Kelly R. Knight

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.

Factors associated with antiretroviral therapy adherence and medication errors among HIV-infected injection drug users

Background:Active drug use is often associated with poor adherence, but few studies have determined psychosocial correlates of adherence in injection drug users (IDUs). Methods:Of 1161 Intervention for Seropositive Injectors-Research and Evaluation study enrollees, 636 were taking antiretrovirals. We assessed self-reported adherence to self-reported antiretroviral regimens and medication errors, which we defined as daily doses that were inconsistent with standard or alternative antiretroviral prescriptions. Results:Most subjects (75%, n = 477) self-reported good (≥90%) adherence, which was strongly associated with an undetectable viral load. Good adherence was independently associated with being a high school graduate, not sharing injection equipment, fewer depressive symptoms, positive attitudes toward antiretrovirals, higher self-efficacy for taking antiretrovirals as prescribed, and greater sense of responsibility to protect others from HIV. Medication errors were made by 54% (n = 346) and were strongly associated with a detectable viral load and fewer CD4 cells. Errors were independently associated with nonwhite race and with depressive symptoms, poorer self-efficacy for safer drug use, and worse attitudes toward HIV medications. Conclusions:Modifiable factors associated with poor adherence, including depressive symptoms and poor self-efficacy, should be targeted for intervention. Because medication errors are prevalent and associated with a detectable viral load and fewer CD4 cells, interventions should include particular efforts to identify medication taking inconsistent with antiretroviral prescriptions.

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.

“You can't do nothing in this damn place”: Sex and intimacy among couples with an incarcerated male partner

In an effort to deepen our understanding of how circumstances of forced separation and the interdiction of physical contact affect womens sexual behavior, we investigated the development and maintenance of heterosexual couples’ intimacy when the male partner is incarcerated. As HIV‐prevention scientists who work with women visiting men at a California state prison, we recognize that correctional control extends to these womens bodies, both when they are within the facilitys walls visiting their mates and when they are at home striving to remain connected to absent men. This paper analyzes the impact of a peculiar public “place “—a penitentiary—on couples’ romantic and sexual interactions, drawing out the implications of imprisonment for relationship decision making, sexual health, and HIV risk. Using qualitative interviews with 20 women who visit their incarcerated partners and 13 correctional officers who interact with prison visitors, we examine how institutional constraints such as the regulation of womens apparel, the prohibition of physical contact, and the lack of privacy result in couples forging alternative “spaces” in which their relationships occur. We describe how romantic scripts, the build‐up of sexual tension during the incarceration period, and conditions of parole promote unprotected sexual intercourse and other HIV/STD risk behavior following release from prison.

HIV intervention for providers study: a randomized controlled trial of a clinician-delivered HIV risk-reduction intervention for HIV-positive people.

Clinician-delivered prevention interventions offer an opportunity to integrate risk-reduction counseling as a routine part of medical care. The HIV Intervention for Providers study, a randomized controlled trial, developed and tested a medical provider HIV prevention training intervention in 4 northern California HIV care clinics. Providers were assigned to either the intervention or control condition (usual care). The intervention arm received a 4-hour training on assessing sexual risk behavior with HIV-positive patients and delivering risk-reduction-oriented prevention messages to patients who reported risk behaviors with HIV-uninfected or unknown-status partners. To compare the efficacy of the intervention versus control on transmission risk behavior, 386 patients of the randomized providers were enrolled. Over six-months of follow-up, patients whose providers were assigned the intervention reported a relative increase in provider-patient discussions of safer sex (OR = 1.49; 95% CI = 1.06 to 2.09), assessment of sexual activity (OR = 1.60; 95% CI = 1.05 to 2.45), and a significant decrease in the number of sexual partners (OR = 0.49, 95% CI = 0.26 to 0.92). These findings show that a brief intervention to train HIV providers to identify risk and provide a prevention message results in increased prevention conversations and significantly reduced the mean number of sexual partners reported by HIV-positive patients.

The life priorities of HIV-seropositive injection drug users: findings from a community-based sample.

Using cross-sectional data from an ethnically diverse sample of 161 HIV-seropositive injection drug users (IDUs), we investigated (1) how HIV-positive IDUs rank their life priorities, (2) whether HIV prioritization (defined as whether or not ranking HIV as a top priority) is associated with risk behaviors, and (3) potential correlates of HIV prioritization. HIV was ranked as the most important priority by 37% of the participants. Among those who did not rank HIV as the top priority, housing, money, and safety from violence were particularly salient priorities. Those who gave the highest priority to HIV were less likely to have unprotected vaginal sex with primary partners who were HIV negative or of unknown serostatus, were less likely to split drugs with a used syringe, and used fewer numbers of injection drugs. HIV prioritization, however, was not associated with sex risk behaviors with nonprimary partners and HIV-positive primary partners. Significant correlates of HIV prioritization included age and the use of a heroin/stimulant mixture. These findings provide a number of important implications for HIV prevention intervention research for HIV-positive IDUs.

Sexual transmission risk behavior reported among behaviorally bisexual HIV-positive injection drug-using men.

Background:Few research studies have examined the HIV transmission risk behaviors of HIV-positive injection drug users (IDUs) who are men who have sex with men and women (MSMW). Methods:We compared unprotected vaginal or anal sex with an HIV-negative or unknown (UNK) status sexual partner of MSMW (n = 118) with men who have sex exclusively with women (MSW; n = 469) and men who have sex exclusively with men (MSM; n = 90) using baseline information from the Intervention for Seropositive Injectors-Research and Evaluation (INSPIRE) study, a 4-city randomized controlled trial. Results:MSMW were twice as likely to report unprotected vaginal sex (P < 0.001) and 3 times as likely to report unprotected anal sex with an HIV-negative/UNK status female partner (P < 0.001) as MSW. MSMW did not differ in their report of unprotected insertive anal sex and were half as likely to report unprotected receptive anal sex with HIV-negative/UNK status men (P = 0.02) as MSM. MSMW were 2 times as likely to report engaging in transactional sex (buying or selling sex in exchange for money, drugs, or housing) than MSM or MSW (81%, 43%, and 36%, respectively; P < 0.001). Conclusions:Further research is needed to understand the contexts of unprotected sex among HIV-positive injection drug-using MSMW. Prevention programs should target the unique prevention needs of this population, particularly their risk with female partners.

Treatment as harm reduction, defunding as harm maximization: The case of methadone maintenance

Despite numerous research studies demonstrating the efficacy of methadone maintenance treatment (MMT) in general and the value of retention in particular, the increasing defunding of this modality has compromised its potential. From 1990 to 1995 the lead author conducted a longitudinal research project to determine the impact of the cost of treatment on 233 San Francisco Bay Area study participants seeking, enrolled in, or defunded from MMT. This paper reports on selected findings from that study. Using variables of drug use, crime, gender and HIV risk, qualitative and quantitative results comparing those seeking treatment with those enrolled in treatment indicated that MMT functioned as a harm-reduction tool. When clients were defunded, however, drug use, crime and HIV risk increased and harm was maximized.

Recent Violence in a Community-Based Sample of Homeless and Unstably Housed Women With High Levels of Psychiatric Comorbidity

OBJECTIVES We determined associations between co-occurring psychiatric conditions and violence against homeless and unstably housed women. METHODS Between 2008 and 2010, we interviewed homeless and unstably housed women recruited from community venues about violence, socioeconomic factors, and psychiatric conditions. We used multivariable logistic regression to determine independent correlates of violence. RESULTS Among 291 women, 97% screened positive for 1 or more psychiatric conditions. Types of violence perpetrated by primary partners and persons who were not primary partners (non-primary partners) included emotional violence (24% vs 50%; P < .01), physical violence (11% vs 19%; P < .01), and sexual violence (7% vs 22%; P < .01). The odds of primary partner and non-primary partner violence increased with each additional psychiatric diagnosis and decreasing levels of social isolation. CONCLUSIONS All types of violence were more commonly perpetrated by non-primary partners, suggesting that an exclusive focus on domestic violence screening in health care or social service settings will miss most of the violence in this population. Contrary to some previous studies, the odds of violence decreased as social isolation increased, suggesting that social isolation may be protective in homeless and unstably housed communities with high levels of comorbidity and limited options.

Agents of change: peer mentorship as HIV prevention among HIV-positive injection drug users.

This paper presents a qualitative investigation of peer mentoring among HIV seropositive injection drug users in a randomized controlled trial, the INSPIRE study. Qualitative analyses of 68 in-depth open-ended interviews conducted in 2005 in Baltimore, New York, Miami, and San Francisco revealed that these individuals conceptualized themselves as change agents through the identity of peer mentor at the three related domains of individual, interpersonal, and community-level change. Implications for program development and future research of peer mentoring as a mechanism for HIV prevention are discussed. This study was funded by the Centers for Disease Control and Prevention and Health Resources and Services Administration (HRSA).