying ease of use and privacy as appealing attributes. Several implementation strategies were suggested for facilitating the adoption of HIVST, including increasing access to tests by mailing kits to community members and increasing demand for kits through media campaigns (e.g., local flyers, social media posts, and booths at tribal events). Community members also recommended discreet packaging of kits and cultural adaptation of accompanying materials (e.g., educational videos featuring community members). The qualitative input from AI community members facilitated identification of implementation strategies that may promote the acceptability and culturally-appropriateness of HIVST.

American Indian and Alaska Native Men's Use of Sexual Health Services, 2006-2010

CONTEXT

American Indian and Alaska Native men experience poorer sexual health than white men. Barriers related to their sex and racial identity may prevent them from seeking care; however, little is known about this population's use of sexual health services.

METHODS

Sexual health service usage was examined among 923 American Indian and Alaska Native men and 5,322 white men aged 15-44 who participated in the 2006-2010 National Survey of Family Growth. Logistic regression models explored differences in service use by race and examined correlates of use among American Indians and Alaska Natives.

RESULTS

Among men aged 15-19 and those aged 35-44, men with incomes greater than 133% of the federal poverty level, men with private insurance, those living in the Northeast and those living in rural areas, American Indians and Alaska Natives were more likely than whites to use STD or HIV services (odds ratios, 1.5-3.2). The odds of birth control service use did not differ by race. Differences in service use were found among American Indian and Alaska Native men: For example, those with a usual source of care had elevated odds of using sexual health services (1.9-3.4), while those reporting no recent testicular exam had reduced odds of using these services (0.3-0.4).

CONCLUSIONS

This study provides baseline data on American Indian and Alaska Native men's use of sexual health services. Research exploring these men's views on these services is needed to help develop programs that better serve them.

HIV, Chlamydia, Gonorrhea, and Primary and Secondary Syphilis among American Indians and Alaska Natives Within Indian Health Service Areas in the United States, 2007-2010

National rates from human immunodeficiency virus (HIV) and sexually transmitted disease (STD) surveillance may not effectively convey the impact of HIV and STDs on American Indian/Alaska Native (AI/AN) communities. Instead, we compared average annual diagnosis rates per 100,000 population of HIV, chlamydia (CT), gonorrhea (GC), and primary and secondary (P&S) syphilis, from 2007 to 2010, among AI/AN aged ≥ 13 years residing in 625 counties in the 12 Indian Health Service Areas, all AI/AN, and all races/ethnicities to address this gap. AI/AN comprised persons reported as AI/AN only, with or without Hispanic ethnicity. Out of 12 IHS Areas, 10 had higher case rates for CT, 3 for GC, and 4 for P&S syphilis compared to rates for all races/ethnicities. Eight Areas had higher HIV diagnosis rates than for all AI/AN, but HIV rates for all IHS Areas were lower than national rates for all races/ethnicities. Two IHS Areas ranking highest in rates of CT and GC and four Areas with highest P&S syphilis also had high HIV rates. STD and HIV rates among AI/AN were greater in certain IHS Areas than expected from observing national rates for AI/AN. Integrated surveillance of overlapping trends in STDs and HIV may be useful in guiding prevention efforts for AI/AN populations.

HIV Among Indigenous peoples: A Review of the Literature on HIV-Related Behaviour Since the Beginning of the Epidemic

From the early days of the HIV epidemic, Indigenous peoples were identified as a population group that experiences social and economic determinants-including colonialism and racism-that increase exposure to HIV. There are now substantial disparities in HIV rates between Indigenous and non-Indigenous peoples in some countries. We conducted a comprehensive literature review to assess the evidence on HIV-related behaviors and determinants in four countries-Australia, Canada, New Zealand and the United States-in which Indigenous peoples share important features of colonization and marginalization. We identified 107 articles over more than 20 years. The review highlights the determinants of HIV-related behaviors including domestic violence, stigma and discrimination, and injecting drug use. Many of the factors associated with HIV risk also contribute to mistrust of health services, which in turn contributes to poor HIV and health outcomes among Indigenous peoples.

Acceptability of routine HIV counselling and testing among a sample of South African students: Testing the Health Belief Model

Routine HIV counseling and testing (RCT) is a necessary first step in accessing health care for persons who may test HIV-positive. Despite the availability of RCT in many South African settings, uptake has often been low. We sought to determine whether the main components of the Health Belief Model (HBM), namely perceived susceptibility, perceived severity, perceived benefits and perceived barriers could predict acceptance of RCT, and whether cues to action predicted uptake of RCT. A sample of 1 113 students at a large South African university completed a battery of instruments measuring acceptability of RCT, previous uptake of HIV testing, and the various HBM variables. Regression analysis showed that perceived susceptibility to HIV, perceived severity of HIV, perceived benefits of RCT, and perceived barriers to RCT explained 25.1% of the variance in acceptance of RCT. The findings of the study are located in the context of existing literature on RCT.

HIV risk perception among HIV negative or status-unknown men who have sex with men in China

Objective. To evaluate HIV risk perception and its associated factors among Chinese MSM. Methods. A cross-sectional study was conducted among MSM with an HIV negative or unknown status in Beijing, China, between 2011 and 2012. A questionnaire interview was conducted and a blood sample was collected for HIV and syphilis testing. Results. Of 887 MSM who reported they were HIV negative or did not know their HIV status before recruitment, only 7.3% reported a high risk of HIV infection, 28.0% medium risk, 52.2% low risk, and 12.5% no risk. In multivariate logistic regression models using those who reported a medium self-perceived risk as a reference group, self-reported high risk of HIV perception was associated with minority ethnicity (odds ratio [OR]: 2.91; 95% confidence interval [CI]: 1.03–8.19), self-reported history of sexually transmitted diseases (OR: 2.27; 95% CI: 1.25–4.10), and HIV testing times since the last HIV testing (OR: 0.47; 95% CI: 0.26–0.84); low self-perceived risk of HIV infection was related to full-time employment (OR: 1.58; 95% CI: 1.15–2.18) and illicit drug use (OR: 0.28; 95% CI: 0.10–0.75). Conclusions. The HIV/AIDS epidemic is rapidly rising among Beijing MSM, but more than half MSM did not perceive this risk.

Is self-perceived HIV risk congruent with reported HIV risk among traditionally lower HIV risk and prevalence adult emergency department patients? Implications for HIV testing

Because reliance on patients' self-perceived risk for HIV might mislead emergency department (ED) clinicians on the need for HIV testing, we aimed to measure congruency between self-perceived and reported HIV risk in a traditional lower prevalence, lower-risk cohort. A random sample of 18- to 64-year-old patients at a large academic urban ED who were by self-report not men-who-have-sex-with-men (MSM) or injection-drug users (IDUs) were surveyed regarding their self-perceived and reported HIV risk. Sixty-two percent of participants were white non-Hispanic, 13.8% Black, and 21.2% Hispanic; and 66.9% previously had been tested for HIV. Linear regression models were constructed comparing self-perceived to reported HIV risk. Among the 329 female ED patients, 50.5% perceived that they were "not at risk" for HIV, yet only 10.9% reported no HIV risk behaviors, while among the 175 male ED patients, 50.9% perceived that they were "not at risk" for HIV, yet only 12.6% reported no HIV risk behaviors. Only 16.9% of women and 15.7% of men who had no self-perceived risk for HIV also reported no HIV risk behaviors. Multivariable linear regression demonstrated a weak relationship between self-perceived and reported risk. Congruency between self-perceived risk and reported HIV risk was low among these non-MSM, non-IDU ED patients.

Interrelationship of alcohol misuse, HIV sexual risk and HIV screening uptake among emergency department patients

Background

Emergency department (ED) patients comprise a high-risk population for alcohol misuse and sexual risk for HIV. In order to design future interventions to increase HIV screening uptake, we examined the interrelationship among alcohol misuse, sexual risk for HIV and HIV screening uptake among these patients.

Methods

A random sample of 18-64-year-old English- or Spanish-speaking patients at two EDs during July-August 2009 completed a self-administered questionnaire about their alcohol use using the Alcohol Use Questionnaire, the Alcohol Use Disorders Identification Test (AUDIT), and the HIV Sexual Risk Questionnaire. Study participants were offered a rapid HIV test after completing the questionnaires. Binging (≥ five drinks/occasion for men, ≥ four drinks for women) was assessed and sex-specific alcohol misuse severity levels (low-risk, harmful, hazardous, dependence) were calculated using AUDIT scores. Analyses were limited to participants who had sexual intercourse in the past 12 months. Multivariable logistic regression was used to assess the associations between HIV screening uptake and (1) alcohol misuse, (2) sexual risk for HIV, and (3) the intersection of HIV sexual risk and alcohol misuse. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were estimated. All models were adjusted for patient demographic characteristics and separate models for men and women were constructed.

Results

Of 524 participants (55.0% female), 58.4% identified as white, non-Hispanic, and 72% reported previous HIV testing. Approximately 75% of participants reported drinking alcohol within the past 30 days and 74.5% of men and 59.6% of women reported binge drinking. A relationship was found between reported sexual risk for HIV and alcohol use among men (AOR 3.31 [CI 1.51-7.24]) and women (AOR 2.78 [CI 1.48-5.23]). Women who reported binge drinking were more likely to have higher reported sexual risk for HIV (AOR 2.55 [CI 1.40-4.64]) compared to women who do not report binge drinking. HIV screening uptake was not higher among those with greater alcohol misuse and sexual risk among men or women.

Conclusions

The apparent disconnection between HIV screening uptake and alcohol misuse and sexual risk for HIV among ED patients in this study is concerning. Brief interventions emphasizing these associations should be evaluated to reduce alcohol misuse and sexual risk and increase the uptake of ED HIV screening.

Can computer-based feedback improve emergency department patient uptake of rapid HIV screening?

OBJECTIVE

We determine whether (1) an audiocomputer-delivered tailored feedback intervention increases emergency department (ED) patient uptake of opt-in, nontargeted rapid HIV screening; and (2) uptake is greater among patients who report more HIV risk and among those whose self-perceived HIV risk increases from baseline after completion of an HIV risk assessment.

METHODS

ED patients aged 18 to 64 years were randomly assigned to receive either an assessment about reported and self-perceived HIV risk or an identical assessment plus feedback about their risk for having or acquiring an HIV infection, tailored according to their reported risk. All participants were offered a fingerstick rapid HIV test. Two-sample tests of binomial proportions were used to compare screening uptake by study arm. Multivariable logistic regression was used to assess the relationship of reported HIV risk and an increase in self-perceived HIV risk with uptake of HIV screening.

RESULTS

Of the 566 participants, the median age was 29 years, 62.2% were women, and 66.9% previously had been tested for HIV. Uptake of HIV screening was similar in the intervention and no intervention arms (54.1% versus 55.5% [Δ=-0.01%; 95% confidence interval {CI} -0.09% to 0.07%]). An increase in self-perceived HIV risk predicted greater uptake of HIV screening for women (odds ratio 2.15; 95% CI 1.08 to 4.28) but not men (odds ratio 1.61; 95% CI 0.60 to 4.30). Uptake of HIV screening was not related to reported HIV risk.

CONCLUSION

Uptake of rapid HIV screening in the ED was not improved by this feedback intervention. Other methods need to be investigated to improve uptake of HIV screening by ED patients.

Effectiveness of increasing emergency department patients' self-perceived risk for being human immunodeficiency virus (HIV) infected through audio computer self-interview-based feedback about reported HIV risk behaviors

OBJECTIVES

Prior research has demonstrated that emergency department (ED) patient acceptance of human immunodeficiency virus (HIV) screening is partially dependent on patients' self-perceived risk of infection. The primary objective of this study was to determine the effectiveness of audio computer-assisted self-interview (ACASI)-based feedback. The intervention aimed to increase patient's self-perceived risk of being HIV infected by providing immediate feedback on their risk behaviors.

METHODS

This 1-year, randomized, controlled trial at a U.S. ED enrolled a random sample of 18- to 64-year-old subcritically ill or injured adult patients who were not known to be HIV infected. All participants completed an anonymous, ACASI-based questionnaire about their HIV risk behaviors related to injection drug use and sex, as well as their self-perceived risk for being HIV infected. Participants were randomly assigned to one of two study groups: an intervention group in which participants received immediate ACASI-based feedback in response to each of their reported risk behaviors or a no-intervention group without feedback. Participants were asked to indicate their level of HIV risk on a five-point scale before and after they answered the questions. Change in level of self-perceived HIV risk was calculated and compared by study group using Pearson's chi-square test. An HIV risk behavior score that summarized reported HIV risk behavior was devised. Because HIV risk behaviors differ by sex, scores were calculated separately for each sex. Linear regression models that adjusted for study group and same subject covariance were employed to determine if higher HIV risk behavior scores were associated with an increase in self-perceived HIV risk.

RESULTS

Of the 566 trial participants, the median age was 29 years (interquartile range [IQR] = 22-43 years), 62.2% were females, and 66.9% had been tested previously for HIV. After answering the reported HIV risk behavior questions, 12.6% of participants had an increase, 79.9% had no change, and 7.5% had a decrease in self-perceived HIV risk. Of the 46.6% of participants who initially indicated that they were not at risk for HIV, 11.4% had an increase in self-perceived HIV risk after answering the reported HIV risk behavior questions. Change in self-perceived HIV risk did not differ by study group (p = 0.77). There were no differences in reported HIV risk scores between the intervention and no-intervention groups for females (p = 0.78) or males (p = 0.86). In the linear regression models, a greater increase in self-perceived HIV risk was associated with higher reported HIV risk behavior scores for females (beta = 0.59, 95% confidence interval [CI] = 0.15, 1.04) but not for males (beta = 1.00, 95% CI = -0.13 to 2.14).

CONCLUSIONS

Some ED patients can be moved, although modestly, to recognize their risk for being HIV infected by asking about their HIV risk behaviors. However, ACASI-based feedback messages about HIV risk behaviors do not increase subjects' self-perceived HIV risk. Female ED patients appear to increase their self-perceived HIV risk more than males when queried about their HIV risk behaviors.

Routine opt-out HIV testing in an urban community health center

Undiagnosed HIV infection remains a significant public health problem. To address this, the Centers for Disease Control and Prevention revised testing recommendations, calling for routine opt-out HIV screening among adults in health care settings. However, these recommendations have not been widely implemented in primary care settings. We examined acceptability of opt-out HIV testing in an urban community health center and factors associated with accepting testing. From July 2007 to March 2008, physicians or a designated HIV tester approached patients presenting for primary care visits during 52 clinical sessions at an urban community health center. Patients were told they "would be tested for HIV unless they declined testing." Enzyme-linked immunosorbent assays, which required venipuncture, were used to test for HIV infection. We extracted demographic, clinical, and visit characteristics from medical records and examined associations between these characteristics and accepting HIV testing using logistic regression. Of 300 patients, 35% agreed to HIV testing, with no new HIV infections detected. Common reasons for declining testing were perceived low risk (54.4%) and self-reported HIV testing previously (45.1%). Younger age (adjusted odds ratio [AOR] = 0.97, 95% confidence interval [CI] = 0.96-0.99), Hispanic ethnicity (AOR = 1.78, 95% CI = 1.01-3.14), and having another blood test during the visit (AOR = 6.36, 95% CI = 3.58-11.28) were independently associated with accepting HIV testing. This study questions whether expanding HIV testing by conducting routine opt-out HIV testing in primary care settings is an acceptable strategy. It is important to understand how various testing strategies may affect HIV testing rates. In addition, further exploration of patients' reasons for declining HIV testing in these settings is warranted.

Sexual health and sexually transmitted infections in the North American Arctic

STI rates reported for the Arctic are much higher than those reported for their southern counterparts.

Our objective was to describe the basic epidemiology of sexually transmitted infections for Arctic and sub-Arctic regions of North America. We summarized published and unpublished rates of chlamydial infection and gonorrhea reported from 2003 through 2006 for Alaska, Canada, and Greenland. In 2006, Alaska reported high rates of chlamydial infection (715 cases/100,000 population) compared with the United States as a whole; northern Canada reported high rates of chlamydial infection (1,693 cases/100,000) and gonorrhea (247 cases/100,000) compared with southern Canada; and Greenland consistently reported the highest rates of chlamydial infection (5,543 cases/100,000) and gonorrhea (1,738 cases/100,000) in the Arctic. Rates were high for both men and women, although the highest incidence of infection was predominantly reported for young women in their early twenties. We propose that community-based participatory research is an appropriate approach to improve sexual health in Arctic communities.