Gabriel Cardenas

Preexposure Prophylaxis for HIV Infection Integrated With Municipal- and Community-Based Sexual Health Services

IMPORTANCE Several randomized clinical trials have demonstrated the efficacy of preexposure prophylaxis (PrEP) in preventing human immunodeficiency virus (HIV) acquisition. Little is known about adherence to the regimen, sexual practices, and overall effectiveness when PrEP is implemented in clinics that treat sexually transmitted infections (STIs) and community-based clinics serving men who have sex with men (MSM). OBJECTIVE To assess PrEP adherence, sexual behaviors, and the incidence of STIs and HIV infection in a cohort of MSM and transgender women initiating PrEP in the United States. DESIGN, SETTING, AND PARTICIPANTS Demonstration project conducted from October 1, 2012, through February 10, 2015 (last date of follow-up), among 557 MSM and transgender women in 2 STI clinics in San Francisco, California, and Miami, Florida, and a community health center in Washington, DC. Data were analyzed from December 18, 2014, through August 8, 2015. INTERVENTIONS A combination of daily, oral tenofovir disoproxil fumarate and emtricitabine was provided free of charge for 48 weeks. All participants received HIV testing, brief client-centered counseling, and clinical monitoring. MAIN OUTCOMES AND MEASURES Concentrations of tenofovir diphosphate in dried blood spot samples, self-reported numbers of anal sex partners and episodes of condomless receptive anal sex, and incidence of STI and HIV acquisition. RESULTS Overall, 557 participants initiated PrEP, and 437 of these (78.5%) were retained through 48 weeks. Based on the findings from the 294 participants who underwent measurement of tenofovir diphosphate levels, 80.0% to 85.6% had protective levels (consistent with ≥4 doses/wk) at follow-up visits. African American participants (56.8% of visits; P = .003) and those from the Miami site (65.1% of visits; P < .001) were less likely to have protective levels, whereas those with stable housing (86.8%; P = .02) and those reporting at least 2 condomless anal sex partners in the past 3 months (88.6%; P = .01) were more likely to have protective levels. The mean number of anal sex partners declined during follow-up from 10.9 to 9.3, whereas the proportion engaging in condomless receptive anal sex remained stable at 65.5% to 65.6%. Overall STI incidence was high (90 per 100 person-years) but did not increase over time. Two individuals became HIV infected during follow-up (HIV incidence, 0.43 [95% CI, 0.05-1.54] infections per 100 person-years); both had tenofovir diphosphate levels consistent with fewer than 2 doses/wk at seroconversion. CONCLUSIONS AND RELEVANCE The incidence of HIV acquisition was extremely low despite a high incidence of STIs in a large US PrEP demonstration project. Adherence was higher among those participants who reported more risk behaviors. Interventions that address racial and geographic disparities and housing instability may increase the impact of PrEP.

Hospitalized HIV-infected patients in the era of highly active antiretroviral therapy.

We interviewed 1038 HIV-positive inpatients in public hospitals in Miami, Florida, and Atlanta, Georgia, to examine patient factors associated with use of HIV care, use of antiretroviral therapy, and unprotected sexual intercourse. Multivariate analyses and multiple logistic regression models showed that use of crack cocaine and heavy drinking were associated with never having had an HIV-care provider, high-risk sexual behavior, and not receiving antiretroviral therapy. Inpatient interventions that link and retain HIV-positive persons in primary care services could prevent HIV transmission and unnecessary hospitalizations.

Drinking Alcohol before Age 13 and Negative Outcomes in Late Adolescence

BACKGROUND Research has shown that adolescents who begin drinking at an early stage in life are at greater risk of developing alcohol dependency, as well as a variety of negative outcomes, for instance, delinquent behavior. Most of these studies have focused on those who begin drinking in middle adolescence, but little attention has been paid to youth who initiate drinking under the age of 13. Twenty percent of adolescents have begun using alcohol by the age of 13. The purpose of the study is to examine whether initiating alcohol use before the age of 13 exacerbates negative outcomes in late adolescence. METHODS Data for the study were derived from 2 school-based statewide surveys conducted in Florida: the 2005 YRBS and the 2006 FYSAS. The sample included 12,352 11th and 12th grade students divided into 3 groups: students who initiated alcohol use under the age of 13, students who initiated alcohol use at age 13 or later, and students who never used alcohol. RESULTS Results showed that after adjusting for gender, ethnicity/race, and grade, adolescents who initiated alcohol use before age 13 were more likely to report problems with school performance and display delinquent behaviors (carrying a gun, carrying a weapon to school, and recent marijuana use). CONCLUSION Although no temporal relationships can be determined between drinking alcohol before age 13 and delinquent behavior outcomes, the results suggested that adolescents under the age of 13 need to be included in national epidemiological surveys on alcohol use and more efforts need to be directed toward the implementation of prevention programs early in elementary and middle schools.

Never in care: characteristics of HIV-infected crack cocaine users in 2 US cities who have never been to outpatient HIV care.

Background:There are very limited data available of the correlates of HIV-infected crack users who have never been to HIV care. Methods:Interviews were conducted at bedside with HIV-infected crack cocaine users who were recruited from the inpatient wards at Jackson Memorial Hospital in Miami, FL, and Grady Memorial Hospital in Atlanta, GA, between August 2006 and July 2009. Participants were asked about their sociodemographic characteristics, drug use, drug/alcohol treatment history, use of HIV care, perceived social support, and mental health status. Multiple logistic regression was performed to identify factors associated with never having been to HIV care. Results:Among 355 study participants, 21% reported never having been to a doctor or clinic for HIV care. Higher adjusted odds of never having been in care were associated with an annual income of less than

An Association between Bullying Behaviors and Alcohol Use among Middle School Students.

5000 [adjusted odds ratio (AOR) = 8.17, 95% confidence interval (CI) = 3.35 to 19.94], residence in Atlanta compared with Miami (AOR = 2.57, 95% CI = 1.36 to 4.83), no history of drug treatment (AOR = 4.13, 95% CI = 2.24 to 7.62), and not being helped into care at the time of HIV diagnosis (AOR = 2.83, 95% CI = 1.56 to 5.15). Conclusions:Our data show that a significant proportion of HIV-infected crack cocaine users in 2 city hospitals have never been to HIV care. Interventions at the time of HIV diagnosis and drug treatment participation may facilitate linkage to care.

Constant temperature and time period effects on Anopheles gambiae egg hatching.

Although a high prevalence of bullying behaviors among adolescents has been documented, little is known about the association between bullying behaviors and alcohol use among perpetrators or victims. This study used data from a representative two-stage cluster random sample of 44, 532 middle school adolescents in Florida. We found a high prevalence of bullying behaviors (30% physical, 52% verbal, 12% cyber). A higher proportion of students (21%) who were involved in any type of bullying behavior used alcohol than students who were not involved (13%). Students involved in bullying behaviors as perpetrators or victims were significantly more likely to have used alcohol in the past-30-days than students who were not involved in bullying. Results suggest that bullying behaviors may be associated with alcohol use and that early evaluation of bullying behavior may be important as part of alcohol-use prevention programs among young adolescents.

HIV-positive patients’ discussion of alcohol use with their HIV primary care providers

ABSTRACT Anopheles gambiae Giles sensu stricto (Diptera: Culicidae) egg development and its relation to environmental parameters is an understudied aspect of vector biology. Although several studies have illustrated the dramatic effects of temperature on egg development, egg hatching dynamics remain unclear. The objective of this study was to expose An. gambiae eggs to various temperatures for different lengths of time and determine the impact on egg development and hatching count. Batches of mosquito eggs (N  =  30 eggs/replicate) were incubated under moist conditions at temperatures of 12, 22, 27, 33, and 42°C for intervals of 1, 3, 7, and 10 days. After that, they were flooded with distilled water at 27°C, and hatching counts were observed for up to 7 days. Mosquito eggs held at 22 and 27°C had the highest overall mean hatching count. During early incubation periods, eggs held at 33°C had hatching counts comparable to 22 and 27°C, but counts decreased drastically during later incubation periods. Temperatures of 12 and 42°C reduced mosquito egg viability, because few eggs hatched in these temperature regimes. Other experiments revealed that during early embryonic development, temperature had a major effect on the developing embryo, while later in embryonic development it had no dramatic effect. Microscopic observation of the An. gambiae embryo showed that extreme low and high temperatures affected the normal development of the embryo. A regression model was developed to describe the effect of incubation temperature and incubation period on egg hatching counts, which demonstrated that the optimum temperature for egg hatching ranges from 24 to 30°C, irrespective of incubation period. The interaction between temperature and time period may have implications for dry-season survival and climate-based models of malaria risk.

Hiv Medical Providers' Perceptions of the Use of Antiretroviral Therapy as Nonoccupational Postexposure Prophylaxis in 2 Major Metropolitan Areas

OBJECTIVES We investigated the prevalence of HIV-positive patients discussing alcohol use with their HIV primary care providers and factors associated with these discussions. METHODS We recruited 1225 adult participants from 10 HIV care clinics in three large US cities from May 2004 to 2005. Multivariate logistic regression analysis was used to assess the associations between self-reported rates of discussion of alcohol use with HIV primary care providers in the past 12 months and the CAGE screening measure of problem drinking and sociodemographic variables. RESULTS Thirty-five percent of participants reported discussion of alcohol use with their primary care providers. The odds of reporting discussion of alcohol were three times greater for problem drinkers than for non-drinkers, but only 52% of problem drinkers reported such a discussion in the prior 12 months. Sociodemographic factors associated with discussion of alcohol use (after controlling for problem drinking) were being younger than 40, male, being non-white Hispanic (compared with being Hispanic), being in poorer health, and having a better patient-provider relationship. CONCLUSIONS Efforts are needed to increase the focus on alcohol use in the HIV primary care setting, especially with problem drinkers. Interventions addressing provider training or brief interventions that address alcohol use by HIV-positive patients in the HIV primary care setting should be considered as possible approaches to address this issue.

Early Linkage to HIV Care and Antiretroviral Treatment among Men Who Have Sex with Men — 20 Cities, United States, 2008 and 2011

Introduction:In 2005, the Centers for Disease Control and Prevention expanded its recommendation of postexposure prophylaxis (PEP) use in the workplace to include nonoccupational exposures (nPEP). The availability and extensive use of nPEP have not achieved widespread acceptance among health-care providers of high-risk populations, and public health and primary care agencies have been sparse in their implementation of nPEP promotion, protocols, and practices. Methods:We conducted a survey of HIV providers (n = 142, response rate = 61%) in Miami-Dade County (Florida) and the District of Columbia that focused on their knowledge, attitudes, beliefs, and practices related to the delivery of nPEP. We then analyzed differences in survey responses by site and by history of prescribing nPEP using bivariate and multivariate logistic regression. Results:More District of Columbia providers (59.7%) reported ever prescribing nPEP than in Miami (39.5%, P < 0.048). The majority of practices in both cities did not have a written nPEP protocol and rarely or never had patients request nPEP. Multivariable analysis for history of prescribing nPEP was dominated by having patients request nPEP [odds ratio (OR) = 21.53] and the belief that nPEP would lead to antiretroviral resistance (OR = 0.14) and having a written nPEP protocol (OR = 7.49). Discussion:Our findings are consistent with earlier studies showing the underuse of nPEP as a prevention strategy. The significance of having a written nPEP protocol and of patient requests for nPEP speaks to the importance of using targeted strategies to promote widespread awareness of the use of HIV antiretroviral medications as a prevention intervention.

Healthcare Access and PrEP Continuation in San Francisco and Miami Following the U.S. PrEP Demo Project.

Early linkage to care and antiretroviral (ARV) treatment are associated with reduced HIV transmission. Male-to-male sexual contact represents the largest HIV transmission category in the United States; men who have sex with men (MSM) are an important focus of care and treatment efforts. With the release of the National HIV/AIDS Strategy and expanded HIV treatment guidelines, increases in early linkage to care and ARV treatment are expected. We examined differences in prevalence of early linkage to care and ARV treatment among HIV-positive MSM between 2008 and 2011. Data are from the National HIV Behavioral Surveillance System, which monitors behaviors among populations at high risk of HIV infection in 20 U.S. cities with high AIDS burden. MSM were recruited through venue-based, time-space sampling. Prevalence ratios comparing 2011 to 2008 were estimated using linear mixed models. Early linkage was defined as an HIV clinic visit within 3 months of diagnosis. ARV treatment was defined as use at interview. Prevalence of early linkage to care was 79% (187/236) in 2008 and 83% (241/291) in 2011. In multivariable analysis, prevalence of early linkage did not differ significantly between years overall (P = 0.44). Prevalence of ARV treatment was 69% (790/1,142) in 2008 and 79% (1,049/1,336) in 2001. In multivariable analysis, ARV treatment increased overall (P = 0.0003) and among most sub-groups. Black MSM were less likely than white MSM to report ARV treatment (P = 0.01). While early linkage to care did not increase significantly between 2008 and 2011, ARV treatment increased among most sub-groups. Progress is being made in getting MSM on HIV treatment, but more efforts are needed to decrease disparities in ARV coverage.