Chelsea D. Voytek

Examining Racial Disparities in HIV : Lessons From Sexually Transmitted Infections Research

Racial differences in the prevalence and incidence of HIV infection and AIDS diagnoses in the United States are striking. These differences have been recognized for nearly 20 years, yet they are not well investigated. In this article, we examine 15 factors identified in the sexually transmitted infection (STI) literature to explain the presence of racial/ethnic disparities in STIs. We review findings from these studies and offer suggestions for future research, with the goal of further understanding and reducing disparities in HIV. In general, the STI literature shows that an evaluation of individual behavior is necessary but insufficient on its own to account for racial/ethnic disparities in STIs. Population parameters should be included within models that traditionally include individual-level factors. The 15 factors can be categorized into 3 broad overarching themes: behavioral, prevention participation, and biologic explanations of differentials in STI transmission and infection. Future research that focuses on only 1 of the 15 factors discussed in this review, to the exclusion of others, is likely to yield poor outcomes. Conversely, an emphasis on the interactions of several factors is more likely to produce effective public health interventions and reductions in HIV transmission.PURPOSE To clarify the roles of objective signs and subjective symptoms in the diagnosis and management of dry eye by describing their use by a group of expert practitioners. Dry eye signs and symptoms do not always correlate well, and there is currently some controversy over the ideal roles of signs and symptoms and their actual use in clinical practice. METHODS A balanced panel of 16 participants in a scientific roundtable on dry eye reviewed 4 patient case studies and completed surveys ranking common diagnostic procedures assessing symptoms and signs by the order in which they would be used. RESULTS Symptom assessment was the predominant diagnostic method. The objective tests most commonly used during the initial examination were tear breakup time (93%), corneal staining (85%), tear film assessment (76%), conjunctival staining (74%), and the Schirmer test (54%). Most panelists used multiple tests, with a median of 6 tests used in the initial examination. CONCLUSIONS Subjective symptoms and objective signs are both important in the diagnosis and management of dry eye, with the patients symptoms and history playing a critical role. Most clinicians use objective signs in dry eye management. However, currently available diagnostic tests do not correlate reliably with symptom severity. Research aimed at developing accurate, objective, responsive measures of dry eye severity is needed.

Behind the Cascade: Analyzing Spatial Patterns along the HIV Care Continuum

Background:Successful HIV treatment as prevention requires individuals to be tested, aware of their status, linked to and retained in care, and virally suppressed. Spatial analysis may be useful for monitoring HIV care by identifying geographic areas with poor outcomes. Methods:Retrospective cohort of 1704 people newly diagnosed with HIV identified from Philadelphias Enhanced HIV/AIDS Reporting System in 2008–2009, with follow-up to 2011. Outcomes of interest were not linked to care, not linked to care within 90 days, not retained in care, and not virally suppressed. Spatial patterns were analyzed using K-functions to identify “hot spots” for targeted intervention. Geographic components were included in regression analyses along with demographic factors to determine their impact on each outcome. Results:Overall, 1404 persons (82%) linked to care; 75% (1059/1404) linked within 90 days; 37% (526/1059) were retained in care; and 72% (379/526) achieved viral suppression. Fifty-nine census tracts were in hot spots, with no overlap between outcomes. Persons residing in geographic areas identified by the local K-function analyses were more likely to not link to care [adjusted odds ratio 1.76 (95% confidence interval: 1.30 to 2.40)], not link to care within 90 days (1.49, 1.12–1.99), not be retained in care (1.84, 1.39–2.43), and not be virally suppressed (3.23, 1.87–5.59) than persons not residing in the identified areas. Conclusions:This study is the first to identify spatial patterns as a strong independent predictor of linkage to care, retention in care, and viral suppression. Spatial analyses are a valuable tool for characterizing the HIV epidemic and treatment cascade.

The Development of a Culturally Relevant, Theoretically Driven HPV Prevention Intervention for Urban Adolescent Females and Their Parents/Guardians

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States, accounting for the large majority of cervical cancer and anogenital warts cases. Two HPV vaccines are currently licensed and recommended for women and girls. However, vaccination rates have been suboptimal, with evidence of disparities influencing both uptake and series completion among African American and Hispanic adolescents. There has been a dearth of theory-based, behavioral interventions targeted to prevent HPV infection and increase HPV vaccine uptake among urban adolescents. This article describes the development of two skills-based intervention curricula aimed to increase HPV prevention and vaccination among low-income urban adolescent females 9 to 18 years old. Guided by the theory of planned behavior, elicitation research was conducted to elucidate the social psychological factors that underlie HPV vaccination intentions (N = 141). The findings were subsequently used to identify theoretical mediators of behavioral change to drive the intervention. Culturally relevant strategies to promote HPV vaccination were translated into the curricula content. Both curricula were designed to motivate and empower participants to reduce risk of being infected with HPV. Targeting theoretical mediators of behavioral change, derived from the voices of the community, may prove to be successful in increasing HPV vaccination and preventing HPV.

Individual and community factors associated with geographic clusters of poor HIV care retention and poor viral suppression.

Background:Previous analyses identified specific geographic areas in Philadelphia (hotspots) associated with negative outcomes along the HIV care continuum. We examined individual and community factors associated with residing in these hotspots. Methods:Retrospective cohort of 1404 persons newly diagnosed with HIV in 2008–2009 followed for 24 months after linkage to care. Multivariable regression examined associations between individual (age, sex, race/ethnicity, HIV transmission risk, and insurance status) and community (economic deprivation, distance to care, access to public transit, and access to pharmacy services) factors and the outcomes: residence in a hotspot associated with poor retention-in-care and residence in a hotspot associated with poor viral suppression. Results:In total, 24.4% and 13.7% of persons resided in hotspots associated with poor retention and poor viral suppression, respectively. For persons residing in poor retention hotspots, 28.3% were retained in care compared with 40.4% of those residing outside hotspots (P < 0.05). Similarly, for persons residing in poor viral suppression hotspots, 51.4% achieved viral suppression compared with 75.3% of those outside hotspots (P < 0.0.05). Factors significantly associated with residence in poor retention hotspots included female sex, lower economic deprivation, greater access to public transit, shorter distance to medical care, and longer distance to pharmacies. Factors significantly associated with residence in poor viral suppression hotspots included female sex, higher economic deprivation, and shorter distance to pharmacies. Conclusions:Individual and community-level associations with geographic hotspots may inform both content and delivery strategies for interventions designed to improve retention-in-care and viral suppression.

Using an internet consumer marketing strategy to reach men who have sex with men for participation in a preventive HIV vaccine clinical trial.

Methods Between 12/1/2011 and 1/3/2012, the HVTU contracted with a consumer marketing company to recruit potential trial participants. For

Going social: Success in online recruitment of men who have sex with men for prevention HIV vaccine research

3000, the company emailed MSM a scripted message inviting them to participate in a clinical HIV vaccine trial, and the company provided the trial site with contact information for those who responded. Site staff emailed and phoned each respondent to provide study information and conduct a phone-screen interview for the trial. Those eligible were scheduled for in-office screening appointments.

Selectively willing and conditionally able: HIV vaccine trial participation among women at "high risk" of HIV infection.

OBJECTIVE To compare the use of four different social media sites to recruit men who have sex with men (MSM) and transgender women to a phase 2b HIV prevention vaccine trial, HVTN 505. DESIGN Retrospective, observational study. METHODS The University of Pennsylvania HIV Vaccine Trials Unit (Penn HVTU) employed street outreach and online recruitment methods to recruit participants for HVTN 505 using a combination of national recruitment images/messages with Philadelphia-specific language and imagery. We compared the efficiency (number of enrolled participants per number of completed phone screens) and effectiveness (number of enrolled participants per time interval employed) of each strategy, as well as the demographics and risk behaviors of the populations. RESULTS Online recruitment strategies populated 37% (71/191) of trial participants at our site. Among the four social media strategies employed, 45.1% (32/71) were enrolled through Facebook, 16.9% (12/71) through Craigslist, 15.5% (11/71) through a web-based marketing company (WBMC), and 22.5% (16/71) via GRINDR. The number of participants enrolled per month of strategy and the months the strategy was employed were Facebook - 32(33months), Craigslist - 12(33months), WBMC - 11(6months), and GRINDR - 16(0.56months). In-person and online recruitment strategies yielded participants of similar demographics and levels of risk behavior. CONCLUSION Use of several social media recruitment modalities produced large numbers of MSM engaging in high risk behavior and willing to participate in an HIV prevention vaccine trial. In comparison to other social media and online strategies, recruitment via GRINDR was the most effective.