Eduardo E. Valverde

Results From a Randomized Controlled Trial of a Peer-Mentoring Intervention to Reduce HIV Transmission and Increase Access to Care and Adherence to HIV Medications Among HIV-Seropositive Injection Drug Users

Background:There is a lack of effective behavioral interventions for HIV-positive injection drug users (IDUs). We sought to evaluate the efficacy of an intervention to reduce sexual and injection transmission risk behaviors and to increase utilization of medical care and adherence to HIV medications among this population. Methods:HIV-positive IDUs (n = 966) recruited in 4 US cities were randomly assigned to a 10-session peer mentoring intervention or to an 8-session video discussion intervention (control condition). Participants completed audio computer-assisted self-interviews and had their blood drawn to measure CD4 cell count and viral load at baseline and at 3-month (no blood), 6-month, and 12-month follow-ups. Results:Overall retention rates for randomized participants were 87%, 83%, and 85% at 3, 6, and 12 months, respectively. Participants in both conditions reported significant reductions from baseline in injection and sexual transmission risk behaviors, but there were no significant differences between conditions. Participants in both conditions reported no change in medical care and adherence, and there were no significant differences between conditions. Conclusions:Both interventions led to decreases in risk behaviors but no changes in medical outcomes. The characteristics of the trial that may have contributed to these results are examined, and directions for future research are identified.

Intimate Partner Violence Perpetration Against Main Female Partners Among HIV-Positive Male Injection Drug Users

Intimate partner violence (IPV) against women is a serious public health and social problem and is associated with a host of adverse health outcomes and behaviors, HIV risk behaviors included, among women who are victimized. Historically, research has focused on correlates of IPV victimization among women; thus, there is less information on the role of men in perpetrating IPV, particularly among men at risk for transmitting HIV to their female partners. We assessed the self-reported prevalence and correlates of perpetration and threat of perpetration of physical and/or sexual IPV against a main female partner among 317 HIV-positive men who were current injection drug users (IDUs). More than 40% of men reported perpetrating physical (39%) and/or sexual (4%) violence against their main female partners in the past year. Multivariate analyses revealed that low education, homelessness, psychologic distress, and unprotected sex with main and nonmain HIV-negative female partners were positively associated with IPV perpetration against main female partners. These findings reveal that IPV perpetration is prevalent among HIV-positive male IDUs and associated with sexual HIV transmission risk behaviors. IPV assessment and treatment among HIV-positive men in HIV care is recommended as a way to prevent IPV perpetration and victimization and to reduce potential HIV transmission.

Health-Related Beliefs and Decisions about Accessing HIV Medical Care among HIV-Infected Persons Who Are Not Receiving Care

In the United States, the publically supported national HIV medical care system is designed to provide HIV medical care to those who would otherwise not receive such care. Nevertheless, many HIV-infected persons are not receiving medical care. Limited information is available from HIV-infected persons not currently in care about the reasons they are not receiving care. From November 2006 to February 2007, we conducted five focus groups at community-based organizations and health departments in five U.S. cities to elicit qualitative information about barriers to entering HIV care. The 37 participants were mostly male (n = 29), over the age of 30 (n = 34), and all but one had not received HIV medical care in the previous 6 months. The focus group discussions revealed health belief-related barriers that have often been overlooked by studies of access to care. Three key themes emerged: avoidance and disbelief of HIV serostatus, conceptions of illness and appropriate health care, and negative experiences with, and distrust of, health care. Our findings point to the potentially important influence of these health-related beliefs on individual decisions about whether to access HIV medical care. We also discuss the implications of these beliefs for provider-patient communication, and suggest that providers frame their communications with patients such that they are attentive to the issues identified by our respondents, to better engage patients as partners in the treatment process.

Factors associated with use of HIV primary care among persons recently diagnosed with HIV: Examination of variables from the behavioural model of health-care utilization

Abstract The delay between testing positive for human immunodeficiency virus (HIV) and entering medical care can be better understood by identifying variables associated with use of HIV primary care among persons recently diagnosed with the virus. We report findings from 270 HIV-positive persons enrolled in the Antiretroviral Treatment Access Study (ARTAS). 74% had not seen an HIV care provider before enrolment; 26% had one prior visit only. Based on Andersens behavioural model of health care utilization, several variables reflecting demographic, healthcare, illness, behavioural, and psychosocial dimensions were assessed and used to predict the likelihood that participants had seen an HIV care provider six months after enrolment. Overall, 69% had seen an HIV care provider by six months. In multivariate analysis, the likelihood of seeing a provider was significantly (p<.05) higher among men, Hispanics (vs. non-Hispanic Blacks), those with higher education, those who did not use injection drugs, those with three or more HIV-related symptoms, those with public health insurance (vs. no insurance), and those who received short-term case management (vs. passive referral). The findings support several conceptual categories of Andersens behavioural model of health services utilization as applied to the use of HIV medical care among persons recently diagnosed with HIV.

Depressive symptoms and food insufficiency among HIV-infected crack users in atlanta and miami

Depression contributes to worse general and HIV-related clinical outcomes. We examined the prevalence of and factors associated with depressive symptomatology among HIV-infected crack cocaine users recruited for Project HOPE (Hospital Visit is an Opportunity for Prevention and Engagement with HIV-positive Crack Users). We used multiple logistic regression to determine sociodemographic correlates associated with screening in for depression. Among 291 participants, three-quarters (73.5%) were identified as depressed. Higher odds of screening in for depression was associated with food insufficiency and monthly income below

Use of and Adherence to Antiretroviral Therapy in a Large U.S. Sample of HIV-infected Adults in Care, 2007-2008

600. Alcohol and crack use were not associated with screening in for depression. Depressive symptomatology is extremely prevalent among HIV-infected crack cocaine users and is associated with food insufficiency and lower income. Screening for depression and food insecurity should be included in HIV prevention and treatment programs. Improved recognition and mitigation of these conditions will help alleviate their contribution to HIV-related adverse health outcomes.

Correlates of depression among HIV-positive women and men who inject drugs.

Background: Antiretroviral therapy (ART) is the cornerstone of HIV clinical care and is increasingly recognized as a key component of HIV prevention. However, the benefits of ART can be realized only if HIV-infected persons maintain high levels of adherence. Methods: We present interview data (collected from June 2007 through September 2008) from a national HIV surveillance system in the United States—the Medical Monitoring Project (MMP)—to describe persons taking ART. We used multivariate logistic regression to assess behavioral, sociodemographic, and medication regimen factors associated with three measures that capture different dimensions of nonadherence to ART: dose, schedule, and instruction. Results: The use of ART among HIV-infected adults in care was high (85%), but adherence to ART was suboptimal and varied across the three measures of nonadherence. Of MMP participants currently taking ART, the following reported nonadherence during the past 48 hours: 13% to dose, 27% to schedule, and 30% to instruction. The determinants of the three measures also varied, although younger age and binge drinking were associated with all aspects of nonadherence. Conclusion: Our results support the measurement of multiple dimensions of medication-taking behavior in order to avoid overestimating adherence to ART.

HIV Infection and Testing among Latino Men Who Have Sex with Men in the United States: The Role of Location of Birth and Other Social Determinants

Introduction:Although depression is common among HIV-positive injection drug users (IDUs), little is known about differences between male and female HIV-positive IDUs. Methods:We used baseline data for 1126 HIV-positive IDUs from a behavioral intervention trial from 2001 through 2005 in 4 US cities. Using the Brief Symptom Inventory-18, scores indicating high risk for depression were calculated separately for men and women based on raw scores of 9 for women and 7 for men. We did separate logistic regressions for men and women to evaluate correlates of depression in 4 domains: sociodemographic, psychosocial, substance use, and sexual behaviors/attitudes. Results:Approximately one third of women and men met the criteria for being at high risk of depression. Women reported significantly more depressive symptoms than men. Correlates linked with depression for both genders included perceived functional limitation, greater negative feelings regarding condom use, lower social support, and lower sense of empowerment. Being physically abused as adults and being Hispanic were correlates specific to men. No unique correlate was identified for women. Discussion:Because of the high prevalence of depression among HIV-positive IDUs, caregivers should screen HIV-positive IDUs for depression and consider treatment for depression. Because of the similarities in correlates of depression among men and women, case finding and interventions for depression are likely to be similar for male and female HIV-positive IDUs.

Sexual risk behaviour and viral suppression among HIV-infected adults receiving medical care in the United States

Background In the United States, Latino men who have sex with men (MSM) are disproportionately affected by HIV. Latino MSM are a diverse group who differ culturally based on their countries or regions of birth and their time in the United States. We assessed differences in HIV prevalence and testing among Latino MSM by location of birth, time since arrival, and other social determinants of health. Methods For the 2008 National HIV Behavioral Surveillance System, a cross-sectional survey conducted in large US cities, MSM were interviewed and tested for HIV infection. We used generalized estimating equations to test associations between various factors and 1) prevalent HIV infection and 2) being tested for HIV infection in the past 12 months. Results Among 1734 Latino MSM, HIV prevalence was 19%. In multivariable analysis, increasing age, low income, and gay identity were associated with HIV infection. Moreover, men who were U.S.-born or who arrived ≥5 years ago had significantly higher HIV prevalence than recent immigrants. Among men not reporting a previous positive HIV test, 63% had been tested for HIV infection in the past 12 months; recent testing was most strongly associated with having seen a health care provider and disclosing male-male attraction/sexual behavior to a health care provider. Conclusions We identified several social determinants of health associated with HIV infection and testing among Latino MSM. Lower HIV prevalence among recent immigrants contrasts with higher prevalence among established immigrants and suggests a critical window of opportunity for HIV prevention, which should prioritize those with low income, who are at particular risk for HIV infection. Expanding health care utilization and encouraging communication with health care providers about sexual orientation may increase testing.

Routine HIV Testing among Providers of HIV Care in the United States, 2009

Objective:To describe the prevalence and association of sexual risk behaviours and viral suppression among HIV-infected adults in the United States. Design:Cross-sectional analysis of weighted data from a probability sample of HIV-infected adults receiving outpatient medical care. The facility and patient response rates were 76 and 51%, respectively. Methods:We analysed 2009 interview and medical record data. Sexual behaviours were self-reported in the past 12 months. Viral suppression was defined as all viral load measurements in the medical record during the past 12 months less than 200 copies/ml. Results:An estimated 98 022 (24%) HIV-infected adults engaged in unprotected vaginal or anal sex; 50 953 (12%) engaged in unprotected vaginal or anal sex with at least one partner of negative or unknown HIV status; 23 933 (6%) did so while not virally suppressed. Persons who were virally suppressed were less likely than persons who were not suppressed to engage in vaginal or anal sex [prevalence ratio, 0.88; 95% confidence interval (CI), 0.82–0.93]; unprotected vaginal or anal sex (prevalence ratio, 0.85; 95% CI, 0.73–0.98); and unprotected vaginal or anal sex with a partner of negative or unknown HIV status (prevalence ratio, 0.79; 95% CI, 0.64–0.99). Conclusion:The majority of HIV-infected adults receiving medical care in the U.S. did not engage in sexual risk behaviours that have the potential to transmit HIV, and of the 12% who did, approximately half were not virally suppressed. Persons who were virally suppressed were less likely than persons who were not suppressed to engage in sexual risk behaviours.