James M. Tesoriero

HIV Behavioral Research Online

Internet access has caused a global revolution in the way people of all ages and genders interact. Many have turned to the Internet to seek love, companionship, and sex, prompting researchers to move behavioral studies online. The sexual behavior of men who have sex with men (MSM) has been more closely studied than that of any other group online given the abundance of gay-oriented websites and concerns about increasing transmission of HIV and other sexually transmitted infections. Not only does the Internet provide a new medium for the conduct of behavioral research and for participant recruitment into an array of research studies, it has the as yet unrealized potential to reach huge numbers of MSM with innovative harm reduction and prevention messages tailored to individualized needs, interests, and risk behavior. Internet-based research on sexual behavior has many advantages in rapidity of recruitment of diverse samples which include individuals unreachable through conventional methods (i.e., non-gay identified and geographically and socially isolated MSM, etc.). Internet-based research also presents some new methodologic challenges in study design, participant recruitment, survey implementation, and interpretation of results. In addition, there are ethical issues unique to online research including difficulties in verifying informed consent, obstacles to surveying minors, and the ability to assure anonymity. This paper presents a review of Internet-based research on sexual behavior in MSM, a general discussion of the methodologic and ethical challenges of Internet-based research, and recommendations for future interdisciplinary research.

Stability of adherence to highly active antiretroviral therapy over time among clients enrolled in the treatment adherence demonstration project.

Adherence to antiretroviral medications is essential to therapeutic success. Many published studies have investigated the degree of adherence or nonadherence, but sample sizes have generally been small, and adherence has seldom been viewed as a longitudinal process. This paper investigates the stability of adherence over time among HIV-infected individuals attending adherence support programs in New York State. The study cohort consists of 435 clients who were on HAART at baseline and who completed at least 2 follow-up interviews. Although cross-sectional nonadherence did not exceed 35%, nonadherence reached 54% when considered across all 3 interviews. Analysis of transition matricies revealed moderate stability in adherence over time (e.g., first follow-up adherence was 81.0% for clients adherent at baseline, compared with 58.3% for clients nonadherent at baseline). Second-order transition matricies offered additional predictive utility. Multivariate results indicated that, for some, it was the transition from a desirable to an undesirable state (e.g., from no illicit drug use to illicit drug use) that increased the likelihood of nonadherence, rather than the presence of these characteristics over time. Findings illustrate the importance of multiple, periodic assessments of adherence and the need to consider strategies to increase stability in the factors affecting adherence to HAART.

Correlation of a brief perceived stress measure with nonadherence to antiretroviral therapy over time.

Adherence to antiretroviral medications has proven to be a challenge for individuals diagnosed with HIV infection. Nonadherence can lead to treatment failure, HIV resistance, and poor health outcomes. Many published studies have described factors associated with poor adherence, yet few have presented validated scales that could practically be applied in treatment settings to identify individuals at higher risk of nonadherence. This article explores the relationship between a revised version of the Perceived Stress Scale and nonadherence to antiretroviral therapy. The scale consists of the following items: How often in the past month have you felt that you were unable to control the important things in your life; confident in your ability to handle your personal problems; that things were going your way; and difficulties were piling up so high you could not handle them? Response options were “never or rarely,” “sometimes,” “often,” and “mostly or always.” In multivariate analysis, clients who scored in the highest quartile of perceived stress were more than twice as likely to be nonadherent at baseline and follow-up 1 and more than 5 times as likely to be nonadherent at follow-up 2 than clients in the lowest quartile of perceived stress scores.

Expanding access to sterile syringes through pharmacies: Assessment of New York's Expanded Syringe Access Program

OBJECTIVES To investigate the evolution of pharmacist practices, attitudes, and experiences with the Expanded Syringe Access Program (ESAP), which permits over-the-counter sale of syringes by registered pharmacies in New York State. DESIGN Longitudinal study. SETTING New York State in 2002 and 2006. PARTICIPANTS 506 (2002) and 682 (2006) managing pharmacists (response rates approximately 70%) at ESAP-registered pharmacies (n = 346 in both years). INTERVENTION Mailed surveys (2002 and 2006). MAIN OUTCOME MEASURES Pharmacist practices, attitudes, and experiences with ESAP over time. RESULTS Approximately 75% of pharmacists reported that ESAP had facilitated timely/emergency access to syringes, and more than 90% in each year reported no problems or very few problems administering ESAP. The practice of placing additional requirements on the sale of syringes decreased from 2002 (51.4%) to 2006 (45.1%), while a 55% increase in syringe sales was reported between 2002 (43.3/month) and 2006 (67.1/month). The sale of sharps containers also increased between 2002 (85.2%) and 2006 (92.8%). Community independent pharmacies and those located outside New York City generally expressed more favorable attitudes and experiences with ESAP, although these differences decreased over time. CONCLUSION Pharmacy-based syringe access is a viable harm-reduction alternative in the fight against blood-borne diseases, with ESAP now equaling the number of syringes being distributed by syringe exchange programs in New York State. Continued education/training is necessary to increase participation in ESAP and to further reduce barriers to ESAP use.

What do pharmacists think about New York State's new nonprescription syringe sale program? Results of a survey

Access to sterile syringes can prevent transmission of blood-borne diseases such as human immunodeficiency virus (HIV) and hepatitis B and C. We conducted a survey of attitudes of pharmacists to aid, in development of the Expanded. Syringe Access Demonstration Program (ESAP) in New York State. ESAP is an HIV prevention initiative that authorizes nonprescription sale of hypodermic needles and syringes by registered pharmacies in New York State beginning January 1, 2001. As part of planning for program implementation, the New York State Department of Health (NYSDOH), in collaboration with the New York State Education Department, conducted a mailed survey of all 4,392 licensed pharmacies in New York State during the summer of 2000. Some surveys (171) were returned as undeliverable. Of the 4,221 eligible respondents, 874 (20.7%) completed surveys were received, of which 574 (65.7%) indicated that their pharmacy would likely participate in ESAP. An additional 11.0% were not sure. Only 139 (15.9%) indicated that they would definitely not participate; 7.4% left this question blank. There were 608 responses to questions on safe disposal practices. Of these, 315 (51.8%) respondents indicated that their pharmacy sold sharps containers, and an additional 29 made them available at no cost. Only 133 (21.9%) respondents to this question did not offer sharps containers and were not interested in doing so. In all, 54 responses indicated that they accepted used hypodernmic needles and syringesfor disposal. Some (170, 28%) that did not accept shaprs for disposal were interested in doing so. More than half (382, 63.0%) did not wish to do so. NYSDOH considered respondent suggestions and minimized ESAP requirements. By March 31, 2001, only 3 months after ESAP became effective, more than half of all licensed pharmacies in New York State were registered for ESAP. Survey results provided useful information to NYSDOH and a good indication of likelihood of registration. The high level of pharmacy participation in ESAP may be reflective of NYSDOH attention to issues raised by pharmacists, as well as the direct effects of outreach to pharmacy chains regarding ESAP.

The Effect of Name-Based Reporting and Partner Notification on HIV Testing in New York State

OBJECTIVES We examined the effect of New Yorks HIV Reporting and Partner Notification law on HIV testing levels and on the HIV testing decisions of high-risk individuals. METHODS In-person interviews were administered to 761 high-risk individuals to assess their knowledge, attitudes, and behaviors regarding HIV testing and reporting. Trends in HIV testing were also assessed in publicly funded HIV counseling and testing programs, Medicaid, and New Yorks Maternal Pediatric Newborn Prevention and Care Program. RESULTS High-risk individuals had limited awareness of the reporting and notification law, and few cited concern about named reporting as a reason for avoiding or delaying HIV testing. HIV testing levels, posttest counseling rates, and anonymous-to-confidential conversion rates among those who tested HIV positive were not affected by the law. Medicaid-related HIV testing rates also remained stable. HIV testing during pregnancy continued to trend upward following implementation of the law. Findings held true within demographic and risk-related subgroups. CONCLUSIONS HIV reporting has permitted improved monitoring of New Yorks HIV/AIDS epidemic. This benefit has not been offset by decreases in HIV testing behavior, including willingness to test among those at high risk of acquiring HIV.

Who Purchases Nonprescription Syringes? Characterizing Customers of the Expanded Syringe Access Program (ESAP)

This study represents the first attempt in the USA to survey pharmacy nonprescription syringe customers at their point of purchase. We surveyed 62 individuals purchasing nonprescription syringes in seven pharmacies located in NYC and Albany, NY, USA. Three quarters of respondents purchased for illicit use, and 36% purchased for medical use, with differences found by race and gender. Half got their syringes from pharmacies “most of the time.” Half had ever been refused a syringe purchase in a NYS pharmacy, with men, Blacks, and Hispanics reporting higher levels of refusals than women or whites. Two thirds reported syringe reuse but very few reported sharing. While approximately one quarter safely obtained and disposed of syringes “most of the time,” two thirds used both safe and unsafe methods. Pharmacy-based syringe access programs are essential in areas not served by syringe exchanges.

Screening persons newly diagnosed with HIV/AIDS for risk of intimate partner violence: early progress in changing practice.

Interventions to prevent intimate partner violence (IPV), including among those at risk for or living with HIV/AIDS, are needed. In 2001, screening persons who test positive for HIV for risk of IPV was required in New York State, launching the first large-scale program to screen for IPV risk in conjunction with HIV counseling and testing (HCT). Written surveys of counselors, physicians, and agency supervisors explored attitudes, practices, knowledge, and training needs surrounding screening for risk of IPV during HCT. Most HCT providers were aware of screening requirements, but practice varied. Counselors were more likely to screen than were physicians and asked more screening questions. Despite guidelines, screening was generally not standardized and sporadic. IPV screening in conjunction with HCT is possible. Building capacity and commitment of local HCT providers through provision of training and by fostering partnerships with public health partner services staff can help overcome identified barriers to preventing IPV in a high-risk population.

Increasing safe syringe collection sites in New York State.

This article describes expansion of options for safe syringe collection in New York State (NYS) in conjunction with efforts to enhance and expand access to hypodermic needles and syringes. Together with activities to educate the public and providers about the dangers of improperly disposed of syringes, the goals were to (1) develop community-based collection sites for individuals to safely dispose of used syringes and (2) improve accessibility of existing health-care facility-based collection sites. During the period of 2002 to 2006, 79 community-based collection sites were created. These sites collected an estimated 2.6 million used syringes during 2006. Significant increases in availability and use of health-care facility-based collection sites was also documented. Efforts to promote safe disposal in NYS are ongoing, informed by these findings.

Mandating the offer of HIV testing in New York: simulating the epidemic impact and resource needs.

Background:A 2010 New York law requires that patients aged 13–64 years be offered HIV testing in routine medical care settings. Past studies report the clinical outcomes, cost-effectiveness, and budget impact of expanded HIV testing nationally and within clinics but have not examined how state policies affect resource needs and epidemic outcomes. Methods:A system dynamics model of HIV testing and care was developed, where disease progression and transmission differ by awareness of HIV status, engagement in care, and disease stage. Data sources include HIV surveillance, Medicaid claims, and literature. The model projected how alternate implementation scenarios would change new infections, diagnoses, linkage to care, and living HIV cases over 10 years. Results:Without the law, the model projects declining new infections, newly diagnosed cases, individuals newly linked to care, and fraction of undiagnosed cases (reductions of 62.8%, 59.7%, 54.1%, and 57.8%) and a slight increase in living diagnosed cases and individuals in care (2.2% and 6.1%). The law will further reduce new infections, diagnosed AIDS cases, and the fraction undiagnosed and initially increase and then decrease newly diagnosed cases. Outcomes were consistent across scenarios with different testing offer frequencies and implementation times but differed according to the level of implementation. Conclusions:A mandatory offer of HIV testing may increase diagnoses and avert infections but will not eliminate the epidemic. Despite declines in new infections, previously diagnosed cases will continue to need access to antiretroviral therapy, highlighting the importance of continued funding for HIV care.