Paul A. Gilbert

Preventing excessive weight gain in pregnancy: how do prenatal care providers approach counseling?

BACKGROUND Excessive weight gain during pregnancy is becoming more common and is associated with many adverse maternal and infant outcomes. There is a paucity of data on how weight gain counseling is actually provided in prenatal care settings. Our objective was to study prenatal care providers and their knowledge, attitudes, and practices regarding prevention of excessive weight gain during pregnancy and, secondarily, their approach to nutrition and physical activity counseling during pregnancy. METHODS We conducted seven focus groups of general obstetrician/gynecologists, midwives, and nurse practitioners. We analyzed data using qualitative methods. RESULTS Providers agreed to participate because they were unsure of the effectiveness of their counseling efforts and wanted to learn new techniques for counseling patients about weight gain, nutrition, and physical activity. We identified several barriers to weight gain counseling, including insufficient training, concern about the sensitivity of the topic, and the perception that counseling is ineffective. Providers all agreed that weight gain was an important topic with short-term and long-term health consequences, but they described widely disparate counseling styles and approaches. CONCLUSIONS Prenatal care providers are deeply concerned about excessive weight gain and its sequelae in their patients but encounter barriers to effective counseling. Providers want new tools to help them address weight gain counseling during pregnancy.

Age-Specific Prevalence of Human Papillomavirus Infection in Males: A Global Review

PURPOSE Global data on age-specific prevalence of human papillomavirus (HPV) infection in males, especially for oncogenic HPV types 16 and 18, are essential for future efforts to prevent HPV-related diseases, including expanded access to HPV prophylactic vaccines for boys and young men. METHODS A systematic review of peer-reviewed publications was conducted to summarize worldwide data on genital HPV-DNA prevalence in men. Studies using polymerase chain reaction or hybrid capture detection assays were included. RESULTS Approximately 6,600 abstracts were identified. Of them, 64 reported age-specific HPV prevalence and were included in the review. Of these, 38 were from populations at high risk of HPV infections, such as sexually transmitted infection clinic attendees, human immunodeficiency virus-positive males, and male partners of women with HPV infection or abnormal cytology. The largest proportions of studies were from Europe (38%) and North America (25%), with smaller proportions from Central and South America (19%), Asia (11%), and Africa (5%). Across all regions, data on HPV prevalence were generally limited to men >18 years of age. HPV prevalence was high among sexually active men in all regions but with considerable variation, from 1% to 84% among low-risk men and from 2% to 93% among high-risk men. Peak HPV prevalence spanned a wide range of ages and was generally not concentrated in the younger age groups. Age-specific prevalence curves were relatively flat or declined only slightly following peak prevalence. CONCLUSIONS Genital HPV infection in men varies widely, both between and within high- and low-risk groups and by geographic region. Compared with that in women, HPV prevalence in men seems to peak at slightly older ages and remains constant or decreases slightly with increasing age, suggesting persistent HPV infection or a higher rate of reinfection.

Acceptability of HPV Vaccine Among a National Sample of Gay and Bisexual Men

Objective: Due to higher rates of human papillomavirus (HPV) infection and anal cancer among gay and bisexual men, we aimed to characterize their willingness to get HPV vaccine and identify correlates of vaccine acceptability. Methods: We surveyed a national sample of men aged 18 to 59 who self-identified as either gay (n = 236) or bisexual (n = 70) during January 2009. We analyzed data using multivariate logistic regression. Results: Most men had heard of HPV vaccine (73%, 224/306) and were willing to get it (74%, 225/306). HPV vaccine acceptability was higher among men who believed their doctor would recommend getting the vaccine (OR = 12.87, 95% CI: 4.63–35.79) and those who were unsure (OR = 3.15, 95% CI: 1.47–6.76), as compared to men who believed their doctor would not recommend it. Acceptability was also higher among men who reported 5 or more lifetime sexual partners (OR = 3.39, 95% CI: 1.34–8.55), perceived greater severity of HPV-related disease (OR = 1.92, 95% CI: 1.18–3.14), perceived higher levels of HPV vaccine effectiveness (OR = 1.97, 95% CI: 1.27–3.06), or reported higher levels of anticipated regret if they did not get vaccinated and later developed an HPV infection (OR = 2.39, 95% CI: 1.57–3.61). Conclusions: HPV vaccine acceptability was high among gay and bisexual men. These findings identify potentially important beliefs and attitudes for future communication efforts about HPV and HPV vaccine among gay and bisexual men.

Interactive “Video Doctor” Counseling Reduces Drug and Sexual Risk Behaviors among HIV-Positive Patients in Diverse Outpatient Settings

Background Reducing substance use and unprotected sex by HIV-positive persons improves individual health status while decreasing the risk of HIV transmission. Despite recommendations that health care providers screen and counsel their HIV-positive patients for ongoing behavioral risks, it is unknown how to best provide “prevention with positives” in clinical settings. Positive Choice, an interactive, patient-tailored computer program, was developed in the United States to improve clinic-based assessment and counseling for risky behaviors. Methodology and Findings We conducted a parallel groups randomized controlled trial (December 2003–September 2006) at 5 San Francisco area outpatient HIV clinics. Eligible patients (HIV-positive English-speaking adults) completed an in-depth computerized risk assessment. Participants reporting substance use or sexual risks (n = 476) were randomized in stratified blocks. The intervention group received tailored risk-reduction counseling from a “Video Doctor” via laptop computer and a printed Educational Worksheet; providers received a Cueing Sheet on reported risks. Compared with control, fewer intervention participants reported continuing illicit drug use (RR 0.81, 95% CI: 0.689, 0.957, p = 0.014 at 3 months; and RR 0.65, 95% CI: 0.540, 0.785, p<0.001 at 6 months) and unprotected sex (RR 0.88, 95% CI: 0.773, 0.993, p = 0.039 at 3 months; and RR 0.80, 95% CI: 0.686, 0.941, p = 0.007 at 6 months). Intervention participants reported fewer mean days of ongoing illicit drug use (-4.0 days vs. -1.3 days, p = 0.346, at 3 months; and -4.7 days vs. -0.7 days, p = 0.130, at 6 months) than did controls, and had fewer casual sex partners at (−2.3 vs. −1.4, p = 0.461, at 3 months; and −2.7 vs. −0.6, p = 0.042, at 6 months). Conclusions The Positive Choice intervention achieved significant cessation of illicit drug use and unprotected sex at the group-level, and modest individual-level reductions in days of ongoing drug use and number of casual sex partners compared with the control group. Positive Choice, including Video Doctor counseling, is an efficacious and appropriate adjunct to risk-reduction efforts in outpatient settings, and holds promise as a public health HIV intervention. Trial Registration Clinicaltrials.gov NCT00447707

HPV Vaccine Acceptability in Heterosexual, Gay, and Bisexual Men

We know little about men’s beliefs about human papillomavirus (HPV) vaccine and willingness to receive it. In January 2009, the authors recruited 296 heterosexual men and 312 gay and bisexual men from a national panel of U.S. households to complete an online survey about HPV and HPV vaccine. The authors analyzed data using logistic regression, controlling for age, education, number of lifetime sexual partners, and urban residence. More gay and bisexual men than heterosexual men were willing to receive HPV vaccine (73% vs. 37%; adjusted odds ratio = 4.99; 95% confidence interval = 3.36, 7.49). Gay and bisexual men reported greater awareness of HPV vaccine, perceived worry about HPV-related diseases, perceived effectiveness of HPV vaccine, and anticipated regret if they declined vaccination and later developed HPV-related disease compared with heterosexual men (all ps < .05). The lower acceptability and different beliefs among heterosexual men suggest that novel interventions for this group may be needed.

A Systematic Community-Based Participatory Approach to Refining an Evidence-Based Community-Level Intervention The HOLA Intervention for Latino Men Who Have Sex With Men

Our community-based participatory research partnership engaged in a multistep process to refine a culturally congruent intervention that builds on existing community strengths to promote sexual health among immigrant Latino men who have sex with men (MSM). The steps were the following: (1) increase Latino MSM participation in the existing partnership, (2) establish an Intervention Team, (3) review the existing sexual health literature, (4) explore needs and priorities of Latino MSM, (5) narrow priorities based on what is important and changeable, (6) blend health behavior theory with Latino MSM’s lived experiences, (7) design an intervention conceptual model, (8) develop training modules and (9) resource materials, and (10) pretest and (11) revise the intervention. The developed intervention contains four modules to train Latino MSM to serve as lay health advisors known as Navegantes. These modules synthesize locally collected data with other local and national data; blend health behavior theory, the lived experiences, and cultural values of immigrant Latino MSM; and harness the informal social support Latino MSM provide one another. This community-level intervention is designed to meet the expressed sexual health priorities of Latino MSM. It frames disease prevention within sexual health promotion.

Human Papillomavirus Vaccination in the United States: Uneven Uptake by Gender, Race/Ethnicity, and Sexual Orientation

OBJECTIVES To assess national differences in human papillomavirus (HPV) vaccine uptake among young adults in the United States by gender, race/ethnicity, and sexual orientation. METHODS We tested group differences in initiation and completion of the HPV vaccine series (i.e., 3 doses) by Rao-Scott χ(2) test among 6444 respondents aged 18 to 30 years from the 2013 National Health Interview Survey. RESULTS Among men, 5% reported receiving the HPV vaccine, with no differences in uptake by race/ethnicity or sexual orientation. By contrast, 30% of the women reported receiving the HPV vaccine, with women of color having lower odds of initiating and completing the vaccine series compared with White women. CONCLUSIONS In the United States, HPV vaccine rates are lagging in men and show disparities among women. Increasing HPV vaccine uptake and series completion among women of color and all men may provide considerable long-term public health benefits.

HIV Testing Among Immigrant Sexual and Gender Minority Latinos in a US Region with Little Historical Latino Presence

Immigrant sexual and gender minority Latinos constitute a vulnerable subgroup about which little is known. We examined HIV testing among 190 such Latinos recruited via respondent-driven sampling in North Carolina, a state with little historical Latino presence but recent, rapid growth of this population. Sixty-eight percent reported an HIV test in the past year, and nearly half reported multiple HIV tests. Concern for their health was the most frequent reason for seeking an HIV test. Reasons not to get tested included fear of a positive test, previous HIV tests, worry that test results might be reported to the government, and concerns that others might treat the person differently if found to be HIV positive. In a multiple variable model, correlates of HIV testing included age, educational attainment, HIV stigma, comfort with sexual orientation, and previous STD diagnoses. Among participants reporting anal sex, consistent condom use was associated with HIV testing, suggesting that protective behaviors may co-occur. These findings may inform the development of more efficacious interventions to increase HIV testing among this subgroup.

Association of human papillomavirus-related knowledge, attitudes, and beliefs with HIV status: a national study of gay men.

Objective. Anal cancer and other diseases caused by human papillomavirus (HPV) are more common among people who are HIV-positive. To understand the potential role of HIV status in HPV prevention efforts, we examined HPV-related knowledge, attitudes, and beliefs among HIV-positive and HIV-negative gay men. Materials and Methods. In January 2009, we interviewed a national sample of 247 adult gay men from the United States that included an oversample of HIV-positive men. Results. Status of HIV was not associated with most beliefs about HPV-related diseases (i.e., genital warts, oral cancer, and anal cancer); however, HIV-positive men had higher worry about and perceived likelihood of these diseases. Most men correctly believed that HIV increases risk of HPV-related diseases, yet 29% to 42% still did not. Relatively few men believed that HPV vaccine works in males or that physicians are allowed to give it to men. Acceptability of the HPV vaccine was high and not associated with HIV status (78% of HIV-positive men vs 74% of HIV-negative men; adjusted odds ratio = 1.48; 95% confidence interval = 0.67-3.27). Conclusions. The high acceptability of HPV vaccine, relatively low knowledge of how HIV increases risk for HPV-related diseases, and misperceptions about HPV vaccine can inform HPV prevention efforts for gay men. The few differences by HIV status suggest that HPV prevention programs may be able to use similar approaches with both HIV-negative and HIV-positive gay men.

A moderating role for gender in racial/ethnic disparities in alcohol services utilization: results from the 2000 to 2010 national alcohol surveys.

BACKGROUND Few nationally representative studies have examined racial/ethnic disparities in alcohol services utilization. Further, little is known about whether racial/ethnic disparities generalize across genders, and what factors account for these disparities. Thus, we aimed to describe the combined impact of race/ethnicity and gender on alcohol services utilization, and to explore the roles for social influence factors in explaining racial/ethnic and gender disparities. METHODS Data were pooled across the 2000, 2005, and 2010 National Alcohol Surveys. Outcomes included lifetime utilization of any services, specialty alcohol treatment, and Alcoholics Anonymous. Social influence factors were assessed as lifetime social pressures (i.e., pressures from a partner, friends, and/or family), legal consequences, and work-related consequences. Core analyses included only those with a lifetime alcohol use disorder (AUD). RESULTS Analyses revealed a pattern of lower services utilization among Latinos and Blacks (vs. Whites) and women (vs. men); further, race-by-gender interactions revealed that Black-White differences were limited to women, and provided some evidence of stronger Latino-White disparities among women (vs. men). Illustrating these patterns, among women, only 2.5% of Latinas and 3.4% of Blacks with a lifetime AUD accessed specialty treatment, versus 6.7% of Whites; among men, corresponding figures were 6.8% for Latinos, 12.2% for Blacks, and 10.1% for Whites. Racial/ethnic differences were typically robust (or stronger) when controlling for demographics and AUD severity. Evidence did not support a role for measured social influence factors in racial/ethnic disparities, but did suggest that these factors contribute to gender disparities, particularly among Whites and Blacks. CONCLUSIONS Findings for substantial Latino-White and Black-White disparities, especially among women, highlight the need for continuing research on explanatory factors and the development of appropriate interventions. Meanwhile, our evidence for persistent gender disparities and for social influence factors as drivers of these disparities tentatively suggests a need for intensified outreach to female heavy drinkers.