Nicole Crepaz

Meta-analysis of High-risk Sexual Behavior in Persons Aware and Unaware They are Infected With Hiv in the United States: Implications for Hiv Prevention Programs

Objectives:To compare the prevalence of high-risk sexual behaviors in HIV+ persons aware of their serostatus with that in HIV+ persons unaware of their status in the United States and to discuss implications for HIV prevention programs. Methods:A meta-analysis was conducted on 11 independent findings. Six findings compared HIV+ aware persons with independent groups of HIV+ unaware persons (between-group comparisons), and 5 findings compared seroconverting individuals before and after being notified of their HIV+ status (within-subject comparisons). Outcomes were self-reported unprotected anal or vaginal intercourse (UAV) during specified recall periods. Results:The analysis integrating all 11 findings indicated that the prevalence of UAV with any partner was an average of 53% (95% confidence interval [CI]: 45%-60%) lower in HIV+ persons aware of their status relative to HIV+ persons unaware of their status. There was a 68% reduction (95% CI: 59%-76%) after adjusting the data of the primary studies to focus on UAV with partners who were not already HIV+. The reductions were larger in between-group comparisons than in within-subject comparisons. Findings for men and women were highly similar. Conclusions:The prevalence of high-risk sexual behavior is reduced substantially after people become aware they are HIV+. Increased emphasis on HIV testing and counseling is needed to reduce exposure to HIV from persons unaware they are infected. Ongoing prevention services are needed for persons who know they are HIV+ and continue to engage in high-risk behavior.

Improving the Reporting Quality of Nonrandomized Evaluations of Behavioral and Public Health Interventions: The TREND Statement

Developing an evidence base for making public health decisions will require using data from evaluation studies with randomized and nonrandomized designs. Assessing individual studies and using studies in quantitative research syntheses require transparent reporting of the study, with sufficient detail and clarity to readily see differences and similarities among studies in the same area. The Consolidated Standards of Reporting Trials (CONSORT) statement provides guidelines for transparent reporting of randomized clinical trials. We present the initial version of the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) statement. These guidelines emphasize the reporting of theories used and descriptions of intervention and comparison conditions, research design, and methods of adjusting for possible biases in evaluation studies that use nonrandomized designs.

Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA.

Background:New HIV infections stem from people who are aware they are HIV positive (approximately 75% of infected persons in the USA) and those who are unaware of their HIV-positive status (approximately 25%). Objective:We estimated the relative contribution of these two groups in sexually transmitting new HIV infections to at-risk (HIV-negative or unknown serostatus) partners in the USA. Methods:The parameters in the estimation included: number of people aware and unaware they are infected with HIV; 33% of the aware group are at low risk of transmitting HIV because of low/undetectable viral load; 57% relative reduction in the prevalence of unprotected anal and vaginal intercourse (UAV) with at-risk partners in persons aware (compared to unaware) they have HIV; and assumed differences in the average number of at-risk UAV partners in each awareness group (ranging from equal to twice as many in the unaware group). Results:The proportion of sexually transmitted HIV from the HIV-positive unaware group was estimated to range from 0.54 (assuming no difference in average number of at-risk UAV partners between groups) to 0.70 (assuming twice as many at-risk UAV partners in the unaware group). Using the lower bounds, the transmission rate from the unaware group was 3.5 times that of the aware group after adjusting for population size differences between groups. Conclusion:The results indicate that the HIV/AIDS epidemic can be lessened substantially by increasing the number of HIV-positive persons who are aware of their status.

Estimating HIV Prevalence and Risk Behaviors of Transgender Persons in the United States: A Systematic Review

Transgender populations in the United States have been impacted by the HIV/AIDS epidemic. This systematic review estimates the prevalence of HIV infection and risk behaviors of transgender persons. Comprehensive searches of the US-based HIV behavioral prevention literature identified 29 studies focusing on male-to-female (MTF) transgender women; five of these studies also reported data on female-to-male (FTM) transgender men. Using meta-analytic approaches, prevalence rates were estimated by synthesizing weighted means. Meta-analytic findings indicated that 27.7% (95% confidence interval [CI], 24.8–30.6%) of MTFs tested positive for HIV infection (four studies), while 11.8% (95% CI, 10.5–13.2%) of MTFs self-reported being HIV-seropositive (18 studies). Higher HIV infection rates were found among African-American MTFs regardless of assessment method (56.3% test result; 30.8% self-report). Large percentages of MTFs (range, 27–48%) reported engaging in risky behaviors (e.g., unprotected receptive anal intercourse, multiple casual partners, sex work). Prevalence rates of HIV and risk behaviors were low among FTMs. Contextual factors potentially related to increased HIV risk include mental health concerns, physical abuse, social isolation, economic marginalization, and unmet transgender-specific healthcare needs. Additional research is needed to explain the causes of HIV risk behavior of transgender persons. These findings should be considered when developing and adapting prevention interventions for transgender populations.

Do prevention interventions reduce HIV risk behaviours among people living with HIV: a meta-analytic review of controlled trials

Objective:To conduct a meta-analytic review of HIV interventions for people living with HIV (PLWH) to determine their overall efficacy in reducing HIV risk behaviours and identify intervention characteristics associated with efficacy. Methods:Comprehensive searches included electronic databases from 1988 to 2004, hand searches of journals, reference lists of articles, and contacts with researchers. Twelve trials met the stringent selection criteria: randomization or assignment with minimal bias, use of statistical analysis, and assessment of HIV-related behavioural or biologic outcomes at least 3 months after the intervention. Random-effects models were used to aggregate data. Results:Interventions significantly reduced unprotected sex [odds ratio (OR), 0.57; 95% confidence interval (CI) 0.40–0.82] and decreased acquisition of sexually transmitted diseases (OR, 0.20; 95% CI, 0.05–0.73). Non-significant intervention effects were observed for needle sharing (OR, 0.47, 95% CI, 0.13–1.71). As a whole, interventions with the following characteristics significantly reduced sexual risk behaviours: (1) based on behavioural theory; (2) designed to change specifically HIV transmission risk behaviours; (3) delivered by health-care providers or counsellors; (4) delivered to individuals; (5) delivered in an intensive manner; (6) delivered in settings where PLWH receive routine services or medical care; (7) provided skills building, or (8) addressed a myriad of issues related to mental health, medication adherence, and HIV risk behaviour. Conclusion:Interventions targeting PWLH are efficacious in reducing unprotected sex and acquisition of sexually transmitted diseases. Efficacious strategies identified in this review should be incorporated into community HIV prevention efforts and further evaluated for effectiveness.

Best-Evidence Interventions: Findings From a Systematic Review of HIV Behavioral Interventions for US Populations at High Risk, 2000-2004

OBJECTIVES The Centers for Disease Control and Preventions HIV/AIDS Prevention Research Synthesis Team conducted a systematic review of US-based HIV behavioral intervention research literature from 2000 through 2004 to identify interventions demonstrating best evidence of efficacy for reducing HIV risk. METHODS Standard systematic review methods were used. Each eligible study was reviewed on the basis of Prevention Research Synthesis Team efficacy criteria that focused on 3 domains: study design, implementation and analysis, and strength of evidence. RESULTS Eighteen interventions met the criteria for best evidence. Four targeted HIV-positive individuals. Of those targeting populations at risk for HIV, 4 targeted drug users, 6 targeted adults at risk because of heterosexual behaviors only, 2 targeted men who have sex with men, and 2 targeted youths at high risk. Eight interventions focused on women, and 13 had study samples with more than 50% minority participants. Significant intervention effects included increased condom use and reductions in unprotected sexual intercourse, number of sexual partners, injection drug use or needle sharing, and newly acquired sexually transmitted infections. CONCLUSIONS Most of the best-evidence interventions are directly applicable for populations in greatest need of effective prevention programs; however, important gaps still exist.

Towards an understanding of sexual risk behavior in people living with HIV: a review of social, psychological, and medical findings.

HIV continues to spread through sexual transmission in the United States and elsewhere [1]. One source of transmission is unsafe sex among people who know they are infected with HIV. Of the estimated 800 000± 900 000 people living with HIV in the United States [2], about two-thirds are aware of their seropositive status [3] and over 70% are sexually active after they learn they are infected [4±8]. Many engage in safer-sex practices; however, a considerable percentage of seropositive persons (range 10% to 60% depending on the speci®c sex acts) [9,10] continue to engage in unprotected sexual behaviors that place others at risk for infection and place themselves at risk for contracting secondary infections (e.g., syphilis, gonorrhea, herpesvirus-6) that may accelerate HIV disease [11,12]. As more and more people with HIV live longer and healthier lives because of antiretroviral therapy [13], an increasing number of sexual transmissions of HIV may stem from those who know they are infected and engage in unprotected sex [9,10,14]. It is, therefore, exceedingly important to understand the factors promoting risky sex in this population so that behavioral interventions can be designed optimally for HIV-positive persons. Indeed, these interventions may be a highly cost-effective approach to reducing sexual transmission of the disease. Numerous studies have examined correlates of risky sex in HIV-seropositive persons. The diversity of results makes it dif®cult to attain an integrated understanding of the ®ndings without a comprehensive review of the literature. Two papers [9,14] provide qualitative reviews of factors associated with unsafe sex in persons living with HIV/AIDS. Those papers are valuable, but they did not cover the full range of psychosocial or medical constructs that have been investigated, did not include all of the studies that examined a speci®c construct, and did not provide data on strength of association with risky sex. Additionally, the previous reviews did not examine whether there are common and unique risk-promoting factors for HIV-positive men and women.

Efficacy of interventions in improving highly active antiretroviral therapy adherence and HIV-1 RNA viral load. A meta-analytic review of randomized controlled trials.

Summary:Adherence to highly active antiretroviral therapy (HAART) is generally suboptimal, limiting the effectiveness of HAART. This meta-analytic review examined whether behavioral interventions addressing HAART adherence are successful in increasing the likelihood of a patient attaining 95% adherence or an undetectable HIV-1 RNA viral load (VL). We searched electronic databases from January 1996 to September 2005, consulted with experts in the field, and hand searched reference sections from relevant articles. Nineteen studies (with a total of 1839 participants) met the selection criteria of describing a randomized controlled trial among adults evaluating a behavioral intervention with HAART adherence or VL as an outcome. Random-effects models indicated that across studies, participants in the intervention arm were more likely than those in the control arm to achieve 95% adherence (odds ratio [OR] = 1.50, 95% confidence interval [CI]: 1.16 to 1.94); the effect was nearly significant for undetectable VL (OR = 1.25; 95% CI: 0.99 to 1.59). The intervention effect for 95% adherence was significantly stronger in studies that used recall periods of 2 weeks or 1 month (vs. ≤7 days). No other stratification variables (ie, study, sample, measurement, methodologic quality, intervention characteristics) moderated the intervention effect, but some potentially important factors were observed. In sum, various HAART adherence intervention strategies were shown to be successful, but more research is needed to identify the most efficacious intervention components and the best methods for implementing them in real-world settings with limited resources.

A meta-analytic review of HIV behavioral interventions for reducing sexual risk behavior of men who have sex with men

This meta-analysis examines the efficacy of international HIV prevention interventions designed to reduce sexual risk behavior of men who have sex with men (MSM). We performed a comprehensive search of published and unpublished English-language reports of HIV prevention interventions that focus on MSM and evaluated changes in risky sexual behavior or biologic outcomes related to sexual risk. Data from 33 studies described in 65 reports were available as of July 2003. Studies with insufficient data to calculate effect sizes were excluded from the meta-analysis. Interventions were associated with a significant decrease in unprotected anal intercourse (odds ratio [OR] = 0.77, 95% confidence interval [CI]: 0.65-0.92) and number of sexual partners (OR = 0.85, 95% CI: 0.61-0.94) and with a significant increase in condom use during anal intercourse (OR = 1.61, 95% CI: 1.16-2.22). Interventions successful in reducing risky sexual behavior were based on theoretic models, included interpersonal skills training, incorporated several delivery methods, and were delivered over multiple sessions spanning a minimum of 3 weeks. Behavioral interventions provide an efficacious means of HIV prevention for MSM. To the extent that proven HIV prevention interventions for MSM can be successfully replicated in community settings and adapted and tailored to different situations, the effectiveness of current HIV prevention efforts can be increased.This article presents an analysis of the correlates of HIV status among samples of injection drug users (IDUs) in Lang Son Province, Vietnam (n = 348), and Ning Ming County, Guangxi Province, China (n = 294), who were interviewed and tested for HIV antibody just before the start of a peer-based HIV prevention intervention in this border region. Participants were largely male, in their 20s, and single. Logistic regression analysis suggests that among Chinese IDUs, border-related factors (eg, living closer to the border, buying drugs across the border more frequently) and younger age are the best predictors of HIV positivity. In Vietnam, HIV status seems to drive behavior (eg, some risk reduction practices are predictive of HIV positivity). These differing patterns may reflect the fact that the intertwined epidemics of heroin injection and HIV began earlier and HIV prevalence has reached significantly higher levels in Lang Son than across the border in Ning Ming. Although border-related factors emerge as predictors in Ning Ming, more IDUs in Lang Son are HIV-positive and may be reacting behaviorally to that status. Their greater likelihood of engaging in risk reduction measures may reflect some combination of a belief that risk reduction can slow disease progression and an altruistic desire to avoid infecting others.

Estimating the Population Size of Men Who Have Sex with Men in the United States to Obtain HIV and Syphilis Rates

Background: CDC has not previously calculated disease rates for men who have sex with men (MSM) because there is no single comprehensive source of data on population size. To inform prevention planning, CDC developed a national population size estimate for MSM to calculate disease metrics for HIV and syphilis. Methods: We conducted a systematic literature search and identified seven surveys that provided data on same-sex behavior in nationally representative samples. Data were pooled by three recall periods and combined using meta-analytic procedures. We applied the proportion of men reporting same-sex behavior in the past 5 years to U.S. census data to produce a population size estimate. We then calculated three disease metrics using CDC HIV and STD surveillance data and rate ratios comparing MSM to other men and to women. Results: Estimates of the proportion of men who engaged in same-sex behavior differed by recall period: past year = 2.9% (95%CI, 2.6–3.2); past five years = 3.9% (3.5–4.4); ever = 6.9% (5.1–8.6). Rates on all 3 disease metrics were much higher among MSM than among either other men or women (38 to 109 times as high). Conclusions: Estimating the population size for MSM allowed us to calculate rates for disease metrics and to develop rate ratios showing dramatically higher rates among MSM than among other men or women. These data greatly improve our understanding of the disproportionate impact of these diseases among MSM in the U.S. and help with prevention planning.