HIV/AIDS: a minority health issue

White and Gray Matter Changes are Associated With Neurocognitive Decline in HIV Infection

OBJECTIVE

To investigate the relationship between neurocognitive deficits and structural changes on brain magnetic resonance imaging in people living with HIV (PLWH) with good virological control on combination antiretroviral therapy, compared with socioeconomically matched control participants recruited from the same communities.

METHODS

Brain magnetic resonance imaging scans, and clinical and neuropsychological data were obtained from virologically controlled PLWH (viral load of <50 c/mL and at least 1 year of combination antiretroviral therapy) and socioeconomically matched control participants. Magnetic resonance imaging was carried out on 3 T scanner with 8-channel head coils and segmented using Classification using Derivative-based Features. Multiple regression analysis was performed to examine the association between brain volume and various clinical and neuropsychiatric parameters adjusting for age, race, and sex. To evaluate longitudinal changes in brain volumes, a random coefficient model was used to evaluate the changes over time (age) adjusting for sex and race.

RESULTS

The cross-sectional study included 164 PLWH and 51 controls, and the longitudinal study included 68 PLWH and 20 controls with 2 or more visits (mean 2.2 years, range 0.8-5.1 years). Gray matter (GM) atrophy rate was significantly higher in PLWH compared with control participants, and importantly, the GM and global atrophy was associated with the various neuropsychological domain scores. Higher volume of white matter hyperintensities were associated with increased atherosclerotic cardiovascular disease risk score, and decreased executive functioning and memory domain scores in PLWH.

INTERPRETATION

These findings suggest ongoing neurological damage even in virologically controlled participants, with significant implications for clinical management of PLWH. ANN NEUROL 2024;95:941-950.

Evaluation of a health system's implementation of a monkeypox care model under the RE-AIM framework

Objective

Emerging infectious diseases challenge healthcare systems to implement new models of care. We aim to evaluate the rapid implementation of a new care model for monkeypox in our health system.

Design

This is a retrospective case series evaluation under the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework of implementation of a testing and care model for monkeypox in a large, integrated health system.

Methods

Atrium Health implemented education of providers, testing protocols, and management of potential monkeypox cases using electronic health record (EHR) data capabilities, telehealth, and collaboration between multiple disciplines. The first 4 weeks of care model implementation were evaluated under the RE-AIM framework.

Results

One hundred fifty-three patients were tested for monkeypox by 117 unique providers at urgent care, emergency departments, and infectious disease clinics in our healthcare system between 18 July 2022 and 14 August 2022. Fifty-eight monkeypox cases were identified, compared with 198 cases in the state during the time period, a disproportionate number compared with the health system service area, and 52 patients were assessed for need for tecovirimat treatment. The number of tests performed and providers sending tests increased during the study period.

Conclusion

Implementation of a dedicated care model leveraging EHR data support, telehealth, and cross-disciplinary collaboration led to more effective identification and management of emerging infectious diseases and is important for public health.

Plain Language Summary

Impact of care model implementation on monkeypox New infectious diseases challenge health systems to implement new care practices. Our health system responded to this challenge by implementing a care model for education, testing, and clinical care of monkeypox patients. We analyzed results from implementing the model. We were able to identify a disproportionate number of monkeypox cases compared with the rest of our state by using our model to educate medical providers, encourage testing, and ensure patients had access to best disease care. Implementation of care models for testing and management of new diseases will improve patient care and public health.

Characterization of Risk Factors Among Individuals with a History of Incarceration Presenting to a Sexually Transmitted Infections Clinic: Implications for HIV and STI Prevention and Care

More than 2 million people are incarcerated in the United States with many millions more processed through correctional facilities annually. Communities impacted by incarceration are also disproportionately impacted by the HIV and sexually transmitted infection (STI) epidemics. However, relatively little is known about the behaviors that place individuals with a history of incarceration at risk for HIV/STI acquisition. We utilized clinical data from patients presenting to an STI clinic located in Providence, Rhode Island. A latent class analysis was conducted on reported HIV acquisition risk behavior and STI testing results on a total of 1129 encounters where a history of incarceration was reported. A total of three classes were identified. Class 1 (N = 187, 11%), more frequently reported 10+ sexual partners (45%), an STI diagnosis (48%) and sex while intoxicated (86%) in the past year as well as identifying as a man who has sex with other men (60%). Class 2 (N = 57, 5%) was more likely to report giving (53%) and receiving (44%) money/drugs for sex in the past year as well as a history of injecting drugs (61%) and using methamphetamine (60%). Class 3 (N = 885, 78%) most frequently reported 0-2 sexual partners (48%), identified as Black (27%), Hispanic/Latino (69%) and a man who only has sex with women (80%). Class 1 had significantly higher odds ratio (1.8, 95% confidence interval = 1.3-2.5) of testing HIV/STI positive. The results provide important insights into risk subgroups for those with a history of incarceration at risk of HIV/STI acquisition.

Informing the future of PrEP navigation: Findings from a five-site cluster evaluation

The PrEP (pre-exposure prophylaxis) Implementation, Data to Care and Evaluation (PrIDE) demonstration project funded 12 health departments (HD) (2016-2019) to scale up PrEP among sexual minorities at risk for HIV. Each health department (HD) conducted an evaluation of at least one local strategy, and, to maximize crossvalidation, an adapted cluster evaluation approach was employed. As a result, five HDs with similar evaluation questions regarding PrEP navigation were identified. Overall, PrEP navigation fit in well with HD clinics and community-based organizations. A hybrid model of patient, peer, and systems navigation linking clients to PrEP and social services was commonly used. Although there were no differences by setting regarding linking clients to PrEP providers, one HD demonstrated that having all PrEP services in the same location contributed the most to PrEP uptake. Navigator skill for case management and rapport building facilitated navigation, whereas staff turnover and lack of client health insurance were challenges. While one HD in a non-Medicaid expansion state was affected by health insurance issues the most, another HD demonstrated that providing payment assistance increased client PrEP use. The findings pinpoint PrEP navigation hybrid modality and having health insurance as promising strategies to increase PrEP uptake among priority groups.

Barriers and Facilitators to Promoting Resilience to HIV/AIDS: A Qualitative Study on the Lived Experiences of HIV-Positive, Racial and Ethnic Minority, Middle-Aged and Older Men Who Have Sex with Men from Ontario, Canada

Evidence-based research has highlighted the need for exploring factors that support the mental health of men who have sex with men living with HIV/AIDS (MSMLWH), and environmental influences that promote their resilience to HIV/AIDS. This exploratory study utilized a community-based participatory research approach to investigate barriers and facilitators to promoting resilience to HIV/AIDS, specifically among racial and ethnic minority, middle-aged and older MSMLWH, a population that continues to be significantly impacted by HIV/AIDS today. This collaborative, qualitative study recruited participants who identified as racial or ethnic minority MSMLWH, were aged 40 or older, and resided in Ontario, Canada. Participants (n = 24) discussed in their interviews barriers and facilitators to promoting resilience to HIV/AIDS, which they recognized from their lived experiences. Utilizing thematic analysis, themes related to barriers and facilitators to promoting resilience to HIV/AIDS were identified. Themes related to identified barriers included: (1) language proficiency, (2) racism, (3) pernicious norms in North American gay culture, and (4) HIV stigma. Themes related to identified facilitators included: (1) compartmentalization, (2) perseverance, and (3) community-based health and social services. This article discusses the implications of the study’s findings, particularly on how they may influence the development of future services for racial and ethnic minority, middle-aged and older MSMLWH.

Biometric Registration to an HIV Research Study may Deter Participation

Biometric registration may improve services associated with HIV research. A cross-sectional, observational survey was used to evaluate biometric fingerprint scanning for identification (ID) verification in the setting of an HIV prevention study. Survey outcomes were dichotomized (discouraged or not discouraged) by biometric scanning and statistical analyses were used to determine if participation decreased by greater than 10% overall and after stratifying by demographic variables and risk behaviors. 206 participants were recruited from a community-based HIV and sexual health research screening program. Participants completed a quantitative survey to assess their perceptions of biometric scanning for ID verification. The majority of participants (n = 160; 77.7%) indicated no deterrence from testing due to biometric scanning, yet a significant number (n = 45; 23.3%, P < .001) reported at least partial deterrence. Research using biometric scanning for ID verification may significantly limit access to HIV prevention services and may risk reducing meaningful participation among marginalized populations.

Disparities in Electronically Monitored Antiretroviral Adherence and Differential Adherence Predictors in Latinx and Non-Latinx White Persons Living with HIV

Antiretroviral therapy (ART) adherence is vital for optimal HIV treatment. However, there is limited ART adherence research on the US Latinx population, who are at increased risk for HIV infection and worse HIV health outcomes. This study examined electronically measured ART adherence (Medication Event Monitoring System) and its association with demographic, clinical, neurocognitive, and sociocultural variables in Latinx and non-Latinx white (NLW) persons living with HIV [PLWH (N = 128)]. Latinx participants demonstrated worse adherence than NLW participants (p = 0.04). Linear regressions revealed different predictors of adherence. Among Latinx participants, recent cocaine use, stress, and, unexpectedly, higher US acculturation predicted worse adherence (ps < 0.05). Among NLW participants, recent cocaine use predicted worse adherence (p < 0.05). Intergroup comparisons within the Latinx group were not conducted due to subsample size. Thus, ethnicity, sociocultural variables, and cocaine use are important considerations for ART adherence, and poor ART adherence may be one pathway explaining worse outcomes in Latinx PLWH. Culturally tailored adherence interventions incorporating substance use treatment, acculturation, and stress management are warranted to improve health outcomes.

Addressing Racial Biases in Medicine: A Review of the Literature, Critique, and Recommendations

This article reviews the literature on racism in medicine in the United States and reflects on the persistent barriers to diminishing racial biases in the U.S. health care system. Espoused strategies for decreasing racial disparities and reducing racial biases among physicians are critiqued, and recommendations are offered. Those recommendations include increasing the number of minority students in medical school, using Xavier University in New Orleans, Louisiana, as the model for medical school preparation; revamping the teaching of cultural competence; ensuring the quality of non-clinical staff; and reducing the risk of burnout among medical providers.

Expanding community engagement in HIV clinical trials: a pilot study using crowdsourcing

OBJECTIVE

To assess the potential for crowdsourcing to complement and extend community advisory board (CAB) feedback on HIV clinical trials. Crowdsourcing involves community members attempting to solve a problem and then sharing solutions.

METHODS

CAB and crowdsourced approaches were implemented in the context of a phase 1 HIV antibody trial to collect feedback on informed consent, participation experiences, and fairness. CAB engagement was conducted through group discussions with members of an HIV CAB. Crowdsourcing involved open events intended to engage the local community, including interactive video modules, animated vignettes, and a creative idea contest. Open coding and analysis of emergent themes were conducted to compare CAB and crowdsourced feedback.

RESULTS

The crowdsourcing activities engaged 61 people across three events; nine people engaged in CAB feedback. Compared with CAB participants, crowdsourcing participants had lower levels of education and income, and higher levels of disability and unemployment. Overlap in CAB and crowdsourced feedback included recommendations for enhancing communication and additional support for trial participants. Crowdsourcing provided more detailed feedback on the impact of positive experiences and socio-economic factors on trial participation. CAB feedback included greater emphasis on institutional regulations and tailoring trial procedures. Crowdsourced feedback emphasized alternative methods for learning about trials and concerns with potential risks of trial participation.

CONCLUSION

Conducting crowdsourcing in addition to CAB engagement can yield a broader range of stakeholder feedback to inform the design and conduct of HIV clinical trials. VIDEO ABSTRACT:.

Sex, Drugs, and Impulse Regulation: A Perspective on Reducing Transmission Risk Behavior and Improving Mental Health Among MSM Living With HIV

Unprotected sexual contact continues to be a main cause of HIV transmission and poses certain key populations at increased risk for HIV infection. One of the populations at high risk are men who have sex with men. A subset of MSM engages in chemsex, whereby consumption of illicit drugs is used to facilitate or enhance sexual activity. This practice can have several negative consequences, such as sexually transmitted infections (including HIV) and mental health problems (including compulsive sexual behavior, addiction, and mood disorders). In this article, we provide our perspective on the current situation that medical professionals dealing with MSM living with HIV often feel empty-handed in how to deal with these behavioral and psychological issues. Close collaboration between somatic and mental health professionals is key to address treatment needs of people living with HIV, regarding the negative consequences of chemsex and their overall quality of life. In this article, we discuss possibilities for psychological treatment, including behavioral skills training to improve impulse control and reduce compulsive sexual behaviors among MSM living with HIV who persistently engage in sexual transmission risk behavior, based on our experience with implementing such an intervention. Important barriers and facilitators for further implementation of behavioral interventions will be discussed. Reduction of HIV transmission risk behavior is needed to achieve the WHO aim to end HIV as a public health threat by 2030. We propose that close collaboration between somatic and mental health professionals and implementation of behavioral interventions for risk populations are key to achieve this goal.

Comparison of Clinical Outcomes of Persons Living With HIV by Enrollment Status in Washington, DC: Evaluation of a Large Longitudinal HIV Cohort Study

Background

HIV cohort studies have been used to assess health outcomes and inform the care and treatment of people living with HIV disease. However, there may be similarities and differences between cohort participants and the general population from which they are drawn.

Objective

The objective of this analysis was to compare people living with HIV who have and have not been enrolled in the DC Cohort study and assess whether participants are a representative citywide sample of people living with HIV in the District of Columbia (DC).

Methods

Data from the DC Health (DCDOH) HIV surveillance system and the DC Cohort study were matched to identify people living with HIV who were DC residents and had consented for the study by the end of 2016. Analysis was performed to identify differences between DC Cohort and noncohort participants by demographics and comorbid conditions. HIV disease stage, receipt of care, and viral suppression were evaluated. Adjusted logistic regression assessed correlates of health outcomes between the two groups.

Results

There were 12,964 known people living with HIV in DC at the end of 2016, of which 40.1% were DC Cohort participants. Compared with nonparticipants, participants were less likely to be male (68.0% vs 74.9%, P<.001) but more likely to be black (82.3% vs 69.5%, P<.001) and have a heterosexual contact HIV transmission risk (30.3% vs 25.9%, P<.001). DC Cohort participants were also more likely to have ever been diagnosed with stage 3 HIV disease (59.6% vs 47.0%, P<.001), have a CD4 <200 cells/µL in 2017 (6.2% vs 4.6%, P<.001), be retained in any HIV care in 2017 (72.9% vs 59.4%, P<.001), and be virally suppressed in 2017. After adjusting for demographics, DC Cohort participants were significantly more likely to have received care in 2017 (adjusted odds ratio 1.8, 95% CI 1.70-2.00) and to have ever been virally suppressed (adjusted odds ratio 1.3, 95% CI 1.20-1.40).

Conclusions

These data have important implications when assessing the representativeness of patients enrolled in clinic-based cohorts compared with the DC-area general HIV population. As participants continue to enroll in the DC Cohort study, ongoing assessment of representativeness will be required.

Cultural Neuropsychology Considerations in the Diagnosis of HIV-Associated Neurocognitive Disorders

Human Immunodeficiency Virus Type-I (HIV) is a health disparities issue that affects culturally and linguistically diverse (CALD) and underrepresented minority populations to a greater degree than non-Hispanic white populations. Neurologically speaking, CALD populations experience worse HIV-related health outcomes, which are exacerbated by inadequate neurocognitive measures, poor normative samples, and the complex interplay of sociocultural factors that may affect test interpretation. Although cross-cultural neuropsychologists are working diligently to correct this gap in the literature, currently, studies examining neurocognitive outcomes among CALD populations are sparse. The most well-studied CALD groups are of African American/Black and Latinx adults in the US, and the chapter therefore focuses on these studies. There is more limited work among other populations in the US, such as Asians, Native Hawaiians, Pacific Islanders, and American Indians/Alaskan Natives, and even fewer studies for many CALD populations outside of the US. For example, HIV neuropsychology data is rare or nonexistent in the First Peoples of Australia and Indigenous People of Canada. It is often not adequately reported in Europe for the migrant populations within those countries or other world regions that have historically large multicultural populations (e.g., South America, Caribbean countries, Asia, and Africa). Therefore, this chapter reviews HIV-related health disparities faced by CALD populations with focus on North American research where it has been specifically studied, with particular attention given to disparities in HIV-Associated Neurocognitive Disorders (HAND). International data was also included for research with focus on First Peoples of Australia and Indigenous People of Canada. The chapter also examines other sociocultural and health factors, including global and regional (e.g., rural versus urban) considerations, migration, and gender. Further, guidelines for incorporating sociocultural consideration into assessment and interpretation of neurocognitive data and HAND diagnosis when working with HIV-positive CALD populations that would be relevant internationally are provided.

Correlation between knowledge on transmission and prevention of HIV/STI and proficiency in condom use among male migrants from Africa and Middle East evaluated by a Condom Use Skills score using a wooden penile model

BACKGROUND

Migrants in Italy are prevalently young adults, with a higher risk of sexual transmitted infections (STI) and HIV infection. Promoting consistent as well as correct use of condoms could reduce failure rate due to their improper use. The aim of our study was to evaluate Condom Use Skills among a migrant population recently landed in Italy, hosted in a government center for asylum seekers.

METHODS

The study sample was composed of 80 male migrants. Sanitary trained interviewers submitted a questionnaire to participants to investigate age, provenience, marital status, educational level and knowledge about transmission and prevention of HIV/STI. Then, we assessed participants' level of condom use skill with the Condom Use Skills (CUS) measure by using a wooden penile model. The interviewer filled in a checklist and assigned 1 point for correct demonstration of each behavior that may prevent condom failure during sex.

RESULTS

Participants' median age was 26 years and the sample was composed of 54 migrants from sub-Saharan Africa and 26 from Middle East. Most of them were married, with a lower middle level of education, up to 8 or 5 years. Half of the sample achieved the highest score in the questionnaire and our CUS showed a large number of people with middle high score classes. The Spearman's rho was 0.30, therefore answers to the questionnaire and CUS score appeared correlated (p < 0.05). In the multivariate model, to have a higher CUS score resulted to be associated to be older than 26 years (p < 0.05), with a higher level of education (p = 0.001), and a higher score in the questionnaire (p < 0.05). There were no significant differences in the level of CUS between single or married men and between African and Middle Asian migrants of the sample.

CONCLUSIONS

Our study shows that educational level influences the quality of knowledge and awareness about STI/AIDS and contribute to correct condom use. Since the half of participants had a low educational level and linguistic problems, the risk of missing campaigns messages or misunderstanding informative materials increases. Direct observation of condom-application on penile model may offer realistic assessment of application skills in these individuals.

A qualitative study examining health literacy and chronic illness self-management in Hispanic and non-Hispanic older adults

PURPOSE

Chronic illness and low levels of health literacy affect health outcomes for many individuals, particularly older adults and racial/ethnic minorities. This study sought to understand the knowledge, strengths, and areas of need regarding self-management of chronic illness in order to lay the groundwork for content development of an intervention to increase health literacy and maximize patient engagement in chronic disease self-care.

PATIENTS AND METHODS

In-depth, qualitative interviews were conducted in Spanish and English with 25 older adults with various chronic illnesses. Topics included knowledge and understanding of chronic conditions, medications, and disease self-management skills. Qualitative data were coded by searching text and conducting cross-case analysis. An inductive analysis was then employed to allow for the patterns and themes to emerge.

RESULTS

Emerged themes included 1) social support, 2) coping strategies, 3) spirituality, 4) chronic disease health literacy, 5) anger, and 6) depression. While participants had a general overall knowledge of chronic illness, they had deficits in knowledge regarding their own illnesses and medications.

CONCLUSION

Chronic illness self-management is a complex and dynamic behavioral process. This study identified themes that leverage patient motivation to engage in self-care in a personalized manner. This information will guide the development of an intervention to promote health literacy and optimal disease self-management.

Eliminating Racial/Ethnic Disparities in AIDS Clinical Trials in the United States: A Qualitative Exploration of an Efficacious Social/Behavioral Intervention

BACKGROUND

African American/Black and Hispanic persons living with HIV (AABH-PLWH) are under-represented in AIDS clinical trials (ACTs) in the United States. Barriers AABH-PLWH experience to ACTs are multi-faceted, including distrust of medical research, low levels of knowledge, unsupportive social norms, lack of referral, and challenges navigating ACT systems. In past research we found a multi-component peer-driven intervention was efficacious in boosting rates of screening for/enrollment into ACTs. The present qualitative study seeks to understand AABH-PLWH's perspectives on which specific intervention features or components had utility. Interventions features explored included structural elements (e.g., small group sessions, individual sessions on the ACT research unit); approaches (e.g., Motivational Interviewing); and specific components (e.g., small-group discussion of historical and cultural factors reducing participation among AABH-PLWH).

METHODS

A total of 37 AABH-PLWH (mean age 50.6 years, SD=7.5 years; 48.6% female; 62.2% African American/Black, 27.0% Hispanic) were purposively selected from a larger study for in-depth interviews, which were audio-recorded, transcribed verbatim, and analyzed using systematic content analysis.

RESULTS

We found the intervention improved knowledge and positive attitudes toward ACTs, and triggered social-level facilitators such as altruism and more positive social norms. Discussions of cultural/historical barriers to ACTs associated with race/ethnicity had utility. Holding a session on the ACT research unit reduced fear and increased motivation. Results highlighted the value of Motivational Interviewing, and several components were perceived as less useful (e.g., involving social network members in ACT decisions).

CONCLUSION

Findings can inform future intervention designs to address racial/ethnic disparities in ACTs and have implications for trials of other conditions where racial/ethnic disparities persist.

Regional differences, socio-demographics, and hidden population of HIV/AIDS in India

This study examines the prevalence of HIV/AIDS in different regions of India, their socio-demographic indicators, and the presence of hidden population infected with HIV. Secondary data analyzed were obtained from national and international agencies. Considering the prevalence of HIV/AIDS in India, the low-prevalence regions in the last decade have shown a steady increase in recent years. Productive age, urbanization, male gender, lower level of education, minority religions, low income, and mobile occupations are associated with HIV pandemic. The hidden population vulnerable to HIV/AIDS are: street children, homeless population, and refugees. These observations can help map the high-risk behavior groups and formulate targeted strategies to curb the HIV menace.

Creating Systems Change to Support Goals for HIV Continuum of Care: The Role of Community Coalitions to Reduce Structural Barriers for Adolescents and Young Adults

Routine population-wide HIV screening, early linkage and long-term retention in healthcare for HIV-infected individuals are key nodes of the HIV continuum of care and are essential elements of the National HIV/AIDS Strategy. Despite this, up to 80% of youth are unaware of their HIV infection status and only 29% are linked to HIV healthcare; less than half are engaged in long-term HIV healthcare, and far fewer maintain viral suppression. To fill this gap and to address the national call to action to establish a seamless system for immediate linkage to continuous and coordinated quality healthcare after diagnosis, this paper describes the processes and mechanisms by which the SMILE Program worked within the infrastructure of the ATN-affiliated Connect to Protect^® (C2P) community coalitions to address structural barriers that hindered youth in their communities from being tested for HIV infection or linked and engaged in healthcare after an HIV positive diagnosis.

Ethnic differences in the links between benefit finding and psychological adjustment in people living with HIV

Experiencing growth after the diagnosis of a life threatening illness is commonly reported among people living with HIV (PLWH). The links between benefit finding and better adjustment in PLWH have been identified, but it is less clear whether these links vary by ethnicity. Minority stress theory suggests that individuals from minority populations may have unique stress experiences, which can have negative health implications but may also provide opportunity for growth. We hypothesized that the association between benefit finding and psychological adjustment would be stronger for Black (n = 80) than White (n = 87) PLWH. Contrary to predictions, the relationship between benefit finding and better adjustment was significant for White but not Black PLWH. Post-hoc analyses suggested that sexual orientation played role in this relationship. The relationship between benefit finding and psychological adjustment may be complex for Black PLWH, or they may achieve adjustment using other resources.

HIV and smoking: associated risks and prevention strategies

High rates of smoking among persons living with HIV (PLWH) may reduce the effectiveness of HIV treatment and contribute to significant morbidity and mortality. Factors associated with smoking in PLWH include mental health comorbidity, alcohol and drug use, health-related quality of life, smoking among social networks and supports, and lack of access to care. PLWH smokers are at a higher risk of numerous HIV-associated infections and non-HIV related morbidity, including a decreased response to antiretroviral treatment, impaired immune functioning, reduced cognitive functioning, decreased lung functioning, and cardiovascular disease. Seventeen smoking cessation interventions were identified, of which seven were randomized controlled trials. The most effective studies combined behavioral and pharmacotherapy treatments that incorporated comprehensive assessments, multiple sessions, and cognitive-behavioral and motivational strategies. Smoking cessation interventions that are tailored to the unique needs of diverse samples and incorporate strategies to reduce the risk of relapse are essential to advancing health outcomes in PLWH.

Using perceptual mapping methods to understand gender differences in perceived barriers and benefits of clinical research participation in urban minority HIV+ patients

Minority participation in HIV clinical trials research is critical to understanding the impact of medications or behavioral interventions, but little is known about gender differences in perceptions of participation. We surveyed 50 minority HIV+ patients from an urban clinic to assess perceived risks/benefits of clinical trial research participation and used innovative marketing methods to analyze results. Perceptual mapping and vector message-modeling, a method that creates 3-D models representing how groups conceptualize elements, were used to assess how male and female participants could be motivated to participate. Results showed men farther away from participation and more concerned with HIV disclosure and experimentation than women. Men expressed distrust of the medical system, doubted HIV's origin, and knew less about research implementation. Women were closer to participation in both behavior and medical trials and perceived medication issues as more significant, including fear of losing medication stability, medications not working, being in the placebo group, and experiencing side effects. Vector modeling shows that messages would need to focus on different aspects of clinical research for men and women and that interventions aimed at minority HIV+ patients to encourage clinical trial participation would need to be targeted to their unique perceptions. Understanding gender perceptions of HIV clinical research has significant implications for targeting messages to increase minority participation.

Socioeconomic Status and Neuropsychological Functioning: Associations in an Ethnically Diverse HIV+ Cohort

OBJECTIVE

There is limited research examining the relationship between socioeconomic status (SES) and neuropsychological functioning, particularly in racial/ethnic minority and HIV+ populations. However, there are complex associations between poverty, education, HIV disease, race/ethnicity, and health outcomes in the US.

METHOD

We explored these relationships among an ethnically diverse sample of 134 HIV+ adults using a standardized SES measure (i.e., the Hollingshead scale), a comprehensive NP test battery, and a functional evaluation (i.e., Patient's Assessment of Own Functioning Inventory and Modified Instrumental Activities of Daily Living Scale).

RESULTS

Bivariate analyses showed that adult SES was significantly, positively correlated with neuropsychological performance on specific tests within the domains of verbal fluency, attention/concentration, learning, memory, processing speed, and executive functioning, and childhood SES was significantly linked to measures of verbal fluency, processing speed, and executive functioning. In a series of linear regressions, controlling for SES significantly attenuated group differences in NP test scores between racial/ethnic minority individuals and non-Hispanic White individuals. Finally, SES scores significantly differed across HIV-Associated Neurocognitive Disorder (HAND) diagnoses. In a binary logistic regression, SES was the only independent predictor of HAND diagnosis.

CONCLUSIONS

HIV+ individuals with lower SES may be more vulnerable to HIV-associated neuropsychological sequelae due to prominent health disparities, although the degree to which this is influenced by factors such as test bias remains unclear. Overall, our results suggest that SES is significantly linked to neuropsychological test performance in HIV+ individuals, and is an important factor to consider in clinical practice.

Recruiting Black Men Who Have Sex with Men and Women (BMSMW) in an Urban Setting for HIV Prevention Research

OBJECTIVES

Concerns related to stigma and confidentiality limit HIV-related study recruitment and retention of Black men who have sex with men and women (MSMW). This paper examines lessons learned from recruitment strategies utilized in enrolling 437 participants between 2007 and 2011 for a randomized controlled trial to test a culturally specific HIV risk-reduction intervention for Black MSMW.

METHODS

Interested respondents completed a brief screener and participants completed surveys at baseline and at post, 3 and 6 months follow-up. Recruitment patterns were assessed by examining the source of study information reported when respondents were asked how they learned about the study. Chi-square tests were then conducted to examine differences in the distribution of participants by self-reported HIV status, age group and socio-economic status (SES) for each type of study information source.

RESULTS

Regardless of HIV or SES, study respondents were more likely to have received information about the study through a service agency than from other sources. Participants ages 30-49 and 50+ years were most likely to have learned about the study from an agency (34.9% and 27.0%, respectively) or another participant/friend (20.1%, 23.1%) and least likely to have found out from bus (0.8%, 0.0%) or radio (1.3%, 0.0%) advertisements; whereas younger participants were more likely to have heard about the study through a friend/participant (23.4%) than an agency (15.4%). Although, 14.1% of participants' ages less than 30 years reported the Internet as their source of study information, this compared to just 2.7% and 4.8% for participants in the 30-49 and 50-plus age groups.

CONCLUSIONS

While agencies and referrals from personal networks appear to be the most significant recruitment source for potential HIV research participants, there is evidence that Internet based tools may enhance recruitment, particularly among younger Black MSMW.

Results from a secondary data analysis regarding satisfaction with health care among African American women living with HIV/AIDS

OBJECTIVE

To analyze satisfaction with health care among African American women living with HIV/AIDS.

DESIGN

Secondary analysis of baseline data of African American women who participated in Protect and Respect, a sexual risk reduction program for women living with HIV/AIDS SETTING: HIV Care Clinic in an urban city in the northeast United States.

PARTICIPANTS

One hundred fifty-seven (157) African American women living with HIV/AIDS.

METHODS

Regression analyses were used to examine the relationships between demographic variables, self-reported health characteristics, communication with health care providers, and satisfaction with health care provider.

RESULTS

A majority of women reported satisfaction with medical services (88%, n = 140). Communication with health care providers, detectable viral load, education, income, self-reported health status, and sexual orientation were significantly bivariately associated with satisfaction with healthcare (all ps < .05). In the multivariate models, no variables significantly predicted satisfaction with healthcare.

CONCLUSION

Because satisfaction with health care can influence the quality of care received, health outcomes, and adherence to provider recommendations among patients living with HIV/AIDS, health care providers' ability to elicit satisfaction from their patients is just as important as the services they provide. This project is one of the first studies to find high rates of satisfaction with health care among African American women living with HIV/AIDS. Further examination of satisfaction with health care among African American women living HIV/AIDS may help in narrowing health care disparities and negative treatment outcomes.

African American race and HIV virological suppression: beyond disparities in clinic attendance

Racial disparities in clinic attendance may contribute to racial disparities in plasma human immunodeficiency virus type 1 : HIV-1) RNA levels among HIV-positive patients in care. Data from 946 African American and 535 Caucasian patients receiving HIV care at the University of North Carolina Center for AIDS Research HIV clinic between January 1, 1999, and August 1, 2012, were used to estimate the association between African American race and HIV virological suppression (i.e., undetectable HIV-1 RNA) when racial disparities in clinic attendance were lessened. Clinic attendance was measured as the proportion of scheduled clinic appointments attended (i.e., visit adherence) or the proportion of six 4-month intervals with at least 1 attended scheduled clinic appointment (i.e., visit constancy). In analyses accounting for patient characteristics, the risk ratio for achieving suppression when comparing African Americans with Caucasians was 0.91 (95% confidence interval: 0.85, 0.98). Lessening disparities in adherence or constancy lowered disparities in virological suppression by up to 44.4% and 11.1%, respectively. Interventions that lessen disparities in adherence may be more effective in eliminating disparities in suppression than interventions that lessen disparities in constancy. Given that gaps in care were limited to be no more than 2 years for both attendance measures, the impact of lessening disparities in adherence may be overstated.

Minorities remain underrepresented in HIV/AIDS research despite access to clinical trials

BACKGROUND AND OBJECTIVE

The reasons for minority underrepresentation in HIV/AIDS clinical trials remain unclear. We aimed to evaluate the knowledge, experience, and factors that influence minority participation in HIV/AIDS studies in the United States.

METHODS

An anonymous, bilingual, self-administered survey on study participation was given to HIV-infected adults attending AIDS Clinical Trials Group-affiliated clinics in the United States and Puerto Rico. Chi-square tests were used to evaluate differences by race, first language, and level of education. Logistic regression was used to estimate odds ratio (OR) and 95% confidence interval (CI) for factors associated with being talked to about participation in a study.

RESULTS

We analyzed 2,175 complete surveys (221 in Spanish). Among respondents, 31% were White, 40% were Black/African American (AA), and 21% were Hispanic. The overall rate of previous participation in any HIV/AIDS study was 48%. Hispanics were less likely to know about studies compared to Whites and AAs (67% vs 74% and 76%, respectively; P < .001). Compared to Whites, AAs and Hispanics were less likely to have been talked to about participating in a study (76% vs 67% and 67%, respectively; P < .001). The OR for being talked to about participating in a study was 0.65 (95% CI, 0.52-0.81) for AAs and 0.65 (95% CI, 0.49-0.85) for Hispanics, compared to Whites. AAs and Hispanics were more likely to state that studies were not friendly to their race (17% and 10% vs 4%; P < .001).

CONCLUSIONS

Minorities continue to face barriers for HIV/AIDS trial participation, even when clinical research is available. Enrollment strategies should better target minorities to improve recruitment in HIV/AIDS research.

The role of at-risk alcohol/drug use and treatment in appointment attendance and virologic suppression among HIV(+) African Americans

The causes of poor clinic attendance and incomplete virologic suppression among HIV(+) African Americans (AAs) are not well understood. We estimated the effect of at-risk alcohol/drug use and associated treatment on attending scheduled appointments and virologic suppression among 576 HIV(+) AA patients in the University of Alabama at Birmingham (UAB) 1917 Clinic Cohort who contributed 591 interviews to the analysis. At interview, 78% of patients were new to HIV care at UAB, 38% engaged in at-risk alcohol/drug use or received associated treatment in the prior year, while the median (quartiles) age and CD4 count were 36 (28; 46) years and 321 (142; 530) cells/μl, respectively. In the 2 years after an interview, half of the patients had attended at least 82% of appointments while half had achieved virologic suppression for at least 71% of RNA assessments. Compared to patients who did not use or receive treatment, the adjusted risk ratio (aRR) for attending appointments for patients who did use but did not receive treatment was 0.97 (95% confidence limits: 0.92, 1.03). The corresponding aRR for virologic suppression was 0.94 (0.86, 1.03). Compared to patients who did not receive treatment but did use, the aRR for attending appointments for patients who did receive treatment and did use was 0.86 (0.78, 0.95). The corresponding aRR for virologic suppression was 1.07 (0.92, 1.24). Use was negatively associated with attendance and virologic suppression among patients not in treatment. Among users, treatment was negatively associated with attendance yet positively associated with virologic suppression. However, aRR estimates were imprecise.

Brief sexual histories and routine HIV/STD testing by medical providers

Clinicians who routinely take patient sexual histories have the opportunity to assess patient risk for sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV), and make appropriate recommendations for routine HIV/STD screenings. However, less than 40% of providers conduct sexual histories with patients, and many do not receive formal sexual history training in school. After partnering with a national professional organization of physicians, we trained 26 (US and US territory-based) practicing physicians (58% female; median age=48 years) regarding sexual history taking using both in-person and webinar methods. Trainings occurred during either a 6-h onsite or 2-h webinar session. We evaluated their post-training experiences integrating sexual histories during routine medical visits. We assessed use of sexual histories and routine HIV/STD screenings. All participating physicians reported improved sexual history taking and increases in documented sexual histories and routine HIV/STD screenings. Four themes emerged from the qualitative evaluations: (1) the need for more sexual history training; (2) the importance of providing a gender-neutral sexual history tool; (3) the existence of barriers to routine sexual histories/testing; and (4) unintended benefits for providers who were conducting routine sexual histories. These findings were used to develop a brief, gender-neutral sexual history tool for clinical use. This pilot evaluation demonstrates that providers were willing to utilize a sexual history tool in clinical practice in support of HIV/STD prevention efforts.

Retention in care within 1 year of initial HIV care visit in a multisite US cohort: who's in and who's out?

Biannual attendance at medical visits is an established measure of retention in HIV care. We examined factors associated with attending at least 2 clinic visits at least 90 days apart among HIV-infected, antiretroviral therapy (ART)-naive HIV Outpatient Study participants entering care during 2000 to 2011. Of 1441 patients, 85% were retained in care during the first year of observation. Starting ART during the year was the strongest correlate of retention (adjusted odds ratio [aOR] 6.4, 95% confidence interval [CI] 4.4-9.4). After adjusting for starting ART, publicly insured patients (aOR 0.6, 95% CI 0.4-1.0), and patients with baseline CD4 counts <200 cells/mm(3) (aOR 0.5, 95% CI 0.3-0.9) or missing CD4 counts (aOR 0.3, 95% CI 0.2-0.6) were less likely to be retained in care. Although most patients had recommended biannual care visits, some ART-naive individuals may require additional interventions to remain in care. Promptly initiating ART may facilitate engagement in care.

Race/ethnicity and HAART initiation in a military HIV infected cohort

Background

Prior studies have suggested that HAART initiation may vary by race/ethnicity. Utilizing the U.S. military healthcare system, which minimizes confounding from healthcare access, we analyzed whether timing of HAART initiation and the appropriate initiation of primary prophylaxis among those at high risk for pneumocystis pneumonia (PCP) varies by race/ethnicity.

Methods

Participants in the U.S. Military HIV Natural History Study from 1998-2009 who had not initiated HAART before 1998 and who, based on DHHS guidelines, had a definite indication for HAART (CD4 <200, AIDS event or severe symptoms; Group A), an indication to consider HAART (including CD4 <350; Group B) or electively started HAART (CD4 >350; Group C) were analyzed for factors associated with HAART initiation. In a secondary analysis, participants were also evaluated for factors associated with starting primary PCP prophylaxis within four months of a CD4 count <200 cells/mm³. Multiple logistic regression was used to compare those who started vs. delayed therapy; comparisons were expressed as odds ratios (OR).

Results

1262 participants were evaluated in the analysis of HAART initiation (A = 208, B = 637, C = 479 [62 participants were evaluated in both Groups A and B]; 94% male, 46% African American, 40% Caucasian). Race/ethnicity was not associated with HAART initiation in Groups A or B. In Group C, African American race/ethnicity was associated with lower odds of initiating HAART (OR 0.49, p = 0.04). Race and ethnicity were also not associated with the initiation of primary PCP prophylaxis among the 408 participants who were at risk.

Conclusions

No disparities in the initiation of HAART or primary PCP prophylaxis according to race/ethnicity were seen among those with an indication for therapy. Among those electively initiating HAART at the highest CD4 cell counts, African American race/ethnicity was associated with decreased odds of starting. This suggests that free healthcare can potentially overcome some of the observed disparities in HIV care, but that unmeasured factors may contribute to differences in elective care decisions.

Aging and HIV/AIDS: neurocognitive implications for older HIV-positive Latina/o adults

In recent years, HIV/AIDS populations have become older and increasingly more ethnically diverse. Concurrently, the prevalence of HIV-related neurocognitive (NC) impairment remains high. This study examined the effects of age and ethnicity on NC function in HIV-positive adults. The sample (N = 126; 84 Latina/o and 42 Non-Hispanic White) completed a comprehensive NC battery. Global NC and domain average demographically-corrected t-scores were generated. There were no significant differences between Younger (<50 years) Latina/os and non-Hispanic Whites on Global NC function or NC domains (all p's >.10), with generally small effect sizes. Older Latina/os (≥50 years) were significantly more impaired than Older Non-Hispanic Whites on processing speed and learning, with trends in Global NC function and memory. Further, effect sizes fell within the medium to large range (Cohen's d's = .49-1.15). This study suggests that older Latina/os are at potentially greater risk for NC impairment, particularly in processing speed and learning, when compared to similarly-aged non-Hispanic whites.

Understanding the disparity: predictors of virologic failure in women using highly active antiretroviral therapy vary by race and/or ethnicity

BACKGROUND

Stark racial/ethnic disparities in health outcomes exist among those living with HIV in the United States. One of 3 primary goals of the National HIV/AIDS Strategy is to reduce HIV-related disparities and health inequities.

METHODS

Using data from HIV-infected women participating in the Women's Interagency HIV Study from April 2006 to March 2011, we measured virologic failure (HIV RNA >200 copies/mL) after suppression (HIV RNA < 80 copies/mL) on highly active antiretroviral therapy. We identified predictors of virologic failure using discrete time survival analysis and calculated racial/ethnic-specific population-attributable fractions (PAFs).

RESULTS

Of 887 eligible women, 408 (46%) experienced virologic failure during the study period. Hispanic and white women had significantly lower hazards of virologic failure than African American women [Hispanic hazard ratio, (HR) = 0.8, 95% confidence interval: (0.6 to 0.9); white HR = 0.7 (0.5 to 0.9)]. The PAF of virologic failure associated with low income was higher in Hispanic [adjusted hazard ratios (aHR) = 2.2 (0.7 to 6.5), PAF = 49%] and African American women [aHR = 1.8 (1.1 to 3.2), PAF = 38%] than among white women [aHR = 1.4 (0.6 to 3.4), PAF = 16%]. Lack of health insurance compared with public health insurance was associated with virologic failure only among Hispanic [aHR = 2.0 (0.9 to 4.6), PAF = 22%] and white women [aHR = 1.9 (0.7 to 5.1), PAF = 13%]. By contrast, depressive symptoms were associated with virologic failure only among African-American women [aHR = 1.6 (1.2 to 2.2), PAF = 17%].

CONCLUSIONS

In this population of treated HIV-infected women, virologic failure was common, and correlates of virologic failure varied by race/ethnicity. Strategies to reduce disparities in HIV treatment outcomes by race/ethnicity should address racial/ethnic-specific barriers including depression and low income to sustain virologic suppression.

HIV prevalence among the female sex workers in major cities in Myanmar and the risk behaviors associated with it

BACKGROUND

Myanmar is one of the countries hardest hit by the human immunodeficiency virus (HIV) epidemic in Asia.

AIM

The objective of the study was to determine HIV prevalence among the female sex workers in major cities in Myanmar and the risk behaviors associated with it.

METHODS

This cross-sectional study was conducted among female sex workers in major cities in Myanmar. Interviews were conducted by trained research assistants, in private, using a questionnaire. The HIV status of the respondents was asked and confirmed by the blood test reports from the laboratories of the Myanmar National AIDS Programme sexually transmitted infections (STI)/acquired immunodeficiency syndrome (AIDS) Teams and nongovernmental organizations (NGOs).

RESULTS

There were 200 respondents in this study. Out of the 136 participants who were tested for HIV, 25 (18.4%) were HIV-positive. Respondents of other ethnic groups than Myanmars and other religions than Buddhist were about six times (odds ratio [OR] 5.9) and five times (OR 4.6), respectively, at higher odds of being HIV-positive. Those who were earning an income of less than 200,000 kyats were almost three times (OR 2.9) at higher odds of being HIV-positive. The difference in the age group was found to be statistically significant (P = 0.001). Respondents who did not have HIV counseling (OR 7.3), who did not use condoms (OR 1.3), and with regular partners who refused the use of condoms (OR 6.0) were at higher odds of being HIV-positive.

CONCLUSION

HIV prevention services should include socioeconomic support programs, and the clients and regular partners of sex workers should also be targeted for behavior-change messages, to reduce condom resistance.

Description of an efficacious behavioral peer-driven intervention to reduce racial/ethnic disparities in AIDS clinical trials

AIDS clinical trials (ACTs) are critical to the development of new treatments for HIV infection. However, people of color living with HIV/AIDS are involved in ACTs at disproportionally low rates, with African-Americans experiencing the greatest under-representation. In this article, we describe the core elements and key characteristics of a highly efficacious multi-component peer-driven intervention (PDI) designed to increase rates of screening for and enrollment into ACTs among African-American and Latino/Hispanic individuals, by addressing the main complex, multi-level barriers they experience to ACTs. We discuss the process of developing the intervention, the theoretical models guiding its delivery format and content, and provide an overview of the intervention's components. We then use brief case studies to illustrate a number of key issues that may arise during intervention implementation. Finally, we describe lessons learned and provide recommendations for the PDI's uptake in clinical and clinical trials settings.

Prevalence and predictors of drug use among adolescents with HIV infection acquired perinatally or later in life

We examined the prevalence and predictors of drug use among a diverse group of adolescents living with HIV infection acquired perinatally or through sexual risk behaviors ("behaviorally acquired"). Adolescents ages 13-21 (n = 166) who were receiving care at one of five pediatric/adolescent HIV clinics in three US cities (Baltimore MD, Washington DC, and New York NY) and were enrolled in a behavioral intervention were interviewed at baseline regarding lifetime drug use experiences and depression symptoms. A majority of study participants reported using alcohol (57.2%) and marijuana (51.2%); 48.8% reported tobacco/cigarette use. The mean age of onset of use for each type of drug was 14 years or younger. A larger proportion of participants with behaviorally acquired HIV than adolescents with perinatally acquired HIV reported lifetime use of alcohol (76.1 vs. 44.4%), marijuana (73.1 vs. 36.4%), tobacco (70.2 vs. 34.3%), and club drugs (22.4 vs. 3%) (all p < 0.001).

Predictors of screening for AIDS clinical trials among African-Americans and Latino/Hispanics enrolled in an efficacious peer-driven intervention: uncovering socio-demographic, health, and substance use-related factors that promote or impede screening

African-American and Latino/Hispanic persons living with HIV/AIDS are underrepresented in AIDS clinical trials (ACTs). The aim of this paper was to uncover factors, either unmodifiable or not directly targeted for change, that predicted screening for ACTs during an efficacious peer-driven intervention (N = 540 total; N = 351 in an intervention arm, N = 189 control). This paper focused on participants assigned to an intervention arm, 56 % of whom were screened for ACTs. We found a decreased odds of screening was associated with closer proximity to the screening site, gay/lesbian orientation, lower mental health symptoms, current injection drug use, more recent HIV diagnosis, lack of prior screening experience, and failure to attend all intervention sessions, but there were no gender or racial/ethnic differences. Efforts to reduce racial/ethnic disparities in ACTs can be enhanced by attending to these specific factors, which may interfere with programmatic efforts to increase African-American and Latino/Hispanic representation in ACTs.

The Hispanic HIV Epidemic

The Hispanic population in the U.S. has been dramatically affected by the HIV epidemic. The impact not only is related to the infection itself and its complications, but also is driven by social factors that lead to increased disparity in health-care access and cultural modeling and to increased social stigma, which leads to marginalization and exacerbates the existing gaps in medical care. Hispanics infected with HIV more frequently receive delayed diagnoses and more often present with AIDS, concomitant opportunistic infections, or coinfections related to their country of origin. The unique characteristics that define the HIV epidemic in Hispanics need further analysis in order to identify new opportunities to improve linkage to health care, increase efficacy in health-care provision, and decrease social disparities related to the Hispanic population.

The state of disparities in opportunistic infection prophylaxis for blacks with HIV/AIDS

OBJECTIVES

The purpose of this review is to identify and analyze published studies that have evaluated disparities for opportunistic infection (OI) prophylaxis between blacks and whites with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) in the United States.

METHODS

The authors conducted a web-based search of MEDLINE (1950-2009) to identify original research articles evaluating the use of OI prophylaxis between blacks and whites with HIV/AIDS. The search was conducted utilizing the following MeSH headings and search terms alone and in combination: HIV, AIDS, Black, race, ethnicity, disparities, differences, access, opportunistic infection, and prophylaxis. The search was then expanded to include any relevant articles from the referenced citations of the articles that were retrieved from the initial search strategy. Of the 29 articles retrieved from the literature search, 19 articles were excluded.

RESULTS

Ten publications met inclusion criteria, collectively published between 1991 and 2005. The collective time periods of these studies spanned from 1987 to 2001. Four studies identified a race-based disparity in that blacks were less likely than whites to use OI prophylaxis, whereas 5 studies failed to identify such a relationship between race and OI prophylaxis. One study identified disparities for Mycobacterium avium complex prophylaxis, but not for Pneumocystis jiroveci pneumonia prophylaxis.

CONCLUSIONS

The evidence regarding race-based disparities in OI prophylaxis is inconclusive. Additional research is warranted to explore potential race-based disparities in OI prophylaxis.

The Experience of Screening for HIV/AIDS Medical Studies among African-American/Black and Latino/Hispanic Persons Living with HIV/AIDS: A Mixed-Methods Exploration

Objective

African-American/Black and Latino/Hispanic persons living with HIV/AIDS (i.e., “PLHA of color”) are under-represented in HIV/AIDS medical studies (HAMS). A crucial entry point into HAMS is screening, but PLHA of color face serious barriers to screening compared to Whites. Recently we evaluated a social/behavioral intervention that substantially increased rates of HAMS screening among PLHA of color. Yet very little is known about the actual screening experience for these under-represented subgroups. Thus, the objectives of the present study were to explore participants’ motivations for and experiences of HAMS screening.

Methods

A total of 186 participants in the larger study’s intervention arm were screened for HAMS, 35 of whom also participated in qualitative interviews. Participants engaged in a structured interview about the screening experience at 4- and 12- months post-baseline (14 items, Cronbach's α=0.72). Further, from a qualitative data set we purposively selected a set of three case studies to contextualize and enrich quantitative findings on screening experiences.

Results

The screening experience was overwhelmingly positive. Almost all participants reported being treated with dignity and respect, did not feel they were being treated like a “guinea pig,” and experienced a high level of trust in the setting and the screener, with no gender or racial/ethnic differences, and no differences based on whether participants were found eligible for HAMS during screening. A number of areas where screening could be improved were also identified.

Conclusions

Despite the complex barriers PLHA of color experience to screening for HAMS, the experience of screening was positive. Moreover, HAMS screening experiences were positive regardless of gender, race/ethnicity, or HAMS eligibility. HAMS screening can therefore be a productive learning experience that may reduce patient concerns about participating in HAMS. As such, fostering screening among PLHA of color can be an important component of reducing racial/ethnic disparities in HAMS.

Interventions to address chronic disease and HIV: strategies to promote smoking cessation among HIV-infected individuals

Tobacco use, especially cigarette smoking, is higher than average in persons living with HIV/AIDS (PLWHA). The Public Health Service Clinical Practice Guideline for Treating Tobacco Use and Dependence states that, during every medical encounter, all smokers should be offered smoking cessation counseling, along with approved medications. The Guideline also recognizes PLWHA as a priority population, given the scarcity of research on effective cessation treatments in this group. The scant evidence suggests that conventional treatments, though worthwhile, are not as successful as might be hoped for. The reasons for this are not entirely clear, but may have to do with the complex array of medical and psychosocial factors that complicate their lives. Clinicians should consider re-treatment strategies for those patients who encounter difficulty when quitting smoking with conventional approaches, switching or augmenting treatments as needed to minimize adverse experiences, and to maximize tolerability, adherence, and cessation outcomes.

Years of potential life lost due to HIV infection and associated factors based on national HIV surveillance data in Latvia, 1991-2010

BACKGROUND

Latvia is still experiencing one of the highest human immunodeficiency virus (HIV) mortality rates in the European Union, and HIV is the 6(th) leading cause of death among young adults (15-39 y) in the country. The aim of the study was to determine the years of potential life lost (YPLL) as an indicator of premature mortality and the associated factors among people living with HIV (PLH) in Latvia.

METHODS

Data from the National Registry of HIV/AIDS Cases was used for the time period 1991-2010. Data on 738 deaths were analysed. The cut-off age for YPLL calculations was 65 y. Univariable analysis was done using Mann-Whitney and Kruskal-Wallis tests. A linear regression model was constructed for determining the independent effects of the particular factors on the number of YPLL.

RESULTS

The total number of YPLL due to HIV in Latvia was 21,097 (50.4/100,000 general population; 511.1/1000 PLH). Each PLH who died had lost 28.8 YPLL on average. The numbers of YPLL reflect the population groups most affected by the HIV epidemic (young men, non-ethnic Latvians, living in the capital city, and being infected via drug injection). Our regression model indicated that among deceased PLH, non-Latvian ethnicity and injecting drug use as the mode of HIV transmission were associated with an additional 2.4 (p = 0.003) and 5.7 (p < 0.001) average YPLL, respectively.

CONCLUSIONS

A considerable number of years of potential life have been lost in Latvia due to HIV. YPLL is significantly associated with ethnicity and mode of HIV transmission.

Socioeconomic determinants associated with willingness to participate in medical research among a diverse population

INTRODUCTION

Although it is federally-mandated that racial/ethnic minorities be included in research studies, recruiting diverse populations remains a challenge. This is particularly difficult when research involves children. The purpose of this study was to assess attitudes and beliefs toward medical research among a racially and socioeconomically diverse population of parents of school children.

METHODS

A cross-sectional parent-report survey was conducted in New York City public elementary schools using stratified random selection to obtain a diverse population. Fear of medical research and likelihood to participate in medical research were assessed using a validated questionnaire. Differences in fear/likelihood to participate in research across race/ethnicity and socioeconomic characteristics were evaluated.

RESULTS

In general, parents were afraid of their child "being treated as a guinea pig", but were willing to allow their child to participate in research if asked by their own doctor. Factors associated with a lower score on fear toward research were; primary language other than English (OR=0.59), access to an interpreter (OR=0.73) and access to medical service within a day (OR=0.51). Latinos had the highest fear score (OR=1.87) compared to Whites. Asians were the ethnic group most likely to participate in research (OR=1.71). Low education level (OR=2.18) and public health insurance (OR=1.37) were associated with a higher score for likelihood of allowing one's child to participate in medical research.

CONCLUSION

Minority parents reported more fear of allowing their children to participate in medical research, but were as likely to consent their children's participation, especially if asked by their own physician.

Longitudinal Pediatric Palliative Care: Quality of Life & Spiritual Struggle (FACE): design and methods

As life expectancy increases for adolescents ever diagnosed with AIDS due to treatment advances, the optimum timing of advance care planning is unclear. Left unprepared for end-of-life (EOL) decisions, families may encounter miscommunication and disagreements, resulting in families being charged with neglect, court battles and even legislative intervention. Advanced care planning (ACP) is a valuable tool rarely used with adolescents. The Longitudinal Pediatric Palliative Care: Quality of Life & Spiritual Struggle study is a two-arm, randomized controlled trial assessing the effectiveness of a disease specific FAmily CEntered (FACE) advanced care planning intervention model among adolescents diagnosed with AIDS, aimed at relieving psychological, spiritual, and physical suffering, while maximizing quality of life through facilitated conversations about ACP. Participants will include 130 eligible dyads (adolescent and family decision-maker) from four urban cities in the United States, randomized to either the FACE intervention or a Healthy Living Control. Three 60-minute sessions will be conducted at weekly intervals. The dyads will be assessed at baseline as well as 3-, 6-, 12-, and 18-month post-intervention. The primary outcome measures will be in congruence with EOL treatment preferences, decisional conflict, and quality of communication. The mediating and moderating effects of threat appraisal, HAART adherence, and spiritual struggle on the relationships among FACE and quality of life and hospitalization/dialysis use will also be assessed. This study will be the first longitudinal study of an AIDS-specific model of ACP with adolescents. If successful, this intervention could quickly translate into clinical practice.

Paying for prevention: challenges to health insurance coverage for biomedical HIV prevention in the United States

Reducing the incidence of HIV infection continues to be a crucial public health priority in the United States, especially among populations at elevated risk such as men who have sex with men, transgender women, people who inject drugs, and racial and ethnic minority communities. Although most HIV prevention efforts to date have focused on changing risky behaviors, the past decade yielded efficacious new biomedical technologies designed to prevent infection, such as the prophylactic use of antiretroviral drugs and the first indications of an efficacious vaccine. Access to prevention technologies will be a significant part of the next decade's response to HIV and advocates are mobilizing to achieve more widespread use of these interventions. These breakthroughs, however, arrive at a time of escalating healthcare costs; health insurance coverage therefore raises pressing new questions about priority-setting and the allocation of responsibility for public health. The goals of this Article are to identify legal challenges and potential solutions for expanding access to biomedical HIV prevention through health insurance coverage. This Article discusses the public policy implications of HIVprevention coverage decisions, assesses possible legal grounds on which insurers may initially deny coverage for these technologies, and evaluates the extent to which these denials may survive external and judicial review. Because several of these legal grounds may be persuasive, particularly denials on the basis of medical necessity, this Article also explores alternative strategies for financing biomedical HIV prevention efforts.

Acceptability and feasibility of rapid HIV testing in an adolescent clinic setting: youth testing attitudes, knowledge, and behaviors

PURPOSE

To assess youths' attitudes, knowledge, and behaviors regarding rapid HIV testing (RHT) and measure acceptability and feasibility of RHT in an adolescent clinic setting.

METHODS

A 2007-2008 project introduced free RHT at an urban, hospital-based adolescent and young adult clinic in Boston, MA. Patients and HIV testing clients were offered either free nonrapid tests or fingerstick RHT. An anonymous questionnaire assessed youths' testing attitudes, knowledge, and behaviors (N = 127). Ordinal logistic regression model was used to determine associations with youth demographic characteristics and testing experience.

RESULTS

Most participants valued rapid results. A minority desired confidentiality from parents and insurance providers. Older youth were more likely to know about testing methods (OR: 1.25; CI: 1.04-1.51) and plan for follow-up (OR: 1.43; CI: 1.14-1.81). Age, gender, and race were unrelated to testing facilitators such as rapidity, confidentiality, and cost, although younger clients were more likely to prefer noninvasive methods. Individuals with previous testing experience were more likely to say that they would contribute to expenses and value rapidity over cost.

CONCLUSION

There was strong support for RHT among youth receiving HIV testing. Offering RHT to youth may facilitate routine testing. Future research should focus on increasing RHT access among diverse populations of youth.

Recruitment and retention of diverse populations in antiretroviral clinical trials: practical applications from the gender, race and clinical experience study

BACKGROUND

Women, particularly women of color, remain underrepresented in antiretroviral (ARV) clinical trials. To evaluate sex-based differences in darunavir/ritonavir-based therapy, the Gender, Race And Clinical Experience (GRACE) study was designed to enroll and retain a high proportion of women representative of the racial/ethnic demographics of women with HIV/AIDS in the United States. The recruitment and retention strategies used in GRACE are described in this article.

METHODS

Recruitment and retention strategies targeting women included selecting study sites that focused on women, involving community consultants, site-specific enrollment plans, access to other ARV drugs, study branding, site and patient toolkits, targeted public relations, site grants for patient support, and subsidized child care and transportation.

RESULTS

The recruitment strategies were successful; 287 (67%) women were enrolled, primarily women of color (black, n=191 [67%], Hispanic, n=60 [21%]). Despite the focus on retention, a greater proportion of women (32.8%) discontinued compared with men (23.2%).

CONCLUSIONS

The successes of GRACE in enrolling a representative population of women were rooted in pretrial preparation, engagement of community advisors, enrollment quotas, choice of study sites and site support. Lessons learned from GRACE may be applied to future study design. Further focus on factors that influence discontinuation is warranted.