Janni J. Kinsler

The Association of Stigma with Self-Reported Access to Medical Care and Antiretroviral Therapy Adherence in Persons Living with HIV/AIDS

BackgroundThe stigma of HIV-infection may profoundly affect the lives of persons living with HIV/AIDS (PLHA). However few studies have examined the association of HIV stigma with multiple components of HIV treatment and care.ObjectivesTo estimate the association between HIV stigma and: self-reported access to care, regular source of HIV care, and antiretroviral therapy adherence; and to test whether mental health mediates these associations. DesignCross-sectional study.Participants202 PLHA living in Los Angeles County in 2007.MeasurementsParticipants completed an anonymous survey, assessing internalized HIV stigma (28-items, alpha = 0.93), self-reported access to medical care (six items, alpha = 0.75), regular source of HIV care, and antiretroviral therapy (ART) adherence.ResultsOne-third of participants reported high levels of stigma; 77% reported poor access to care; 42.5% reported suboptimal ART adherence; and 10.5% reported no regular source of HIV care. In unadjusted analysis, those reporting a high level of stigma were more likely to report poor access to care (OR = 4.97, 95% CI 2.54–9.72), regular source of HIV care (OR = 2.48, 95% CI 1.00–6.19), and ART adherence (OR = 2.45, 95% CI 1.23–4.91). In adjusted analyses, stigma was significantly associated with poor access to care (OR = 4.42, 95% CI 1.88–10.37), but not regular source of HIV care or ART adherence. Mental health mediated the relationship between stigma and ART adherence, but not poor access to care or regular source of HIV care.ConclusionsThe association of stigma with self-reported access to care and adherence suggests that efforts to improve these components of HIV care will require a better understanding of the possible effects of stigma and it′s mediators.

Acceptability of pre-exposure prophylaxis as an HIV prevention strategy: barriers and facilitators to pre-exposure prophylaxis uptake among at-risk Peruvian populations

This study examined pre-exposure prophylaxis (PrEP) acceptability among female sex workers, male-to-female transgendered persons and men who have sex with men in Lima, Peru. Focus groups explored social issues associated with PrEP acceptability and conjoint analysis assessed preferences among eight hypothetical PrEP scenarios with varying attribute profiles and their relative impact on acceptability. Conjoint analysis revealed that PrEP acceptability ranged from 19.8 to 82.5 out of a possible score of 100 across the eight hypothetical PrEP scenarios. Out-of-pocket cost had the greatest impact on PrEP acceptability (25.2, P < 0.001), followed by efficacy (21.4, P < 0.001) and potential side-effects (14.7, P < 0.001). Focus group data supported these findings, and also revealed that potential sexual risk disinhibition, stigma and discrimination associated with PrEP use, and mistrust of healthcare professionals were also concerns. These issues will require careful attention when planning for PrEP roll-out.

The Impact of Acculturation on Utilization of HIV Prevention Services and Access to Care Among an At-Risk Hispanic Population

Introduction. HIV/AIDS disproportionately affects Hispanics in the United States, a diverse and heterogeneous population. The purpose of this study was to evaluate the relationship of acculturation with HIV and hepatitis C testing, and access to care among Hispanics at risk for HIV. Methods. We recruited 600 Hispanics from STD clinics, community-based organizations, and needle exchange programs in Los Angeles County. Results. Low levels of acculturation were significantly associated with having fewer HIV tests (OR 1.98, 95% CI 1.24, 3.15), no hepatitis C tests (OR 2.61, 95% CI 1.77, 3.84), testing positive for HIV (OR 2.67, 95% CI 1.04, 6.83), and low levels of access to care (β=0.06; p<.05). Conclusions. Low levels of acculturation are an important barrier to the use of HIV-related health care services. Our findings may inform the development of effective interventions that address the cultural and behavioral differences among Hispanic subgroups.

Using laboratory surveillance data to estimate engagement in care among persons living with HIV in Los Angeles County, 2009.

Poor engagement in HIV care has been associated with delayed access to antiretroviral treatment and increased HIV transmission. Using viral load (VL) results from HIV laboratory surveillance data to conduct longitudinal and cross-sectional analyses, we examined linkage to care, retention in care, and their associated factors in 37,325 persons living with HIV (PLWH) in Los Angeles County (LAC). Linkage to care was considered timely if a VL test result was present ≤3 months of diagnosis. Successful retention in care was defined as having two or more VL test results ≥90 days apart during 2009. Of 6841 persons newly diagnosed with HIV in 2007-2009, 67% were linked to care within 3 months of diagnosis. Factors associated with delayed linkage to care included being African American, Latino, and Asian/Pacific Islander (adjusted hazard ratio [AHR]=0.81; 95% CI=0.75-0.87, AHR=0.83; 95% CI=0.77-0.89, AHR=0.82; 95% CI=0.71-0.94, respectively). Of the 37,325 PLWH, 52% were retained in care during 2009. Factors associated with lack of retention in care included injection drug use (adjusted prevalence ratio [APR]=0.88; 95% CI=0.84-0.93), incarceration at diagnosis (APR=0.56; 95% CI=0.51-0.61), being diagnosed in pre-highly active antiretroviral therapy (HAART) era (APR=0.94; 95% CI=0.92-0.96) or at a public facility (APR=0.97; 95% CI=0.95-1.00), age <45 years (APR=0.87; 95% CI=0.86-0.89), and having concurrent HIV/AIDS diagnoses (APR=0.94; 95% CI=0.92-0.96). This study demonstrates the value of using VL surveillance data to monitor engagement in care among PLWH, and its potential to improve linkage and retention efforts where disparities in care are observed.

Using Conjoint Analysis to Measure the Acceptability of Rectal Microbicides Among Men Who Have Sex with Men in Four South American Cities

Conjoint Analysis (CJA), a statistical market-based technique that assesses the value consumers place on product characteristics, may be used to predict acceptability of hypothetical products. Rectal Microbicides (RM)—substances that would prevent HIV infection during receptive anal intercourse—will require acceptability data from potential users in multiple settings to inform the development process by providing valuable information on desirable product characteristics and issues surrounding potential barriers to product use. This study applied CJA to explore the acceptability of eight different hypothetical RM among 128 MSM in Lima and Iquitos, Peru; Guayaquil, Ecuador; and Rio de Janeiro, Brazil. Overall RM acceptability was highest in Guayaquil and lowest in Rio. Product effectiveness had the greatest impact on acceptability in all four cities, but the impact of other product characteristics varied by city. This study demonstrates that MSM from the same region but from different cities place different values on RM characteristics that could impact uptake of an actual RM. Understanding specific consumer preferences is crucial during RM product development, clinical trials and eventual product dissemination.ResumenEl Análisis Conjunto (CJA por sus siglas en inglés) es una técnica estadística de mercadotecnia que sirve para evaluar la valoración que los consumidores otorgan a las características de un producto, y que puede ser usada para predecir la aceptabilidad de productos hipotéticos. Para el desarrollo de microbicidas rectales (MR)—sustancias que podrían prevenir la infección por VIH durante el coito anal receptivo—es necesario contar con datos de aceptabilidad, características deseadas y probables barreras para el empleo de MR por usuarios potenciales, en múltiples escenarios. Este estudio aplica CJA para explorar la aceptabilidad de ocho diferentes MR hipotéticos entre 128 HSH en Lima e Iquitos, Perú; Guayaquil, Ecuador; y Río de Janeiro, Brasil. En general, la más alta aceptabilidad se dio en Guayaquil y la más baja en Río. La eficacia del producto tuvo el mayor impacto sobre la aceptabilidad en las cuatro ciudades, pero el impacto de otras características del producto varió por ciudades. Este estudio demuestra que los HSH, aunque son de la misma región, pero de diferentes ciudades, otorgan valores distintos a las características de los MR, lo cual podría afectar el uso de un MR real. Es crucial entender las preferencias específicas de los consumidores durante la investigación, desarrollo y eventual difusión de los MR.

Lubricant use among men who have sex with men reporting receptive anal intercourse in Peru: implications for rectal microbicides as an HIV prevention strategy.

This study assessed lubricant use during receptive anal intercourse (RAI) among Peruvian men who have sex with men (MSM) and willingness to use a hypothetical rectal microbicide (RM) formulated as a lubricant to prevent HIV infection. Data were collected from 843 Peruvian MSM for the 2008 HIV Sentinel Surveillance using a computerized self-interview. Half of the participants reported using a lubricant with their last sex partner during RAI, while 77% were willing to use a lubricant to prevent HIV transmission. Lubricant use with last sex partner was significantly associated with unprotected RAI (odds ratio [OR] 1.59, 95% confidence interval [CI], 1.23, 2.05; P < 0.001) and willingness to use a future lubricant RM (OR 1.56, 95% CI: 1.24, 1.95; P < 0.001). This study provides information on the behaviours associated with lubricant use and non-use among MSM practicing RAI in Peru that should inform future RM studies in Peru and other Latin American countries.

Time trends in failure to return for HIV test results.

Goal: The purpose of this study was to examine time trends of failure to return for HIV test results among a mobile van population in Los Angeles. Study Design: This study examined administrative records from 9340 patients of the Mobile HIV Testing van between January 1997 and December 2004. Results: Between 1997 and 2004, a worsening trend was found in the percentage of clients who failed to return for HIV test results. Multivariate analyses showed that the adjusted odds of returning for test results significantly increased relative to 1997, the first year tested. The odds of returning for test results ranged from 1.56 (95% CI = 1.21, 2.00) in 1998 to 2.46 (95% CI = 1.89, 3.19) in 2004. Conclusion: The proportion of MoHOP clients failing to return for test results was high and increased substantially between 1997 and 2004. Given the importance of identifying HIV-infected persons, understanding ways to improve return rates for test results is critical, especially for public health officials, clinicians, and researchers implementing and evaluating HIV prevention strategies.

The role of mental health in mediating the relationship between social support and optimal ART adherence

Optimal adherence to antiretroviral therapy (ART) is essential for reducing mortality and morbidity in persons living with HIV/AIDS (PLWHA), as well as for reducing the risk of further HIV transmission. While studies have identified psychosocial factors such as lack of social support and poor mental health status as important barriers to optimal ART adherence, few studies have explored the potential of a mediation effect of psychosocial factors on the relationship between social support and optimal ART adherence. This paper assessed whether mental health status mediated the relationship between social support and optimal ART adherence among a cross-sectional sample of 202 persons living with HIV who were recruited from HIV clinical care sites and community-based organizations in Los Angeles County (LAC). Participants completed a survey that included social support items from the Medical Outcome Study: Social Support Survey (MOS-SSS) Instrument, mental health measures from the Medical Outcomes Study Short Form (SF-12), and ART adherence based on self-report. Among those currently taking ART, 61.7% reported having optimal adherence. Social support was significantly associated with a high score on the mental health status scale (AOR =2.90; 95% CI=1.14–5.78) and optimal ART adherence (AOR=1.81; 95% CI=1.81; 95% CI=1.18–2.79). When mental health status was introduced into the model, the association between social support and optimal ART adherence was no longer significant. Our findings suggest the HIV interventions targeting social support to improve ART adherence will likely be most successful if the support bolsters the mental health of the participants. Clearly, better understanding the relationships among social support, mental health, and ART adherence will be critical for development and implementation of future ART adherence interventions.

Unintentional injury depictions in popular children's television programs

Objectives: The frequency and magnitude of depictions of risky events and unintentional injuries in top ranked children’s animated and live action television programs was assessed. Methods: Qualitative and quantitative media content analysis were used. Scenes from television episodes were examined for the depiction of risky events and unintentional injuries. Results: A total of 201 actual and potential injury related events were tabulated in 99 episodes aired in 2003 and 2004. Only 26% of the risky events depicted led to an injury or physical consequence. More than 80% of the events involved behavioral or environmental risk factors. Safety factors were not present in over 90% of risky events depicted. The general tone and context of events was humor or indifference rather than concern or action, with little or no relevance to the plot. Conclusion: Unintentional injuries are the leading cause of death and disability for children, yet animated and live action television programs marketed to children continue to portray injury risk inaccurately. Working with the children’s television production industry to improve injury depiction is a much needed advocacy activity.

Rectal douching among Peruvian men who have sex with men, and acceptability of a douche-formulated rectal microbicide to prevent HIV infection.

Rectal douching has attracted recent interest as a possible rectal microbicide (RM) formulation since many men who have sex with men (MSM) practice the behaviour prior to receptive anal intercourse (RAI).1 Acceptability research on rectal douches used by MSM found that if douches were available as an RM, MSM would be highly likely to use them when condoms were not used.2 This study reports on the practice of rectal douching, and the acceptability of a hypothetical RM formulated as a rectal douche among Peruvian MSM, a population with an estimated HIV prevalence of 12.2% compared with 0.61% in the general population.3 This retrospective study was based on data collected from a convenience sample of 824 MSM reporting RAI from three Peruvian cities (Lima, the Pacific coast capital, and the …