HIV Infection and AIDS in the Deep South

HIV Screening Among Young Black Men Who Have Sex with Women in New Orleans, LA

There are significant disparities in HIV acquisition, with Black individuals facing disproportionately more new diagnoses. Per Centers for Disease Control and Prevention (CDC), all people aged 13-64 should be tested at least once in their lifetime, and men at increased risk (e.g., those who have male sexual contact, multiple partners, have partners with multiple partners, or share drug injection equipment) should be tested annually. The study included young Black men who have sex with women (MSW), aged 15-26, and who live in New Orleans, LA. Survey data was used to elicit the frequency and factors associated with three self-reported outcomes: (1) history of ever HIV testing, (2) HIV screening in the last year among those who were recommended per CDC, and (3) HIV positivity. Of the 1321 men included, 694/1321 men (52.5%) reported ever having been HIV tested. There were 708/1321 (54.2%) men who met the recommendation for annual screening and 321/708 (45.3%) of these eligible men reported being tested in the previous year. Of those ever tested, 44/694 (6.3%) self-reported testing positive. In logistic regression analysis, older age (OR: 1.27, p < 0.001), prior STI testing (OR: 6.45, p < 0.001), and prior incarceration (OR:1.70, p = 0.006) were positively associated with having ever received an HIV test, and ever having a male partner (OR: 3.63, p = 0.014) was associated with HIV positivity. Initiatives to improve HIV testing rates among young Black men who have sex with women are needed to reduce the burden of HIV and help the End the Epidemic initiative.

Population Density and Health Outcomes in Women with HIV in the Southern United States: A Retrospective Longitudinal Analysis

Purpose: Published studies have revealed challenges for people with human immunodeficiency virus (HIV) living in rural areas compared to those in urban areas, such as poor access to HIV care, insufficient transportation, and isolation. The purpose of this study was to examine associations between population density and multiple psychosocial and clinical outcomes in the largest cohort of women with HIV (WWH) in the United States. Methods: Women's Interagency HIV Study (WIHS) participants from Southern sites (n = 561) in 2013-2018 were categorized and compared by population density quartiles. The most urban quartile was compared with the most rural quartile in several psychosocial and clinical variables, including HIV viral load suppression, HIV medication adherence, HIV care attendance, depression, internalized HIV stigma, and perceived discrimination in healthcare settings. Results: Although women in the lowest density quartile were unexpectedly more highly resourced, women in that quartile had greater odds of not attending an HIV care visit in the last six months (odds ratio [OR] = 0.64, 95% confidence interval [CI] [0.43-0.95]), yet higher odds for having fully suppressed HIV when compared to women in the highest density quartile (OR = 1.64, 95% CI [1.13-2.38]). Highly urban WWH had greater likelihood of unsuppressed HIV, even after controlling for income, employment, and health insurance, despite reporting greater HIV care adherence and similar medication adherence. Discussion: Further investigation into the reasons for these disparities by population density is needed, and particular clinical attention should be focused on individuals from high population density areas to help maximize their health outcomes.

Characterizing residential mobility among people with HIV in Tennessee and its impact on HIV care outcomes

OBJECTIVE

Our objective was to assess the prevalence and patterns of mobility among people with HIV (PWH) in Tennessee and its impact on HIV care outcomes.

DESIGN

Retrospective cohort study.

METHODS

We combined residential address and HIV surveillance data from PWH in Tennessee from 2016 to 2018. Using Poisson regression, we estimated associations between in-state mobility (change in address or total miles moved) in 1 year and outcomes in the subsequent year; retention: having two CD4 + /HIV RNA values (labs) in a calendar year at least 3 months apart, loss to follow-up (LTFU): having labs at baseline but not the subsequent year, and viral suppression: HIV RNA less than 200 copies/ml. We applied a kernel density estimator to origin-destination address lines to visualize mobility patterns across demographic subgroups.

RESULTS

Among 17 428 PWH [median age 45 years (interquartile range; IQR 34-53)], 6564 (38%) had at least one move. Median miles moved was 8.9 (IQR 2.6-143.4)). We observed in-state movement between major cities (Chattanooga, Knoxville, Memphis and Nashville) and out-of-state movement to and from Georgia and Florida. Having at least one in-state move was associated with a decreased likelihood of retention [adjusted relative risk (aRR) = 0.91; 95% confidence interval (CI) 0.88-0.95], and an increased risk of LTFU (aRR = 1.17; 95% CI 1.04-1.31, two to three moves vs. none). Greater distance moved in-state was associated with decreased retention and increased LTFU (aRR = 0.53; 95% CI 0.49-0.58, aRR = 2.52; 95% CI 2.25-2.83, respectively for 1000 vs. 0 miles). There was no association between mobility and viral suppression.

CONCLUSION

Mobility is common among PWH in Tennessee and is associated with initial poor engagement in HIV care.

Syphilis Screening Among Young Black Men Who Have Sex With Women in New Orleans, LA

BACKGROUND

Current US syphilis screening focuses on men who have sex with men (MSM), because of the increased risk of infection in their sexual networks, and on pregnant people, because of complications associated with congenital syphilis. However, screening for men who have sex with women (MSW) who are at increased risk of syphilis is also recommended. Factors associated with syphilis testing and positivity were assessed among young, Black MSW.

METHODS

Data from the Check It study-a seek, test, and treat study for chlamydia in New Orleans, LA, among Black MSW aged 15 to 26 years-were used. Survey data were used to elicit self-reported syphilis testing, self-reported testing results, and sociodemographic and behavioral factors associated with these 2 outcomes.

RESULTS

Per the Centers for Disease Control and Prevention, all men in the study were recommended for syphilis screening because of their age, race, and geographic location. Of the 1458 men included, 272 (18.7%) reported ever having been syphilis tested, 267 men reported their results, and 23 (8.6%) reported testing positive. In logistic regression, older age (odds ratio [OR], 1.21 per year older; P < 0.001), prior Chlamydia trachomatis , Neisseria gonorrhoeae , and/or HIV testing (OR, 50.32; P < 0.001), and younger age at sexual debut (0.90 per year older, P = 0.005) were significantly associated with prior syphilis testing. In addition, testing positive for C. trachomatis and/or N. gonorrhoeae during the study was significantly associated with a history of syphilis positivity (OR, 3.08; P = 0.031).

CONCLUSIONS

Although syphilis testing was associated with factors that might increase the risk of acquisition, only 19% of individuals meeting Centers for Disease Control and Prevention testing recommendations had ever been screened.

Racial disparity in ART adherence is closed in states with high social trust: Results from the Medical Monitoring Project (MMP), 2015

Racial/ethnic disparities persist in antiretroviral therapy (ART) adherence and viral suppression. We examined associations between state-level social trust and individual-level ART adherence and viral suppression and assessed whether these relationships varied by race/ethnicity. The Medical Monitoring Project (MMP) annually reports nationally representative estimates of the behavioral and clinical characteristics of HIV-positive adults in primary care. A total of 3298 adults diagnosed with HIV between 2015 and 2016 from 16 US states were included. We used weighted logistic regression to model the association between state-level social trust, race/ethnicity (Non-Hispanic Black, White, and Hispanic/Latino), and cross-product interactions with ART adherence (a binary measure derived from three self-reported questions), and viral suppression (a binary measure corresponding to plasma HIV RNA < 200 copies/ml). Social trust was the percentage of people in each state who agreed that most people in their neighborhood could be trusted. A high level of social trust was associated with a higher likelihood of ART adherence (PR [prevalence ratio] = 1.17; 95% confidence interval [CI]: 1.05-1.30). In covariate-adjusted analyses, the association between state-level social trust and individual-level ART adherence significantly varied by race/ethnicity (Wald χ2  F = 9.8 [df = 4], p = 0.044). Social trust was positively associated with ART, but the effect was smaller for Blacks than for Whites (PR = 0.66; 95% CI: 0.57-0.82) in states with the lowest social trust. Black-White differences were closed and no longer significant above mean social trust (PP [predicted probability] = 0.50 vs. 0.53, at two standard deviations). Racial/ethnic disparities in ART adherence were closed among individuals living in states with high social trust. Understanding the mechanisms that promote social trust among neighbors may have downstream impacts on reducing disparities in ART adherence among people with HIV (PWH).

Locating the Risk: Using Participatory Mapping to Contextualize Perceived HIV Risk across Geography and Social Networks among Men Who Have Sex with Men in the Deep South

HIV incidence among African American (AA) young men who have sex with men (YMSM) has remained stable even though they made up the largest number of new HIV diagnoses among men who have sex with men (MSM) in 2017. HIV spreads at increased rates in dense sexual networks. Identifying the location of risk behaviors "activity spaces" could inform geographically circumscribed HIV prevention interventions. Utilizing the modified social ecological model we completed five semi-structured focus groups incorporating a modified social mapping technique, based on Singer et al.'s approach. Participants included 27 AA YMSM. Focus groups explored how and where HIV transmission happens in Jackson, Mississippi. Result themes included: 1) location of sexual behaviors, 2) knowledge of geographic hotspots of HIV infection in Jackson, and 3) traveling to meet partners: at home and away. HIV transmission or "activity spaces" may be occurring outside identified HIV hot spots. Mixed geospatial and qualitative methods offered a comprehensive assessment of where HIV transmission occurs, and suggests that geographically circumscribed interventions may need to focus on where individuals living with HIV reside and in specific geographic locations where they engage in behaviors that raise their HIV acquisition risks.

Examining the Implementation of Conditional Financial Incentives Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework to Improve HIV Outcomes among Persons Living with HIV (PLWH) in Louisiana

Economic strengthening interventions are needed to support HIV outcomes among persons living with HIV (PLWH). The Baton Rouge Positive Pathway Study (BRPPS), a mixed method implementation science study, was conducted to assess key RE-AIM components tied to the provision of conditional financial incentives among PLWH in Baton Rouge, Louisiana. Seven hundred and eighty-one (781) PLWH enrolled at four HIV clinic sites were included in the final analyses. Participants completed an initial baseline survey, viral load test, and were contacted at 6 and 12 months (±1 month) post-enrollment for follow-up labs to monitor viral load levels. Participants received up to USD140 in conditional financial incentives. The primary analyses assessed whether participation in the BRPPS was associated with an increase in the proportion of participants who were: (a) engaged in care, (b) retained in care and (c) virally suppressed at baseline to 6 and 12 months post-baseline. We constructed a longitudinal regression model where participant-level outcomes at times t0 (baseline) and t1 (6- or 12-month follow-up) were modeled as a function of time. A secondary analysis was conducted using single-level regression to examine which baseline characteristics were associated with the outcomes of interest at 12-month follow-up. Cost analyses were also conducted with three of the participating clinics. Most participants identified as Black/African American (89%). Fewer than half of participants reported that they were unemployed or made less than USD5000 annually (43%). Over time, the proportion of participants engaged in care and retained in care significantly increased (70% to 93% and 32% to 64%, p < 0.00). However, the proportion of virally suppressed participants decreased over time (59% to 34%, p < 0.00). Implementation costs across the three sites ranged from USD17,198.05 to USD396,910.00 and were associated with between 0.37 and 1.34 HIV transmissions averted at each site. Study findings provide promising evidence to suggest that conditional financial incentives could help support engagement and retention in HIV care for a high need and at risk for falling out of HIV care population.

Associations Between Experienced HIV Stigma, Resulting Consequences, and the HIV Care Continuum: Moderating Effects of Two Resilience Characteristics Among Persons Living with HIV (PLWH) in Louisiana

INTRODUCTION

HIV-related stigma continues to serve as a major barrier to HIV care. HIV stigma reduction interventions are urgently needed to promote and protect the health of persons living with HIV (PLWH). Resilience has been identified as a potential leverage to mitigate the impact of HIV-related stigma among PLWH.

METHODS

We examined whether two resilience measures (i.e., social support and resilience assets and resources [RAR]) moderated the relationship between experienced HIV stigma and the HIV care continuum as well as how they moderated the relationship between the consequences of experienced HIV stigma (CES) and the HIV care continuum among 300 PLWH in Louisiana. Separate bootstrapping analyses were conducted to test for evidence of moderated moderation.

RESULTS

Most participants were Black (79%) and had been living with HIV for 10 years or more. A relatively high sample of men who have sex with men (MSM) were enrolled (37%). The most common CES were depression (67%). The most common manifestation of experienced HIV stigma was being gossiped about (53%). Participants reported moderate levels of social support. In terms of RAR, most participants (71%) reported that they knew of groups that could support them in responding to experienced HIV stigma. After adjusting for potential covariates, social support and RAR both significantly moderated the relationship between experienced HIV stigma and length of time since their last HIV care visit, B(SE) = .003(.001), p = .03. At high levels of RAR and high levels of social support, those with higher levels of experienced HIV stigma reported a longer length of time since their last HIV care visit than those who reported lower levels of experienced HIV stigma (B(SE) = .17(.04), p < .001). RAR moderated the relationship between social support and HIV care, B(SE) = .01(.004), p < .001. Those who experienced greater CES reported a longer length of time since their last doctor's visit B(SE) = .04(.02), p < .05. Experienced HIV stigma was not significantly associated with viral load results. However, social support significantly moderated the relationship between experienced stigma and viral load results. At higher levels of social support, those who experienced lower levels of stigma were more likely to report an undetectable viral load than those who had higher levels of stigma, B(SE) = - .13(.03), p < .001. Finally, both RAR and social support moderated the relationship between CES and viral load results. Those who reported higher levels of RAR B(SE) = - .07(.02), p < .001, and social support, B(SE) = - .02(.01), p < .05, also reported having an undetectable viral load at most recent HIV care visit. CES was not significantly related to reporting an undetectable viral load (p = .61).

CONCLUSIONS

Enrolled PLWH already have some level of resilience which plays an important protective role within the context of the HIV care continuum up to a certain extent. Interventions to enhance the RAR and social support components may be useful especially among MSM and persons who have been living with HIV for a shorter period of time.

HIV Prevention Among Cisgender Men Who have Sex with Transgender Women

Cisgender men who have sex with transgender women face elevated risk for HIV, yet are understudied in prevention research. We conducted in-depth interviews with 19 men who have sex with transgender women in Baltimore, Maryland and Atlanta, Georgia to explore perspectives on HIV prevention. Participants used several strategies to reduce HIV risk: condoms, frequent HIV testing, communication about HIV status with partners, and limiting the types of sex acts performed. While condom use was inconsistent, it was preferred over pre-exposure prophylaxis, in part due to medical distrust. HIV self-testing was generally viewed unfavorably. Although most participants were referred to the study by their transgender women partners, they recommended reaching other men who have sex with transgender women in bars, nightclubs, online, and through social media. HIV prevention interventions should be inclusive of the needs and experiences of men who have sex with transgender women.

Spatial analysis of HIV infection and the associated correlates among transgender persons in the United States

Identifying the geographic hotspots of HIV infection among high-risk populations such as transgender people is critical to ending the HIV epidemic in the United States (U.S.). This study examined the spatial pattern of HIV positivity rate and the associated correlates among transgender persons in the 48 contiguous states and the District of Columbia in the U.S. The data source was the 2015 U.S. Transgender Survey (n = 27,715). We conducted spatial analyses, with state as the unit of analysis. We fitted a spatial lag regression model to assess demographic, social, and behavioral risk variables associated with HIV. The HIV positivity rate ranged by state from 0.5% to 17.1%, with a mean of 2.9%. There was a significant positive global spatial autocorrelation (global Moran's I = 0.42, p = 0.001). The identified spatial clusters of high values (hot spots i.e., states with high HIV positivity rates surrounded by states with similarly high rates) included five neighboring states (Arkansas, Louisiana, Mississippi, Alabama, and Tennessee) in the Southern region. HIV positivity rate was positively associated with the percentage of transgender persons who were non-Hispanic Black, had no high school education, living in poverty, and engaged in sex work. Structural interventions are needed to address education, poverty, racial discrimination, and sex work that predispose transgender persons to HIV.

HIV Related Knowledge, HIV Testing Decision-Making, and Perceptions of Alcohol Use as a Risk Factor for HIV among Black and African American Women

The HIV/AIDS epidemic disproportionately affects Black and African American women in the United States. This study examined the extent of HIV related knowledge, HIV testing decision-making, and perceptions of alcohol use as a risk factor for HIV among Black and African American women in urban and suburban communities. Seven focus groups were conducted with 37 women aged 18 to 49 residing in the Commonwealth of Massachusetts. Women participating in focus groups had a wide breadth of HIV related knowledge. Findings suggest the influence of interpersonal relationships and provider-patient interactions on HIV testing, the need for building community capacity and leveraging community resources towards HIV prevention, and the influence of alcohol outlet density on HIV vulnerability and exposure in communities of color. Comprehensive multifaceted evidence informed interventions that are culturally relevant and gender responsive are needed to reduce HIV/AIDS disparities.

Associations between population density and clinical and sociodemographic factors in women living with HIV in the Southern United States

To explore the associations of urbanicity with clinical/behavioral outcomes and sociodemographic factors among women living with HIV in the Southern United States, 523 participants of the Women's Interagency HIV Study were classified into population density quartiles. Rural-Urban Commuting Area codes revealed that 7% resided in areas where >30% commute to urban areas, 2% resided in small towns or rural areas, and 91% resided in varying densities of urban areas. Although women in lower density, mostly suburban areas reported higher socioeconomic indicators such as advanced education and greater annual household income, larger proportions of women in the lowest density quartile perceived discrimination in health care settings and agreed with several internalized HIV stigma scale items. Women in the lower quartiles had higher CD4 counts, while those in the lowest quartile were more likely to have a suppressed HIV viral load, report being employed, and not report a history of drug use or current heavy alcohol use. More research is needed to understand the interplay between population density and mechanisms contributing to HIV control as well as increased internalized stigma and perceived discrimination, along with how to target interventions to improve outcomes for individuals with HIV across urban, suburban, and rural areas.

Feasibility, acceptability, and preliminary impact of telemedicine-administered cognitive behavioral therapy for adherence and depression among African American women living with HIV in the rural South

Women living with HIV are disproportionally affected by depression and mental healthcare access. A pilot feasibility trial using videoconferencing compared cognitive behavioral therapy for antiretroviral therapy adherence and depression (N = 11) to supportive psychotherapy (N = 11). Participants completed 10-12 weekly therapy sessions and 6-month follow-up. Retention at 6 months was 95 percent. Depression symptoms significantly decreased in both arms; antiretroviral therapy adherence remained high as measured via self-report and Wisepill. Satisfaction with intervention components was high; videoconferencing was highly acceptable and comparable to face-to-face counseling. This study demonstrates the feasibility of telemedicine-administered psychotherapy addressing mental health needs among women living with HIV.

Accessing Pre-exposure Prophylaxis (PrEP): Perceptions of Current and Potential PrEP Users in Birmingham, Alabama

Limited studies to date assess barriers to and facilitators of PrEP uptake and utilization using a patient-centered access to care framework, among diverse socio-demographic groups, or in the U.S. Deep South, an area with disproportionate HIV burden. We examine perceptions of PrEP access in qualitative interviews with 44 current and potential PrEP users in Birmingham, Alabama. Participants were 32 years old on average, 66% Black, 66% gay or lesbian, 70% male, and 66% single. Perceived barriers to PrEP access included: lack of PrEP awareness and advertisement; sexuality-related stigma; time and resource constraints; and concerns about the adequacy and technical quality of PrEP services. Perceived facilitators to PrEP access were: PrEP-related information gathering and sharing; increased dialogue and visibility around PrEP; social, programmatic, and clinical support; and, lastly, self-preservation; personal motivation; and treatment self-efficacy. Results point to opportunities to address complex barriers to equitable PrEP access using multilevel and multimodal solutions.

Suboptimal HIV Pre-exposure Prophylaxis Awareness and Willingness to Use Among Women Who Use Drugs in the United States: A Systematic Review and Meta-analysis

In the United States (U.S.), more than 12 million women reported illicit drug use in the past month. Drug use has been linked to increased risk for HIV, but little is known about the uptake of HIV pre-exposure prophylaxis (PrEP) to prevent HIV among women who use drugs (WWUD). Following the PRISMA guideline, we conducted a multi-database literature search to assess engagement along the PrEP care continuum among WWUD in the U.S. Seven studies with a total of 755 women were included in the review: 370 (49%) Black, 126 (16.7%) Hispanics, and 259 (34.3%) Whites. Employing random-effect models, data indicate 20.6% (95% CI 8.7%, 32.4%) of WWUD were aware of PrEP, and 60.2% (95% CI 52.2%, 68.2%) of those aware were also willing to use PrEP. Notwithstanding study limitations, our findings suggest there may be potential to increase PrEP uptake among WWUD, but efforts must first concentrate on improving PrEP awareness among this population.

Comparing Patient Demographics and Tumor Characteristics of HIV-Positive and HIV-Negative Patients with Cancer in South Carolina

We compared the demographic and disease characteristics of HIV-positive (HIV+) and HIV-negative (HIV−) individuals with a diagnosis of cancer in South Carolina. HIV-positive patients with cancer were reflective of the HIV+ caseload in South Carolina, with HIV+ patients with cancer more likely to be male (odds ratio [OR]: 2.78: 95% confidence interval [CI]: 2.33-3.32), black (OR: 7.68; 95% CI: 6.52-9.06), and younger at cancer diagnosis (OR: 0.92; 95% CI: 0.91-0.92). Controlling for year of birth, HIV+ patients with cancer did not receive cancer diagnoses at a younger age than HIV− controls. HIV-positive individuals did not have more advanced tumor stages or grades at cancer diagnosis; however, after controlling for other factors, HIV+ individuals were still more likely to be deceased at follow-up (OR: 2.64; 95% CI: 2.20-3.17) when compared to HIV− controls. Future studies should use survival analysis methods to identify the characteristics that shorten survival among HIV+ patients with cancer.

Depression, ART Adherence, and Receipt of Case Management Services by Adults with HIV in North Carolina, Medical Monitoring Project, 2009-2013

Depression among persons with HIV is associated with antiretroviral therapy (ART) interruption and discontinuation, virological failure, and poor clinical and survival outcomes. Case management services can address needs for emotional counseling and other supportive services to facilitate HIV care engagement. Using 2009-2013 North Carolina Medical Monitoring Project data from 910 persons engaged in HIV care, we estimated associations of case management utilization with "probable current depression" and with 100% ART dose adherence. After weighting, 53.2% of patients reported receiving case management, 21.7% reported depression, and 87.0% reported ART adherence. Depression prevalence was higher among those reporting case management (24.9%) than among other patients (17.6%) (p < 0.01). Case management was associated with depression among patients living above the poverty level [adjusted prevalence ratio (aPR), 2.05; 95% confidence interval (CI) 1.25-3.36], and not among other patients (aPR, 1.01; 95% CI 0.72-1.43). Receipt of case management was not associated with ART adherence (aPR, 1.00; 95% CI 0.95-1.05). Our analysis indicates a need for more effective depression treatment, even among persons receiving case management services. Self-reported ART adherence was high overall, though lower among persons experiencing depression (unadjusted prevalence ratio, 0.92; 95% CI 0.86-0.99). Optimal HIV clinical and prevention outcomes require addressing psychological wellbeing, monitoring of ART adherence, and effective case management services.

The Interaction of Sexual Validation, Criminal Justice Involvement, and Sexually Transmitted Infection Risk Among Adolescent and Young Adult Males

BACKGROUND

Young men who have been involved with the criminal justice system are more likely to have concurrent sexual partners, a key driver of sexually transmitted infections. The value men place on having sexual relationships to validate themselves may play an important role in understanding this association.

METHODS

Data were from a household survey. Young men (N = 132), aged 16 to 24 years, self-reported whether they ever spent time in jail or juvenile detention and if they had sexual partnerships that overlapped in time. A novel scale, "Validation through Sex and Sexual Relationships" (VTSSR) assessed the importance young men place on sex and sexual relationships (α = 0.91). Weighted logistic regression accounted for the sampling design.

RESULTS

The mean (SD) VTSSR score was 23.7 (8.8) with no differences by race. Both criminal justice involvement (CJI) (odds ratio [OR], 3.69; 95% confidence interval [CI], 1.12-12.1) and sexual validation (OR, 1.10; 95% CI, 1.04-1.16) were associated with an increased odds of concurrency; however, CJI did not remain associated with concurrency in the fully adjusted model. There was effect modification, CJI was associated with concurrency among those who scored high on sexual validation (OR, 9.18; 95% CI, 1.73-48.6]; however, there was no association among those who scored low on sexual validation. Racial differences were observed between CJI and concurrency, but not between sexual validation and concurrency.

CONCLUSIONS

Sexual validation may be an important driver of concurrency for men who have been involved with the criminal justice system. Study findings have important implications on how sexual validation may explain racial differences in rates of concurrency.

Resilience attenuates the association between neurocognitive functioning and everyday functioning in individuals aging with HIV in the Deep South

OBJECTIVES

Adults aging with HIV are at risk for poorer neurocognitive and daily functioning. Identifying factors to protect such outcomes is a significant research priority. The aim of this study was to explore the role of resilience in cognitive and everyday functioning in a largely African American and low socioeconomic status sample of adults and older adults with HIV in the Deep South.

METHODS/DESIGN

In this cross-sectional study 100 HIV+ middle-aged and older adults (range 40-73; 61% aged 50+) completed a comprehensive neurocognitive battery along with self-reported measures of resilience and everyday functioning.

RESULTS

Higher resilience was associated with better global neurocognitive functioning (rho = 0.31, P < 0.01), as well as better functioning in all domains (verbal fluency, executive functioning, speed of information processing, learning, working memory) except recall and motor skills. Resilience was also significantly associated with instrumental activities of daily living (IADL) dependence, with lower resilience observed in those with IADL dependence compared with those who were IADL independent (P < 0.01). In a multiple regression adjusting for data-driven covariates (verbal IQ, income, depression), and global neurocognitive impairment, resilience was the only significant (P = 0.02) correlate of IADL dependence. A follow-up mediation showed that the direct relationship between neurocognitive functioning and IADL declines was fully attenuated after accounting for shared variance with resilience.

CONCLUSIONS

Resilience is associated with better cognitive and functional outcomes in people aging with HIV. While further work is needed to understand these associations over time, results suggest interventions to build resilience may promote successful aging in this vulnerable population.

Estimating epidemiological parameters of a stochastic differential model of HIV dynamics using hierarchical Bayesian statistics

Current estimates of the HIV epidemic indicate a decrease in the incidence of the disease in the undiagnosed subpopulation over the past 10 years. However, a lack of access to care has not been considered when modeling the population. Populations at high risk for contracting HIV are twice as likely to lack access to reliable medical care. In this paper, we consider three contributors to the HIV population dynamics: at-risk population exhaustion, lack of access to care, and usage of anti-retroviral therapy (ART) by diagnosed individuals. An extant problem in the mathematical study of this system is deriving parameter estimates due to a portion of the population being unobserved. We approach this problem by looking at the proportional change in the infected subpopulations. We obtain conservative estimates for the proportional change of the infected subpopulations using hierarchical Bayesian statistics. The estimated proportional change is used to derive epidemic parameter estimates for a system of stochastic differential equations (SDEs). Model fit is quantified to determine the best parametric explanation for the observed dynamics in the infected subpopulations. Parameter estimates derived using these methods produce simulations that closely follow the dynamics observed in the data, as well as values that are generally in agreement with prior understanding of transmission and diagnosis rates. Simulations suggest that the undiagnosed population may be larger than currently estimated without significantly affecting the population dynamics.

The Associations of Resilience and HIV Risk Behaviors Among Black Gay, Bisexual, Other Men Who Have Sex with Men (MSM) in the Deep South: The MARI Study

Resilience is an understudied intrapersonal factor that may reduce HIV risk among men who have sex with men (MSM). Multivariable Poisson regression models were used to estimate the prevalence ratio (PR) of sexual risk behaviors, HIV prevalence, and history of sexually transmitted infections (STIs) with resilience scores in a population-based study among 364 black MSM in the Deep South. Participants with higher resilience scores had a lower prevalence of condomless anal sex with casual sexual partners in past 12 months (PR = 0.80, p value = 0.001) and during their last sexual encounter (PR = 0.81; p value = 0.009). Resilience was inversely associated with a lower prevalence of condomless anal sex with main sexual partners, participating in a sex party/orgy and having a STI in the past 12 months. Resilience may have a protective effect on HIV among black MSM, especially in the Deep South, and should be further explored in studies with prospective designs.

Perceived Stigma in People Living With HIV in Qom

Objective: This study aimed to report on perceived stigma by PLWH and factors that affect it. Materials and methods: A cross-sectional study was carried out on 120 PLWH in Qom, Iran from November 2015 to April 2016. Persian version of Fife and Wright's scale was used to measure perceived stigma. Results: The mean score of stigma was 73.19 ± 12.23 (range: 48-97). The means of external stigma and internal stigma were 43.70 ± 8.61 (range: 19-60), and 29.49 ± 5.32 (range: 17-40), respectively. Living in a rural areas (β = 10.341, p = 0.006), unemployment status (β = 6.910, p = 0.006), and poor support from family members (β = 4.772, p = 0.028) significantly increased the level of perceived stigma. PLWH experience a considerable level of stigma in their daily life. Mass media involvement to increase public awareness and reduce HIV related stigma need be more highlighted. Conclusion: Working with the patients' families, interventions in the rural areas and workplaces, and providing social supports is necessary to minimize the HIV related stigma.

A Flow-Based Model of the HIV Care Continuum in the United States

BACKGROUND

Understanding the flow of patients through the continuum of HIV care is critical to determine how best to intervene so that the proportion of HIV-infected persons who are on antiretroviral treatment and virally suppressed is as large as possible.

METHODS

Using immunological and virological data from the Centers for Disease Control and Prevention and the North American AIDS Cohort Collaboration on Research and Design from 2009 to 2012, we estimated the distribution of time spent in and dropout probability from each stage in the continuum of HIV care. We used these estimates to develop a queueing model for the expected number of patients found in each stage of the cascade.

RESULTS

HIV-infected individuals spend an average of about 3.1 months after HIV diagnosis before being linked to care, or dropping out of that stage of the continuum with a probability of 8%. Those who link to care wait an additional 3.7 months on average before getting their second set of laboratory results (indicating engagement in care) or dropping out of care with probability of almost 6%. Those engaged in care spent an average of almost 1 year before achieving viral suppression on antiretroviral therapy or dropping out with average probability 13%. For patients who achieved viral suppression, the average time suppressed on antiretroviral therapy was an average of 4.5 years.

CONCLUSIONS

Interventions should be targeted to more rapidly identifying newly infected individuals, and increasing the fraction of those engaged in care that achieves viral suppression.

Comparing the geographic distribution and location characteristics of HIV-seropositive and HIV-seronegative individuals with a diagnosis of cancer living in the southeast US

As HIV-seropositive individuals live longer, they are more likely to acquire conditions seen in the general population. Excluding AIDS-defining malignancies, HIV-seropositive individuals are more likely to develop cancer than individuals in the general population. In order to better inform future screening and prevention efforts in this population, we compared the geographic distribution and location characteristics of HIV-seropositive and HIV-seronegative cancer cases in South Carolina (SC). To do this we obtained linked HIV and cancer data from the SC enhanced HIV/AIDS Reporting System and Central Cancer Registry. Location-related information on SC residents (e.g., employment status, income levels, race of householder, and educational attainment) was obtained from the 2000 US Census. Hotspot analyses were used to analyze the geographic distribution of HIV-seropositive and HIV-seronegative cancer cases using the Getis-Ord Gi* statistic. Poisson regression analyses assessed if county demographic and geographic characteristics were associated with HIV-positive cancer case rates.

Testing a Computerized Cognitive Training Protocol in Adults Aging With HIV-Associated Neurocognitive Disorders: Randomized Controlled Trial Rationale and Protocol

Background

HIV-associated neurocognitive disorders occur in nearly 50% of adults with HIV. Such disorders can interfere with everyday functioning such as driving and medication adherence. Therefore, cognitive interventions are needed to address such neurocognitive disorders as well as improve everyday functioning, especially as people age with HIV.

Objective

This article reports and discusses the overall rationale and development of speed of processing training, a computerized Internet cognitive training program, to improve this specific neurocognitive ability as well as everyday functioning and quality of life in adults aging with HIV. Although this protocol has been shown to improve speed of processing, everyday functioning, and quality of life in healthy, community-dwelling older adults in the advanced cognitive training in vital elderly (ACTIVE) study, its efficacy in adults aging with HIV has not been established. Nevertheless, such a cognitive intervention is particularly germane as 52%-59% of adults with HIV experience HIV-associated neurocognitive disorders (HAND), and both the frequency and severity of such disorders may increase with advancing age.

Methods

The description of this longitudinal randomized controlled trial covers the following: (1) rationale for speed of processing training in this clinical population, (2) overview of overall study design, (3) eligibility criteria and HAND, (4) intervention dosage, (5) assessment battery, and (6) examination of biomarkers.

Results

The project was funded in April 2016 and enrolment is on-going. The first results are expected to be submitted for publication in 2020.

Conclusions

Similar novel cognitive intervention approaches are suggested as they may be of value to those with HAND and may utilize similar features of this current randomized controlled trial (RCT) protocol to examine their therapeutic efficacy.

Trial Registration

ClinicalTrials.gov NCT02758093; https://clinicaltrials.gov/ct2/show/NCT02758093 (Archived by Webcite at http://www.webcitation.org/6p8C5fBCX)

Development and Validation of the Masculine Attributes Questionnaire

The present study describes the development and validation of the Masculine Attributes Questionnaire (MAQ). The purpose of this study was to develop a theoretically and empirically grounded measure of masculine attributes for sexual health research with African American young men. Consistent with Whitehead’s theory, the MAQ items were hypothesized to comprise two components representing reputation-based and respect-based attributes. The sample included 505 African American men aged 19 to 22 years (M = 20.29, SD = 1.10) living in resource-poor communities in the rural South. Convergent and discriminant validity of the MAQ were assessed by examining the associations of masculinity attributes with psychosocial factors. Criterion validity was assessed by examining the extent to which the MAQ subscales predicted sexual risk behavior outcomes. Consistent with study hypotheses, the MAQ was composed of (a) reputation-based attributes oriented toward sexual prowess, toughness, and authority-defying behavior and (b) respect-based attributes oriented toward economic independence, socially approved levels of hard work and education, and committed romantic relationships. Reputation-based attributes were associated positively with street code and negatively related to academic orientation, vocational engagement, and self-regulation, whereas respect-based attributes were associated positively with academic and vocational orientations and self-regulation. Finally, reputation-based attributes predicted sexual risk behaviors including concurrent sexual partnerships, multiple sexual partners, marijuana use, and incarceration, net of the influence of respect-based attributes. The development of the MAQ provides a new measure that permits systematic quantitative investigation of the associations between African American men’s masculinity ideology and sexual risk behavior.

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

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

The South Carolina rural-urban HIV continuum of care

The HIV continuum of care model is widely used by various agencies to describe the HIV epidemic in stages from diagnosis through to virologic suppression. It identifies the various points at which persons living with HIV (PLWHIV) within a population fail to reach their next step in HIV care. The rural population in the Southern United States is disproportionally affected by the HIV epidemic. The purpose of this study was to examine these rural-urban disparities using the HIV care continuum model and determine at what stages these differences become apparent. PLWHIV aged 13 years and older in South Carolina (SC) were identified using data from the enhanced HIV/AIDS Reporting System. The percentages of PLWHIV linked to care, retained in care, and virologically suppressed were determined. Rural versus urban residence was determined using the Office of Management and Budget classification. There were 14,523 PLWHIV in SC at the end of 2012; 11,193 (77%) of whom were categorized as urban and 3305 (22%) as rural. There was no difference between urban and rural for those who had received any care: 64% versus 64% (p = .61); retention in care 53% versus 53% (p = .71); and virologic suppression 49% versus 48% (p = .35), respectively. The SC rural-urban HIV cascade represents the first published cascade of care model using rural versus urban residence. Although significant health care disparities exist between rural and urban residents, there were no major differences between rural and urban residents at the various stages of engagement in HIV care using the HIV continuum of care model.

Engagement in and continuity of HIV care among African and Caribbean Black women living with HIV in Ontario, Canada

Engagement in care is a key component of the HIV care cascade, yet there are knowledge gaps regarding how to assess HIV care engagement. This study aimed to develop a tool to assess HIV care engagement and to assess associations between HIV care engagement and quality of life (QOL) among African, Caribbean and Black (ACB) women living with HIV (WLWH). We conducted a cross-sectional survey with ACB WLWH across Ontario, Canada. We developed the 'HIV Engagement in and Continuity of Care Scale' (HECCS). We conducted exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) to test the scale's factor structure. We conducted structural equation modeling (SEM) with maximum likelihood estimation to examine the associations between the HECCS and QOL. EFA yielded four factors: access to care, care by doctor/health professionals, control of HIV care, and appointment timekeeping. The CFA of the HECCS demonstrated good model fit: χ² (DF: 1; n = 173) = 1.175, p = 0.278; CFI: 0.998; Tucker-Lewis Index (TLI): 0.990; RMSEA: 0.032. The HECCS was associated with increased QOL. The model fit the data well: χ² (DF: 31, n = 173) = 51.19, p = 0.013; CFI = 0.955; TLI = 0.934; RMSEA = 0.062. Engagement in and continuity of care is multifaceted. We recommend interventions to promote the institutional capacity to better engage ACB WLWH in HIV care.

The Health, Enlightenment, Awareness, and Living (HEAL) Intervention: Outcome of an HIV and Hepatitis B and C Risk Reduction Intervention

African American women have among the highest HIV/AIDS and hepatitis B and C incidence rates in the United States, especially among those homeless or incarcerated. The objective of this study was to evaluate the Health Enlightenment, Awareness and Living Intervention, designed to decrease HIV/AIDS, hepatitis and related risky behaviors. The thirteen-session intervention was implemented among homeless and formerly incarcerated low-income African American women, ages 18 to 55, in Atlanta, Georgia from 2006 to 2010. A single group repeated measures study design was employed and consisted of a pre-test (n = 355) group, an immediate post-test (n = 228) group with a response rate of 64%, and a six-month follow up (n = 110) group with response rate of 48%, completing a 135-item survey. Paired-sample t-tests, McNemar tests, and repeated measures ANOVA were applied to compare survey results. Participants demonstrated statistically significant increases in hepatitis B and C knowledge over time (p < 0.001). Statistically significant decreases were also reported for unprotected sex in exchange for money, drugs or shelter (p = 0.008), and sex under the influence of drugs or alcohol (p < 0.001). Reported substance use decreased with statistical significance for alcohol (p = 0.011), marijuana (p = 0.011), illegal drugs (p = 0.002), and crack/cocaine (p = 0.003). Findings broaden the evidence base related to the effectiveness of HIV/AIDS and hepatitis risk reduction interventions designed for homeless and previously incarcerated African American women.

Does it really matter which drug you choose? An examination of the influence of type of drug on type of risky sexual behavior

This study investigates whether certain types of substances are differentially related to certain risky sexual behaviors (RSBs) within the same population and determines whether combination substance use (SU) has additive, redundant or antagonistic effects on RSBs. African-American youth aged 9-19 participated in a large, community-based survey assessing substance use and sexual behaviors. Multilevel modeling was used to predict the differential influence of alcohol, marijuana, and cocaine use on condom use measured in the past 90days and at last intercourse, sex while drunk/high, and number of sexual partners. Tests of the within-participant relations showed that participants increasing their SU over time concurrently increased their RSBs, establishing a strong link between the two behaviors (alcohol: condom β=-0.045, sex while drunk/high β=0.138, sex partners β=0.102; marijuana: condom β=-0.081, sex while drunk/high β=0.255, sex partners β=0.166; cocaine: condom β=-0.091, sex while drunk/high β=0.103, sex partners β=0.031; all p's<0.01). Tests of the between-participant relations showed that, generally, youth reporting less SU across their teenage years were also more likely to report fewer RSBs over this period (alcohol: condom β=-0.128, sex while drunk/high β=0.120, sex partners β=0.169; marijuana: condom β=-0.170, sex while drunk/high β=0.638, sex partners β=0.357; cocaine: condom β=-0.353; all p's<0.05). Moreover, the combination of some substances has unique redundant or antagonistic effects on RSB. Such findings support the consideration of type of SU, and particular combinations of substances, on RSBs in intervention development.

Exploring Experiences and Perceptions of Older African American Males Aging With HIV in the Rural Southern United States

The HIV (human immunodeficiency virus) epidemic in the United States remains a serious public health concern. Despite treatment and prevention efforts, approximately 50,000 new HIV cases are transmitted each year. Estimates indicate that 44% of all people diagnosed with HIV are living in the southern region of the United States. African Americans represent 13.2% of the United States population; however, 44% (19,540) of reported new HIV cases in 2014 were diagnosed within this ethnic group. The majority of cases were diagnosed in men (73%, 14,305). In the United States, it is estimated that 21% of adults living with HIV are 50 years or older. There exists limited data regarding how well African American men are aging with HIV disease. The purpose of this study was to explore the perceptions and experiences of older African American men living with HIV in rural Georgia. Data were collected from 35 older African American men living with HIV using focus groups and face-to-face personal interviews. Qualitative content analysis revealed six overlapping themes: (1) Stigma; (2) Doing Fine, Most of the Time; (3) Coping With Age-Related Diseases and HIV; (4) Self-Care; (5) Family Support; and (6) Access to Resources. The findings from this study provide new insights into the lives of rural HIV-infected African American men, expands our understanding of how they manage the disease, and why many return to or remain in rural communities.

Examining the Relationships Between Religiosity, Spirituality, Internalized Homonegativity, and Condom Use Among African American Men Who Have Sex With Men in the Deep South

The Sexual Health in Faith Traditions Study evaluated the relationships between religiosity, spirituality, internalized homonegativity, and sexual risk behaviors among a sample of African American men who have sex with men living in the Deep South. Participants were recruited primarily from Black Gay Pride celebrations to complete a self-administered, paper-and-pencil survey. Structural equation modeling was used to determine relationships between key constructs and condom use for insertive ( n = 285) and receptive ( n = 263) anal intercourse in the past 3 months. Almost half of respondents reported using condoms "every time" when engaging in insertive (48.3%) or receptive (45.1%) anal intercourse. Religiosity and spirituality were differentially associated with dimensions of internalized homonegativity. While no significant direct relationships were reported between either religiosity or spirituality and condom use, dimensions of internalized homonegativity mediated significant indirect relationships. Findings suggest that religiosity and spirituality influence African American men who have sex with men's internalized homonegativity and, subsequently, engagement in safer sex behaviors.

Distance to testing sites and its association with timing of HIV diagnosis

Early HIV diagnosis enables prompt treatment initiation, thereby contributing to decreased morbidity, mortality, and transmission. We aimed to describe the association between distance from residence to testing sites and HIV disease stage at diagnosis. Using HIV surveillance data, we identified all new HIV diagnoses made at publicly funded testing sites in central North Carolina during 2005-2013. Early-stage HIV was defined as acute HIV (antibody-negative test with a positive HIV RNA) or recent HIV (normalized optical density <0.8 on the BED assay for non-AIDS cases); remaining diagnoses were considered post-early-stage HIV. Street distance between residence at diagnosis and (1) the closest testing site and (2) the diagnosis site was dichotomized at 5 miles. We fit log-binomial models using generalized estimating equations to estimate prevalence ratios (PR) and robust 95% confidence intervals (CI) for post-early-stage diagnoses by distance. Models were adjusted for race/ethnicity and testing period. Most of the 3028 new diagnoses were black (N = 2144; 70.8%), men who have sex with men (N = 1685; 55.7%), and post-early-stage HIV diagnoses (N = 2010; 66.4%). Overall, 1145 (37.8%) cases traveled <5 miles for a diagnosis. Among cases traveling ≥5 miles for a diagnosis, 1273 (67.6%) lived <5 miles from a different site. Residing ≥5 miles from a testing site was not associated with post-early-stage HIV (adjusted PR, 95% CI: 0.98, 0.92-1.04), but traveling ≥5 miles for a diagnosis was associated with higher post-early HIV prevalence (1.07, 1.02-1.13). Most of the elevated prevalence observed in cases traveling ≥5 miles for a diagnosis occurred among those living <5 miles from a different site (1.09, 1.03-1.16). Modest increases in post-early-stage HIV diagnosis were apparent among persons living near a site, but choosing to travel longer distances to test. Understanding reasons for increased travel distances could improve accessibility and acceptability of HIV services and increase early diagnosis rates.

Safety and Tolerability of Stribild in the Southeast United States

PURPOSE

The purpose of this study is to assess postmarketing safety and tolerability of Stribild (elvitegravir [EVG]/cobicistat [COBI]/tenofovir disoproxil fumarate [TDF]/emtricitabine [FTC]).

METHODS

A retrospective, pharmacoepidemiologic study in 2 outpatient HIV clinics in the Southeast United States was conducted among adults receiving EVG/COBI/TDF/FTC. We evaluated incidence and treatment-related adverse events, including change in serum creatinine (SCr).

RESULTS

Patients were primarily treatment experienced (n = 173, 60%), African American (n = 210, 73%), and males (n = 187, 65%). One hundred ninety-five (68%) patients had any increase in SCr, and 65 (23%) had an increase of ≥0.3 mg/dL. Mean SCr change from baseline to peak was 0.2 mg/dL. Being treatment experienced (odds ratio [OR] = 2.21, 95% confidence interval [CI]: 1.12-4.38) was associated with SCr ≥0.3 mg/dL, while body mass index ≥30 kg/m(2) (OR = 0.41, 95% CI: 0.18-0.93) was protective. Twenty (7%) patients discontinued therapy, 3 due to acute kidney injury.

CONCLUSION

Our results demonstrate limited adverse events and low discontinuation rates associated with EVG/COBI/TDF/FTC.

Condom Use in the Context of Main and Casual Partner Concurrency: Individual and Relationship Predictors in a Sample of Heterosexual African American Men

Researchers have identified engagement in sexual concurrency, particularly when condom use is inconsistent, as a risk factor for HIV and other sexually transmitted infections. This risk is particularly salient in rural communities in which dense interconnection of sexual networks can promote the spread of sexually transmitted infections. The authors investigated individual and relationship factors that predict inconsistent condom use in the context of main and casual partner sexual concurrency among 176 rural African American men. The individual psychosocial factors investigated included impulsivity and anger/hostility. Relationship variables included fidelity expectations, criticism from partners, and relationship control in both main and casual relationships. No individual risk factors were associated with main partner inconsistent condom use; however, impulsivity and anger/hostility positively predicted inconsistent condom use with a casual partner. Relationship control in the main partnership predicted inconsistent condom use with the main partner. Criticism from the main partner positively predicted inconsistent condom use with a casual partner. Finally, expectations for a casual partner's fidelity positively predicted inconsistent condom use with that partner. These findings underscore the importance of considering the influence of one sexual partnership on behavior in another and of taking this complexity into account in the development of preventive interventions.

HIV Risk Behaviors, Perceptions, and Testing and Preexposure Prophylaxis (PrEP) Awareness/Use in Grindr-Using Men Who Have Sex With Men in Atlanta, Georgia

Geosocial-networking smartphone applications such as Grindr can help men who have sex with men (MSM) meet sexual partners. Given the high incidence of HIV in the Deep South, the purpose of our study was to assess HIV risk and preexposure prophylaxis (PrEP) awareness and use in a sample of HIV-uninfected, Grindr-using MSM residing in Atlanta, Georgia (n = 84). Most (n = 71; 84.6%) reported being somewhat or very concerned about becoming HIV infected. Most (n = 74; 88.1%) had been tested for HIV in their lifetimes. About three fourths (n = 65; 77.4%) were aware of PrEP, but only 11.9% currently used the medication. HIV continues to disproportionately impact MSM and represents a significant source of concern. As the number of new infections continues to rise, it is important to decrease risks associated with acquisition and transmission of HIV by increasing rates of HIV testing and the use of biobehavioral interventions such as PrEP.

Feasibility and Acceptability of Global Positioning System (GPS) Methods to Study the Spatial Contexts of Substance Use and Sexual Risk Behaviors among Young Men Who Have Sex with Men in New York City: A P18 Cohort Sub-Study

Background

No global positioning system (GPS) technology study has been conducted among a sample of young gay, bisexual, and other men who have sex with men (YMSM). As such, the purpose of this study was to evaluate the feasibility and acceptability of using GPS methods to understand the spatial context of substance use and sexual risk behaviors among a sample of YMSM in New York City, a high-risk population.

Methods

Data came from a subsample of the ongoing P18 Cohort Study (n = 75). GPS feasibility and acceptability among participants was measured with: 1) a pre- and post-survey and 2) adherence to the GPS protocol which included returning the GPS device, self-report of charging and carrying the GPS device as well as objective data analyzed from the GPS devices. Analyses of the feasibility surveys were treated as repeated measures as each participant had a pre- and post-feasibility survey. When comparing the similar GPS survey items asked at baseline and at follow-up, we present percentages and associated p-values based on chi-square statistics.

Results

Participants reported high ratings of pre-GPS acceptability, ease of use, and low levels of wear-related concerns in addition to few concerns related to safety, loss, or appearance, which were maintained after baseline GPS feasibility data collection. The GPS return rate was 100%. Most participants charged and carried the GPS device on most days. Of the total of 75 participants with GPS data, 75 (100%) have at least one hour of GPS data for one day and 63 (84%) had at least one hour on all 7 days.

Conclusions

Results from this pilot study demonstrate that utilizing GPS methods among YMSM is feasible and acceptable. GPS devices may be used in spatial epidemiology research in YMSM populations to understand place-based determinants of health such as substance use and sexual risk behaviors.

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

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

A county-level analysis of persons living with HIV in the southern United States

This study uses county-level surveillance data to systematically analyze geographic variation and clustering of persons living with diagnosed HIV (PLWH) in the southern United States in 2011. Clusters corresponding to large metropolitan areas - including Miami, Atlanta, and Baltimore - had HIV prevalence rates higher (p < .001) than the regional rate. Regression analysis within the counties included in these clusters determined that race was a significant indicator for PLWH. These results provide a general picture of the distribution of PLWH in the southern United States at the county level and provide insights for identifying local geographic areas with a high number of PLWH, as well as subpopulations that may have an increased risk of infection.

STI/HIV Sexual Risk Behavior and Prevalent STI Among Incarcerated African American Men in Committed Partnerships: The Significance of Poverty, Mood Disorders, and Substance Use

African Americans face disproportionate sexually transmitted infection including HIV (STI/HIV), with those passing through a correctional facility at heightened risk. There is a need to identify modifiable STI/HIV risk factors among incarcerated African Americans. Project DISRUPT is a cohort study of incarcerated African American men recruited from September 2011 through January 2014 from prisons in North Carolina who were in committed partnerships with women at prison entry (N = 207). During the baseline (in-prison) study visit, participants responded to a risk behavior survey and provided a urine specimen, which was tested for STIs. Substantial proportions reported multiple partnerships (42 %), concurrent partnerships (33 %), and buying sex (11 %) in the 6 months before incarceration, and 9 % tested positive for an STI at baseline (chlamydia: 5.3 %, gonorrhea: 0.5 %, trichomoniasis: 4.9 %). Poverty and depression appeared to be strongly associated with sexual risk behaviors. Substance use was linked to prevalent STI, with binge drinking the strongest independent risk factor (adjusted odds ratio: 3.79, 95 % CI 1.19-12.04). There is a continued need for improved prison-based STI testing, treatment, and prevention education as well as mental health and substance use diagnosis.

Impact of a community popular opinion leader intervention among African American adults in a southeastern United States community

We examine the impact of an adapted community popular opinion leader (C-POL) intervention targeting alcohol-using social networks in Southeast Louisiana. A pre-post C-POL was conducted between October 2009 and April 2013, targeting alcohol users. A total of 65 popular opinion leaders were recruited, trained, and deployed into their social networks to diffuse intervention messages. Anonymous community surveys conducted within the venues among 99 male and female participants at baseline and 197 at 6 months to 1 year later revealed significant behavioral and knowledge changes. Average sexual risk score based on 7 sexual risk items declined from 15.3 to 11.9 (p<0.001); the number of vaginal and anal sex partners in the last year decreased from 11.3 to 7.7 and 3.9 to 2.3, respectively (p<0.01); and HIV knowledge score (based on % correct) increased from 67.2 to 76.8% (p<0.001). Findings add to the evidence base surrounding peer interventions.

Geosocial-Networking App Usage Patterns of Gay, Bisexual, and Other Men Who Have Sex With Men: Survey Among Users of Grindr, A Mobile Dating App

Background

Geosocial-networking apps like Grindr have been used increasingly among men who have sex with men (MSM) to meet anonymous partners. These mobile dating apps employ global positioning system technology to facilitate connections with other users based on their current location. These new technologies have generated quicker and easier modes for men who have sex with men to meet potential partners based on attraction and physical proximity.

Objective

The aim of this study is to describe geosocial-networking app use and recent sexual behaviors of MSM in the Atlanta metropolitan statistical area.

Methods

Our sample was recruited from Grindr, the most commonly used of these mobile apps among MSM, using broadcast advertising. Advertisements were displayed over the course of a 72-hour period and participants were directed to a Web-based survey.

Results

In total, 604 men clicked through the advertisement, and 92 users completed the survey. One-third (38.0%) of the men reported using these mobile apps to meet new sexual partners, and one-fifth (18.5%) used them to “kill time” when bored. Men reporting currently being in a relationship were less likely to report using these mobile apps to meet other MSM to date or to find a boyfriend or romantic partner, but more likely to report using these mobile apps to meet other MSM to have sex, X²₂₄=12.1, P=.016. Respondents had current accounts on 3.11 mobile apps (SD 1.84) on average, with Grindr being the most common (100%), followed by Scruff (52.5%), and Jack’d (45.7%). Most men were most active in the late night (40.2%), and on weekdays (64.1%). Each day, on average, men reported opening these mobile apps 8.38 times (SD 8.10) and spent 1.31 hours (SD 1.15) on these mobile apps. The age respondents began using these mobile apps was associated with the age at their first instance of insertive anal sex (r₈₀=.527, P<.001) and receptive anal sex (r₇₆=.527, P<.001).

Conclusions

These findings suggest that MSM use multiple mobile apps and spend significant time on them. For these reasons, HIV prevention interventions could be delivered on these mobile apps.

A faith-based community partnership to address HIV/AIDS in the southern United States: implementation, challenges, and lessons learned

Though race and region are not by themselves risk factors for HIV infection, regional and racial disparities exist in the burden of HIV/AIDS in the US. Specifically, African Americans in the southern US appear to bear the brunt of this burden due to a complex set of upstream factors like structural and cultural influences that do not facilitate HIV/AIDS awareness, HIV testing, or sexual risk-reduction techniques while perpetuating HIV/AIDS-related stigma. Strategies proposed to mitigate the burden among this population have included establishing partnerships and collaborations with non-traditional entities like African American churches and other faith-based organizations. Though efforts to partner with the African American church are not necessarily novel, most of these efforts do not present a model that focuses on building the capacity of the African American church to address these upstream factors and sustain these interventions. This article will describe Project Fostering AIDS Initiatives That Heal (F.A.I.T.H), a faith-based model for successfully developing, implementing, and sustaining locally developed HIV/AIDS prevention interventions in African American churches in South Carolina. This was achieved by engaging the faith community and the provision of technical assistance, grant funding and training for project personnel. Elements of success, challenges, and lessons learned during this process will also be discussed.

Impact of a routine, opt-out HIV testing program on HIV testing and case detection in North Carolina sexually transmitted disease clinics

BACKGROUND

The impact of routine, opt-out HIV testing programs in clinical settings is inconclusive. The objective of this study was to estimate the impact of an expanded, routine HIV testing program in North Carolina sexually transmitted disease (STD) clinics on HIV testing and case detection.

METHODS

Adults aged 18 to 64 years who received an HIV test in a North Carolina STD clinic from July 1, 2005, through June 30, 2011, were included in this analysis, dichotomized at the date of implementation on November 1, 2007. HIV testing and case detection counts and rates were analyzed using interrupted time series analysis and Poisson and multilevel logistic regression.

RESULTS

Preintervention, 426 new HIV-infected cases were identified from 128,029 tests (0.33%), whereas 816 new HIV-infected cases were found from 274,745 tests postintervention (0.30%). Preintervention, HIV testing increased by 55 tests per month (95% confidence interval [CI], 41-72), but only 34 tests per month (95% CI, 26-42) postintervention. Increases in HIV testing rates were most pronounced in women and non-Hispanic whites. A slight preintervention decline in case detection was mitigated by the intervention (mean difference, 0.01; 95% CI, -0.02 to 0.05). Increases in case detection rates were observed among women and non-Hispanic blacks.

CONCLUSIONS

The impact of a routine HIV screening in North Carolina STD clinics was marginal, with the greatest benefit among persons not traditionally targeted for HIV testing. The use of a preintervention comparison period identified important temporal trends that otherwise would have been ignored.