Factors Associated with Recent HIV Testing among Heterosexuals at High Risk for HIV Infection in New York City

Trends and associated factors in HIV testing among heterosexual men and women in Melbourne, Australia, 2011-2020

BACKGROUND

Despite the increase in the proportion of HIV notifications attributed to heterosexuals in Australia, little is known about their HIV testing behaviours. We investigated the trends and factors associated with HIV testing behaviours among heterosexuals.

METHODS

We analysed the trend and proportion of heterosexuals attending the centre for the first time between 2011 and 2020, who had ever tested and tested for HIV in the past 12months and the median number of months since their last HIV test. We identified factors associated with HIV testing behaviours using univariable and multivariable logistic regressions.

RESULTS

Of the 78652 heterosexuals included, 53.1% were men and 46.9% were women. Overall, the proportion of heterosexuals who had ever tested for HIV was 40.8%, with a declining testing trend from 40.2% in 2011 to 36.5% in 2020 (P trend <0.001). Overall, the proportion of heterosexuals tested for HIV in the past 12months was 15.7%, with no significant change from 15.3% in 2011 to 14.7% in 2020 (P trend =0.489). The median number of months since the last HIV test decreased from 18.0 (IQR 6.9-37.3) in 2011 to 15.0 (IQR 6.4-32.5) in 2020 (P trend <0.001). Individuals who had condomless sex with casual partners (aOR 0.92, 95% CI 0.88-0.96) and who were diagnosed with a sexually transmitted infection (aOR 0.88, 95% CI 0.84-0.93) were less likely to have ever tested for HIV.

CONCLUSIONS

HIV testing was low among heterosexuals, and individuals who engaged in condomless sex and had another sexually transmitted infection were less likely to be tested. To reduce HIV transmission, strategies to improve HIV testing among heterosexuals are needed.

Hepatitis C Co-infection in People Living With HIV—Epidemiologic Differences Between Men Who Have Sex With Men MSM and Non-MSM

People living with human immunodeficiency virus (PLHIV) constitute a unique group at higher risk of hepatitis C virus (HCV) co-infection. In light of the diverse profiles of PLHIV, we differentiated between men who have sex with men (MSM) and non-MSM in the characterization of the epidemiologic features of HIV/HCV co-infection. Clinical data of HCV co-infection patients from the HIV specialist clinic in Hong Kong were retrospectively collected in conjunction with their HIV subtypes and HCV genotypes. Logistic regression models were used to identify factors associated with HIV/HCV co-infection in MSM. Survival analysis was performed to compare the time lag between HIV and HCV diagnoses between two groups. Latent class analysis was conducted to describe the features of different classes of co-infections. Four classes of HIV/HCV co-infections were identified: local MSM acquiring HCV after HIV diagnosis, local MSM with HIV/HCV co-diagnoses, local non-MSM, and non-local non-MSM. Accounting for over half of the co-infections, MSM were more likely to be younger, local residents, and associated with HCV genotype 3, compared to genotypes 1 and 6 in non-MSM. Overall, MSM had higher odds of achieving HIV viral suppression and co-diagnosing with a sexually transmitted infection at HCV diagnosis, and having a longer time lag between HIV and HCV diagnoses. Drug injection accounted for a majority of non-MSM HCV infection. There were distinctive epidemiologic differences between MSM and non-MSM co-infected with HIV and HCV, the characteristics of which could inform intervention strategies for achieving HCV micro-elimination.

HIV Testing Correlates: U.S. and Foreign Born High-Risk Black Heterosexual Men

In the U.S., Black men are disproportionately affected by HIV, with some of the highest HIV incidence rates and lowest rates of HIV testing. We examined correlates of HIV testing and knowledge among participants of the Barbershop Talk with Brothers (BTWB) project, an HIV prevention program targeting high-risk sexual behaviors among Black heterosexual men in Brooklyn, New York. Specifically, we examined differences between U.S. vs. foreign-born status and HIV testing rates, HIV knowledge, and socio-demographic factors. Of the 855 men included, the mean age was 33 years and 35.0% were foreign-born. Lifetime HIV testing was reported at 84%, with greater proportion of U.S. vs foreign-born men reporting lifetime (88.6% vs. 75.0%) and recent testing (68.6% vs. 51.0%), p < 0.001. Among foreign-born men, recent HIV testing was associated with lower stigma and greater HIV transmission knowledge than those un-tested. The authors recommend tailored approaches to increasing HIV testing in Black communities, based on nativity and social factors.

Epidemiological factors associated with the absence of previous HIV testing among HIV-positive persons in Singapore, 2012-2017

OBJECTIVE

To assess the temporal trend and identify risk factors associated with the absence of previous HIV testing prior to their diagnosis among HIV-positive persons in Singapore.

STUDY DESIGN

Cross-sectional.

SETTING AND PARTICIPANTS

We analysed data of HIV-positive persons infected via sexual transmission, who were notified to the National HIV Registry in 2012-2017.

OUTCOMES

Epidemiological factors associated with the absence of HIV testing prior to diagnosis were determined separately for two groups of HIV-positive persons: early and late stages of HIV infection at diagnosis.

RESULTS

2188 HIV-positive persons with information on HIV testing history and CD4 cell count were included in the study. The median age at HIV diagnosis was 40 years (IQR 30-51). Nearly half (45.1%) had never been tested for HIV prior to their diagnosis. The most common reason cited for no previous HIV testing was 'not necessary to test' (73.7%). The proportion diagnosed at late-stage HIV infection was significantly higher among HIV-positive persons who had never been tested for HIV (63.9%) compared with those who had undergone previous HIV tests (29.0%). Common risk factors associated with no previous HIV testing in multivariable logistic regression analysis stratified by stage of HIV infection were: older age at HIV diagnosis, lower educational level, detection via medical care and HIV infection via heterosexual transmission. In the stratified analysis for persons diagnosed at early-stage of HIV infection, in addition to the four risk factors, women and those of Malay ethnicity were also less likely to have previous HIV testing prior to their diagnosis.

CONCLUSION

Targeted prevention efforts and strategies are needed to raise the level of awareness of HIV/AIDS and to encourage early and regular screening among the at-risk groups by making HIV testing more accessible.

Reimaging an AIDS free generation: Examining youth and young adults' personal agency and its association with HIV testing

Exploring youth and young adult's agency may be a way to increase HIV testing and help end the HIV epidemic. We used data from the National Survey of Teens and Young Adults (15-24) on HIV/AIDS (N = 1,437). Data were collected from September 21-October 1, 2012. The sample included 748 girls and 689 boys; and the mean age is 20 years (SD: 3.02). Youth and young adults completed a 40-question survey on attitudes and knowledge about HIV. Using a multivariable logistic regression analysis, study findings suggest that focusing on protective health behaviors like the role youth can play in ending the epidemic and hearing about an AIDS-free generation were both associated with an increase in HIV testing. Our study finds that enhancing the role and influence of personal agency can inform HIV prevention and intervention programs that are specific to youth.

Barriers and Facilitators for HIV Testing Practice Among Ethiopian Women Aged 15-24 years: Analysis of the 2016 Ethiopian Demographic and Health Survey

BACKGROUND

In developing countries, youth women are most at risk of HIV infection. Center for Disease Control recommends that people who participate in high-risk behaviors get tested for HIV at least annually. In 2016, the Ethiopian Ministry of Health set goals to identify 90% of the people living with HIV by 2030. But undiagnosed HIV infections are still high in the country. To alleviate the problem, it is vital to identify the factors that hinder HIV testing practice. Therefore, this study aimed to identify the facilitators and barriers of HIV testing practice among Ethiopian youth women.

METHODS

The analysis was done on 6401 women aged 15-24 years using data from the 2016 Ethiopia Demographic Health Survey (EDHS). The main outcome variable was self-reported HIV testing practice. Multivariable logistic regression was used to identify the facilitators and barriers of HIV testing practice.

RESULTS

In this study, 37.7% [95% CI: (33.6, 39.1)] of youth women were tested for HIV in their life. Being married (AOR=4.7; 95% CI: (3.67, 6.01)), divorced [AOR=6.2; 95% CI: (3.98-9.54)], having primary level of education [AOR=2.4;95% CI: (1.79-3.13)], and secondary level of education [AOR=4.0; 95% CI: (2.87-5.63)], being rich [AOR=2.3;95% CI: (1.39-3.91)] and being in the highest wealth index catagory [AOR=2.6;95% CI: (1.30-5.16)] increase the odds of HIV testing. However, lack of media acccess [AOR = 0.7; 95 CI %: (0.54-0.87)], lack of comprehensive HIV knowledge [AOR = 0.68; 65% CI: (0.53-0.86)] and having discriminatory attitude towards PLHIV[AOR=0.79;95% CI: (0.64-0.97)] decrease the odds of HIV testing.

CONCLUSION

The practice of HIV testing among youth populations was low as compared to national recommendations. Lack of media access, lack of comprehensive knowledge about HIV, and having discriminatory attitudes were the barriers to HIV testing practice. Marriage, secondary or higher education attainment, and high wealth index category were the facilitators for HIV testing. Improving HIV-related knowledge, improving media access, and minimizing discriminatory attitudes are strongly recommended to promote HIV testing practice.

Learning About HIV: Predicting the Sources of Knowledge That Matter Regarding HIV Testing Among a National Sample of Black and Latinx Adolescents and Young Adults in the United States

This study investigated the knowledge and beliefs of a nationally representative sample of youth and young adults about HIV based on the microsystems and mesosystems of the ecodevelopmental theory. We used a stratified sample (n = 538) of Black and Latinx adolescents and young adults in the United States, 15-24 years of age, at risk of becoming infected with HIV to assess the source of their HIV knowledge and its association with HIV testing to identify modifiable factors that can support the development of interventions addressing HIV-related risks. Using a logistic regression analysis, findings suggest that identifying protective health behaviors, such as providing adolescents and young adults with sexual health information that is accurate, trustworthy, and safe, could be one way to reduce their risk of HIV infection. Expanding knowledge about the important role and influence of sources of HIV-related knowledge on testing behaviors can inform HIV prevention and intervention programs specific to this population.

Social Media Use and HIV Screening Uptake Among Deaf Adults in the United States: Cross-Sectional Survey Study

Background

About 46% of US adults obtain recommended HIV screening at least once during their lifetime. There is little knowledge of screening rates among deaf and hard-of-hearing adults who primarily use American Sign Language (ASL), or of social media as a potentially efficacious route for HIV prevention outreach, despite lower HIV/AIDS-specific health literacy and potentially higher HIV seropositivity rates than hearing peers.

Objective

We investigated both the likelihood of HIV screening uptake among deaf adults in the past year and over one year ago, and the relationship between social media use and HIV screening uptake among deaf adult ASL users.

Methods

The Health Information National Trends Survey in ASL was administered to 1340 deaf US adults between 2015-2018. Modified Poisson with robust standard errors was used to assess the relationship between social media usage as a predictor and HIV screening as an outcome (screened more than one year ago, screened within the past year, and never been screened), after adjusting for sociodemographics and sexually transmitted disease (STD) covariates.

Results

The estimated lifetime prevalence of HIV screening uptake among our sample was 54% (719/1340), with 32% (429/1340) in the past year. Being of younger age, male gender, black, lesbian, gay, bisexual, or queer, or having some college education or a prior STD were associated with HIV screening uptake. Adjusting for correlates, social media use was significantly associated with HIV screening in the past year, compared to either lifetime or never.

Conclusions

Screening falls well short of universal screening targets, with gaps among heterosexual, female, Caucasian, or older deaf adults. HIV screening outreach may not be effective because of technological or linguistic inaccessibility, rendering ASL users an underrecognized minority group. However, social media is still a powerful tool, particularly among younger deaf adults at risk for HIV.

HIV Prevention for Black Heterosexual Men: The Barbershop Talk with Brothers Cluster Randomized Trial

Objectives. To identify the impact of a strengths-focused HIV prevention program among high-risk heterosexual Black men. Methods. Barbershops in Brooklyn, New York, neighborhoods with high rates of heterosexually transmitted HIV were randomized to the intervention or an attention control program. Men were recruited from barbershops between 2012 and 2016 and participated in a single small group, peer-led session focused on HIV risk reduction skills and motivation, community health empowerment, and identification of personal strengths and communication skills. The outcome was defined as 1 or more acts of condomless anal or vaginal sex in the preceding 90 days at a 6-month interview. Results. Fifty-three barbershops (24 intervention, 29 control) and 860 men (436 intervention, 424 control) were recruited; follow-up was completed by 657 participants (352 intervention, 305 control). Intervention exposure was associated with a greater likelihood of no condomless sex (64.4%) than control group participation (54.1%; adjusted odds ratio = 1.61; 95% confidence interval = 1.05, 2.47). Conclusions. Program exposure resulted in reduced sexual risk behaviors, and the program was acceptable for administration in partnership with barbershops. Public Health Implications. Dissemination of similar programs could improve public health in communities with high rates of HIV attributable to heterosexual transmission.

"Like I Have No Choice": A Qualitative Exploration of HIV Diagnosis and Medical Care Experiences While Incarcerated and Their Effects

It is estimated that one in six Black and Latino adult persons living with HIV (PLWH) spend time in correctional institutions each year. Yet after release, PLWH of color evidence poor HIV health outcomes across the HIV care continuum. This study, guided by an ecological approach and Critical Race Theory, sought to understand the lived experiences of socioeconomically disadvantaged PLWH of color who received an HIV diagnosis and/or medical care while incarcerated, and the ways in which those experiences influenced engagement in medical care after release. Drawn from a larger study in Brooklyn, NY, in 2013-2016, a subset of 28 participants who received in-depth qualitative interviews were purposively sampled for a secondary analysis of participants who received an HIV diagnosis and/or medical care while incarcerated. Using an Interpretive Phenomenological Analysis, we found participant's experiences were shaped by longstanding mistrust of the medical establishment. While incarcerated, lack of autonomy, substandard medical care, and poor social support exacerbated medical mistrust and avoidance of HIV medical care long after release. Engagement in HIV medical care and treatment were also impacted by a dynamic interplay of factors including substance use, prolonged periods of denial, poverty, and repeated bouts of incarceration. Given that experiences of HIV diagnosis and medical care while incarcerated have long-ranging, adverse effects, we argue that a better understanding of the ways in which PLWH of color experience HIV diagnosis and medical care while incarcerated may serve to inform intervention efforts within correctional institutions to improve HIV health outcomes.

Missed Opportunities for HIV Prevention: Individuals Who HIV Seroconverted Despite Accessing Healthcare

Individuals with a negative HIV test before a positive one (seroconverters) may represent missed opportunities for prevention. To inform HIV prevention strategies, we aimed to characterize patients who seroconverted despite accessing care. We identified patients at a large, urban healthcare system who seroconverted between 2009 and 2014. Demographics, visits, and HIV-related variables were extracted from the medical records. We performed descriptive statistics, assessed for trends, and tested for associations according to sex. 220 seroconverters were identified: 45% were female, 87% were non-Hispanic Black or Hispanic, and median number of negative tests prior to diagnosis was 2 (IQR 1-3). Overall, 49% reported heterosexual contact as their risk factor and the proportion with heterosexual risk increased over time (24% in 2009 vs. 56% in 2014, p = 0.03). Compared to men, women were older at the time of diagnosis (35 vs. 26 years old, p < 0.01), had more visits between their latest negative and positive HIV test (4 vs. 2, p < 0.01), and were more likely to be diagnosed in the context of screening (64% vs. 56%, p = 0.05). We identified a population that became HIV-infected despite multiple healthcare encounters and undergoing HIV testing multiple times. Patients were mostly heterosexual and almost half were female. To avoid missed opportunities for those already accessing care, HIV prevention efforts should include strategies tailored to individuals with less frequently recognized risk profiles.

Latent Classes of Sexual Risk Among Black Men Who Have Sex with Men and Women

Black men who have sex with men and women (BMSMW) are at high risk for HIV and other sexually transmitted infections (STIs). Despite knowing that HIV/STI risk varies by sexual positioning practices, limited data have characterized the risk profiles of BSMW. This study utilized latent class analysis (LCA) to explore BMSMW's sexual risk profiles regarding condomless sexual positioning practices. Participants were BMSMW in intervention studies in Los Angeles, Chicago, and Philadelphia. LCA was used to characterize their sexual risk profiles. Age, study location, HIV status, social support, and internalized homophobia were used as covariates in a multinomial regression model predicting the likelihood of class membership. Among the 546 participants, three latent classes of risk were identified: Seropositive Serosorters, Seronegative/unknown Serosorters, and Main Partners Only. All groups had the greatest probabilities of condomless sex with main partners. Seropositive Serosorters had the highest probabilities of condomless sex with HIV-positive partners. Seronegative/unknown Serosorters had the highest probabilities of condomless sex with HIV-negative or unknown status partners. HIV-positive BMSMW had 87% lower odds of being classified as Seronegative/unknown Serosorters than Seropositive Serosorters than HIV-negative/unknown status BMSMW (AOR = 0.13, 95% CI 0.06, 0.28). HIV-positive BMSMW had 71% lower odds of being classified as Main Partners Only than Seropositive Serosorters than HIV-negative/unknown status BMSMW (AOR = 0.29, 95% CI 0.16, 0.51). Findings highlight opportunities for clinicians to promote condom use and risk reduction among BMSMW with differing sexual risk profiles. Increased understanding of sexual positioning practices among BMSMW might help address HIV/STIs among this group.

Latent class analysis of a syndemic of risk factors on HIV testing among black men

Syndemic methodology has been employed in several studies of HIV-related outcomes affecting Black men who have sex with men (BMSM) and rarely in Black heterosexual men. In contrast to the most common method for assessing syndemics, the use of a syndemic component index, latent class analysis can identify unique combinations of risk factors that may form a syndemic. Analyzing a primarily heterosexual sample of 1,786 Black men from the 2015 Behavioral Risk Factor Surveillance System (BRFSS), we used a 4 latent class model based on depression diagnosis, poverty, and healthcare access to predict ever having been HIV tested. Class 1 was characterized by low proportions of all the risk factors. Class 2 had relatively high healthcare barriers, being the most likely to not have a personal doctor (.8175) and the most likely to have no routine checkup in the past year (.6327) but had relatively low depression diagnosis and poverty. Class 3 had relatively high poverty (.8853), but generally low barriers to healthcare access. Class 4 was characterized by high proportions of all the risk factors. Using log-binomial regression models, there was a significantly lower prevalence of ever having been HIV tested among class 3 (PR = 0.69, 95% CI 0.49, 0.98) and class 4 (PR = 0.49, 95% CI 0.28, 0.84) compared to class 1. When adjusting for education, age, and marital status, the associations were attenuated but still significant for class 3 (aPR = 0.71, 95% CI 0.52, 0.96) and class 4 (aPR = 0.60, 95% CI 0.46, 0.78). Latent class analysis may better serve syndemic research aims in understanding HIV-related outcomes among high-risk populations. Future research using this method to evaluate HIV testing outcomes among BMSM is recommended.

HIV Prevalence, Knowledge, Attitudes, and Practices Among Polydrug Users in Brazil: A Biological Survey Using Respondent Driven Sampling

Brazil has a concentrated HIV epidemic among key populations. In 2009, the Ministry of Health conducted a survey in 10 Brazilian cities aiming to estimate HIV prevalence, knowledge, and associated risk behaviors of polysubstance users (PSU). Using Respondent Driven Sampling (RDS), 3449 PSU were recruited, answered an Audio-Computer Self Assisted Interview (ACASI) and were tested for HIV and syphilis. Analyses were weighted by individual's social network size generated on RDSAT. Pooled HIV prevalence was 5.8% but varied across cities. Most PSU were male, non-white, without income, unemployed, with low levels of education. Overall, 12.0% used injectable drugs, 48.7% had sex with occasional partners and 46.4% engaged in commercial sex. A majority received free condoms (71.4%) but 76.7% exhibited inconsistent condom use. Findings can support policies aiming to improve health care and preventive interventions tailored to this population that remains at high risk of acquiring and transmitting HIV/STI in multiple scenarios.

Doing battle with "the monster:" how high-risk heterosexuals experience and successfully manage HIV stigma as a barrier to HIV testing

Background

Annual HIV testing is recommended for populations at-risk for HIV in the United States, including heterosexuals geographically connected to urban high-risk areas (HRA) with elevated rates of HIV prevalence and poverty, who are primarily African American/Black or Hispanic. Yet this subpopulation of “individuals residing in HRA” (IR-HRA) evidence low rates of regular HIV testing. HIV stigma is a recognized primary barrier to testing, in part due to its interaction with other stigmatized social identities. Guided by social-cognitive and intersectionality theories, this qualitative descriptive study explored stigma as a barrier to HIV testing and identified ways IR-HRA manage stigma.

Methods

In 2012-2014, we conducted in-depth qualitative interviews with 31 adult IR-HRA (74% male, 84% African American/Black) with unknown or negative HIV status, purposively sampled from a larger study for maximum variation on HIV testing experiences. Interviews were audio-recorded and professionally transcribed verbatim. Data were analyzed using a systematic content analysis approach that was both theory-driven and inductive.

Results

Stigma was a primary barrier to HIV testing among IR-HRA. In the context of an under-resourced community, HIV stigma was experienced as emerging from, and being perpetuated by, health care organizations and educational institutions, as well as community members. Participants noted it was “better not to know” one’s HIV status, to avoid experiencing HIV-related stigma, which could interact with other stigmatized social identities and threaten vital social relationships, life chances, and resources. Yet most had tested for HIV previously. Factors facilitating testing included health education to boost knowledge of effective treatments for HIV; understanding HIV does not necessitate ending social relationships; and tapping into altruism.

Conclusions

In the context of economic and social inequality, HIV stigma operates on multiple, intersecting layers. IR-HRA struggle with an aversion to HIV testing, because adopting another stigmatized status is dangerous. They also find ways to manage stigma to engage in testing, even if not at recommended levels. Findings highlight strategies to reduce HIV stigma at the levels of communities, institutions, and individuals to improve rates of annual HIV testing necessary to eliminate HIV transmission and reduce HIV-related racial and ethnic health disparities among IR-HRA.

Determinants of HIV testing and receipt of test results among adolescent girls in Nigeria: the role of assets and decision-making

Purpose Many adolescent girls in Nigeria do not test for HIV despite being at high risk. While the influence of psychosocial factors on HIV testing has been examined, there is less evidence regarding the impact of assets and control of assets on HIV testing. This study investigated the protective effects of specific adolescent girls' assets on decision-making regarding HIV testing. Methods Cross-sectional data from the 2013 Nigeria Demographic and Health Survey was analyzed. The main outcome variables were self-reports of having been tested for HIV and knowledge of a place that offers HIV testing. Binary logistic regression was used with employment, education, wealth index, home ownership, land ownership and decision making as potential predictors. Demographic characteristics were controlled in the analysis. Results Age [odds ratio (OR = 1.49)], employment (OR = 3.38), education (OR = 3.16), wealth index (OR = 1.33) and decision making (OR = 3.16) were positively associated with HIV testing. Age (OR = 1.20), employment (OR = 1.33), education (OR = 1.38), wealth (OR = 1.64), land ownership (OR = 1.42), and decision making (OR = 1.26) were positively associated with knowledge of an HIV testing location. Conclusion Our findings suggest that assets play an important role with HIV testing decisions for adolescent girls. Further research to elucidate the specific asset-based needs of adolescent girls will be needed to enhance decisions surrounding uptake of HIV testing and receipt of test results in Nigeria.

Cost-Effectiveness of Peer- Versus Venue-Based Approaches for Detecting Undiagnosed HIV Among Heterosexuals in High-Risk New York City Neighborhoods

INTRODUCTION

We used a computer simulation of HIV progression and transmission to evaluate the cost-effectiveness of a scale-up of 3 strategies to seek out and test individuals with undiagnosed HIV in New York City (NYC).

SETTING

Hypothetical NYC population.

METHODS

We incorporated the observed effects and costs of the 3 "seek and test" strategies in a computer simulation of HIV in NYC, comparing a scenario in which the strategies were scaled up with a 1-year implementation or a long-term implementation with a counterfactual scenario with no scale-up. The simulation combined a deterministic compartmental model of HIV transmission with a stochastic microsimulation of HIV progression, calibrated to NYC epidemiological data from 2003 to 2015. The 3 approaches were respondent-driven sampling (RDS) with anonymous HIV testing ("RDS-A"), RDS with a 2-session confidential HIV testing approach ("RDS-C"), and venue-based sampling ("VBS").

RESULTS

RDS-A was the most cost-effective strategy tested. When implemented for only 1 year and then stopped thereafter, using a societal perspective, the cost per quality-adjusted life-year (QALY) gained versus no intervention was $812/QALY, $18,110/QALY, and $20,362/QALY for RDS-A, RDS-C, and VBS, respectively. When interventions were implemented long term, the cost per QALY gained versus no intervention was cost-saving, $31,773/QALY, and $35,148/QALY for RDS-A, RDS-C, and VBS, respectively. When compared with RDS-A, the incremental cost-effectiveness ratios for both VBS and RDS-C were dominated.

CONCLUSIONS

The expansion of the RDS-A strategy would substantially reduce HIV-related deaths and new HIV infections in NYC, and would be either cost-saving or have favorable cost-effectiveness.

Syndemic Risk Classes and Substance Use Problems among Adults in High-Risk Urban Areas: A Latent Class Analysis

Substance use problems tend to co-occur with risk factors that are especially prevalent in urban communities with high rates of poverty. The present study draws on Syndemics Theory to understand profiles of risk and resilience and their associations with substance use problems in a population at risk for adverse outcomes. African-American/Black and Hispanic heterosexual adults (N = 2,853) were recruited by respondent-driven sampling from an urban area with elevated poverty rates, and completed a structured assessment battery covering sociodemographics, syndemic factors (that is, multiple, co-occurring risk factors), and substance use. More than one-third of participants (36%) met criteria for either an alcohol or a drug problem in the past year. Latent class analysis identified profiles of risk and resilience, separately for women and men, which were associated with the probability of a substance use problem. Almost a third of women (27%) and 38% of men had lower risk profiles-patterns of resilience not apparent in other types of analyses. Profiles with more risk and fewer resilience factors were associated with an increased probability of substance use problems, but profiles with fewer risk and more resilience factors had rates of substance use problems that were very similar to the general adult population. Relative to the lowest risk profile, profiles with the most risk and fewest resilience factors were associated with increased odds of a substance use problem for both women [adjusted odds ratio (aOR) = 8.50; 95% CI: 3.85-18.74] and men (aOR = 11.68; 95% CI: 6.91-19.74). Addressing syndemic factors in substance use treatment and prevention may yield improved outcomes.

Pre-exposure prophylaxis for HIV prevention in women: current perspectives

There are ~900,000 new HIV infections among women every year, representing nearly half of all new HIV infections globally. In the US, nearly one-fifth of all new HIV infections occur among women, and women from racial and ethnic minority communities experience disproportionately high rates of new HIV infections. Thus, there is a need to develop and implement effective HIV prevention strategies for women in the US and internationally, with a specific need to advance strategies in minority communities. Previous studies have demonstrated that oral HIV pre-exposure prophylaxis (PrEP), the use of antiretroviral medications by HIV-uninfected persons to prevent HIV acquisition, can reduce HIV incidence among women who are adherent to PrEP. However, to date, awareness and uptake of PrEP among women have been very limited, suggesting a need for innovative strategies to increase the knowledge of and access to PrEP among women in diverse settings. This narrative review summarizes the efficacy and safety data of PrEP in women, discusses considerations related to medication adherence for women who use PrEP, and highlights behavioral, social, and structural barriers to maximize the effectiveness of PrEP in women. It also reviews novel modalities for PrEP in women which are being developed and tested, including topical formulations and long-acting injectable agents that may offer advantages as compared to oral PrEP and proposes a community-oriented, social networking framework to increase awareness of PrEP among women. If women are provided with access to PrEP and support to overcome social and structural barriers to adhere to PrEP, this prevention strategy holds great promise to impact the HIV epidemic among women in the US and globally.

It's a Process: Reactions to HIV Diagnosis and Engagement in HIV Care among High-Risk Heterosexuals

After HIV diagnosis, heterosexuals in high-poverty urban areas evidence delays in linkage to care and antiretroviral therapy initiation compared to other groups. Yet barriers to/facilitators of HIV care among these high-risk heterosexuals are understudied. Under the theory of triadic influence, putative barriers to HIV care engagement include individual/attitudinal-level (e.g., fear, medical distrust), social-level (e.g., stigma), and structural-level influences (e.g., poor access). Participants were African-American/Black and Hispanic adults found newly diagnosed with HIV (N = 25) as part of a community-based HIV testing study with heterosexuals in a high-poverty, high-HIV-incidence urban area. A sequential explanatory mixed-methods design was used. We described linkage to HIV care and clinical outcomes [CD4 counts, viral load (VL) levels] over 1 year, and then addressed qualitative research questions about the experience of receiving a new HIV diagnosis, its effects on timely engagement in HIV care, and other barriers and facilitators. Participants were assessed five times, receiving a structured interview battery, laboratory tests, data extraction from the medical record, a post-test counseling session, and in-person/phone contacts to foster linkage to care. Participants were randomly selected for qualitative interviews (N = 15/25) that were recorded and transcribed, then analyzed using systematic content analysis. Participants were 50 years old, on average (SD = 7.2 years), mostly male (80%), primarily African-American/Black (88%), and low socioeconomic status. At the first follow-up, rates of engagement in care were high (78%), but viral suppression was modest (39%). Rates improved by the final follow-up (96% engaged, 62% virally suppressed). Two-thirds (69%) were adequately retained in care over 1 year. Qualitative results revealed multi-faceted responses to receiving an HIV diagnosis. Problems accepting and internalizing one’s HIV status were common. Reaching acceptance of one’s HIV-infected status was frequently a protracted and circuitous process, but acceptance is vital for engagement in HIV care. Fear of stigma and loss of important relationships were potent barriers to acceptance. Thus, partially as a result of difficulties accepting HIV status, delays in achieving an undetectable VL are common in this population, with serious potential negative consequences for individual and public health. Interventions to foster acceptance of HIV status are needed.