Yuko Mizuno

The Efficacy of HIV/STI Behavioral Interventions for African American Females in the United States: A Meta-Analysis

OBJECTIVES We evaluated the efficacy of HIV behavioral interventions for African American females in the United States, and we identified factors associated with intervention efficacy. METHODS We conducted a comprehensive literature review covering studies published from January 1988 to June 2007, which yielded 37 relevant studies. Data were analyzed using mixed-effects models and meta-regression. RESULTS Overall, behavioral interventions had a significant impact on reductions in HIV-risk sex behaviors (odds ratio [OR] = 0.63; 95% confidence interval [CI] = 0.54, 0.75; n = 11 239; Cochrane Q(32) = 84.73; P < .001) and sexually transmitted infections (STIs; OR = 0.81; 95% CI = 0.67, 0.98; n = 8760; Cochrane Q(16) = 22.77; P = .12). Greater intervention efficacy was observed in studies that specifically targeted African American females used gender- or culture-specific materials, used female deliverers, addressed empowerment issues, provided skills training in condom use and negotiation of safer sex, and used role-playing to teach negotiation skills. CONCLUSIONS Behavioral interventions are efficacious at preventing HIV and STIs among African American females. More research is needed to examine the potential contribution of prevention strategies that attend to community-level and structural-level factors affecting HIV infection and transmission in this population.

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.

Estimating the Number of Persons Who Inject Drugs in the United States by Meta-Analysis to Calculate National Rates of HIV and Hepatitis C Virus Infections

Background Injection drug use provides an efficient mechanism for transmitting bloodborne viruses, including human immunodeficiency virus (HIV) and hepatitis C virus (HCV). Effective targeting of resources for prevention of HIV and HCV infection among persons who inject drugs (PWID) is based on knowledge of the population size and disparity in disease burden among PWID. This study estimated the number of PWID in the United States to calculate rates of HIV and HCV infection. Methods We conducted meta-analysis using data from 4 national probability surveys that measured lifetime (3 surveys) or past-year (3 surveys) injection drug use to estimate the proportion of the United States population that has injected drugs. We then applied these proportions to census data to produce population size estimates. To estimate the disease burden among PWID by calculating rates of disease we used lifetime population size estimates of PWID as denominators and estimates of HIV and HCV infection from national HIV surveillance and survey data, respectively, as numerators. We calculated rates of HIV among PWID by gender-, age-, and race/ethnicity. Results Lifetime PWID comprised 2.6% (95% confidence interval: 1.8%–3.3%) of the U.S. population aged 13 years or older, representing approximately 6,612,488 PWID (range: 4,583,188–8,641,788) in 2011. The population estimate of past-year PWID was 0.30% (95% confidence interval: 0.19 %–0.41%) or 774,434 PWID (range: 494,605–1,054,263). Among lifetime PWID, the 2011 HIV diagnosis rate was 55 per 100,000 PWID; the rate of persons living with a diagnosis of HIV infection in 2010 was 2,147 per 100,000 PWID; and the 2011 HCV infection rate was 43,126 per 100,000 PWID. Conclusion Estimates of the number of PWID and disease rates among PWID are important for program planning and addressing health inequities.

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.

Acceptability of A-CASI by HIV-positive IDUs in a multisite, randomized, controlled trial of behavioral intervention (INSPIRE).

Audio computer-assisted self-interviewing (A-CASI) is now widely used to gather information from many types of research participants, including injection drug users (IDUs). The purpose of this study was to describe how HIV-positive IDUs participating in an intervention trial viewed A-CASI and to identify the characteristics of participants who held unfavorable attitudes toward A-CASI. Using a sample of participants who completed 12-month assessments (n = 821), we found that most (>80%) of the sample held favorable or neutral attitudes toward A-CASI. Approximately 18% said that they would prefer an interview with a person to a computer, 12% said that they did not understand the questions they heard on the computer, and 14% said that the computer made it hard to be open and honest about risk behavior. Multivariate analyses found that participants who were more socially marginalized (with unstable housing and lower sense of empowerment) and had greater physical limitations and lower CD4 cell counts were consistently more likely to report various negative A-CASI attitudes; however, some outcome-specific findings were also noted. Our research supports the feasibility and general acceptability of A-CASI with HIV-positive IDUs, and it suggests further research exploring the associations between A-CASI attitudes and characteristics of disadvantaged populations.

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.

Correlates of health care utilization among HIV-seropositive injection drug users

This study sought to identify correlates of poor health care utilization among HIV-positive injection drug users (IDUs) using Andersens behavioural health model. We used baseline data from INSPIRE, a study of HIV-positive IDUs (n=1161) to identify predisposing, enabling, and need factors related to poor utilization (defined as fewer than two outpatient visits in the past six months, or identification of emergency room (ER) as the usual place for care). Using bivariate and multivariate models, we found a number of enabling factors that could facilitate the use of health care services such as having health insurance, having seen a case manager, and better engagement with health care providers. These enabling factors could be modified through interventions targeting HIV-positive IDUs. In addition, health insurance and case management appear to be important factors to address because they contributed in making other factors (e.g. lower education, lack of stable housing) non-significant barriers to outpatient care utilization. In the future, these findings may be used to inform the development of interventions that maximize use of scarce HIV resources and improve health care utilization among HIV-positive IDUs.

Economic Well-Being and Black Adult Feelings Toward Immigrants and Whites, 1984

Duringthe1980s,about10millionlegalimmigrantscametotheUnitedStates,afiguresecondonlytotheprevioushighrecordedinthe first decade of this century. These newcomers were notable fortheirplaceoforigin,because80%camefromAsiaandLatinAmer-ica (Thornton, 1995). More than three quarters of them settled injust six states; more than one half settled in eight metropolitanareas, including New York, Chicago, Los Angeles, Boston, andHouston (Frey & Tilove, 1995). Furthermore, for every 10 immi-grants who settled in urban America, 9 residents left for areas withfewer foreign nationals; most who fled were White. Along with anatural population increase, immigrants concentrating in increas-inglynon-Whiteurbanareashaveescalatedinteractionamongeth-nic minorities and have begun to transform the racial balance inAmerica’s cities and in the nation.

Beliefs that Condoms Reduce Sexual Pleasure—Gender Differences in Correlates Among Heterosexual HIV-Positive Injection Drug Users (IDUs)

Studies consistently find that negative condom beliefs or attitudes are significantly associated with less condom use in various populations, including HIV-positive injection drug users (IDUs). As part of efforts to reduce sexual risk among HIV-positive IDUs, one of the goals of HIV interventions should be the promotion of positive condom beliefs. In this paper we sought to identify the correlates of negative condom beliefs and examined whether such correlates varied by gender, using a subsample (those with an opposite-sex main partner; n = 348) of baseline data collected as part of a randomized controlled study of HIV-positive IDUs. In multivariate analyses, we found more significant correlates for women than for men. With men, perception that their sex partner is not supportive of condom use (negative partner norm) was the only significant correlate (Beta = −0.30; p < 0.01; R2 = 0.18). Among women, negative partner norm (Beta = −0.18; p < 0.05); having less knowledge about HIV, STD, and hepatitis (Beta = −0.16; p < 0.05); lower self-efficacy for using a condom (Beta = −0.40; p < 0.01); and more episodes of partner violence (Beta = 0.15; p < 0.05) were significantly associated with negative condom beliefs (R2 = 0.36). These findings suggest important gender-specific factors to consider in interventions that seek to promote positive condom beliefs among HIV-positive IDUs.

Is Sexual Serosorting Occurring Among HIV-Positive Injection Drug Users? Comparison Between Those with HIV-Positive Partners Only, HIV-Negative Partners Only, and Those with any Partners of Unknown Status

Using baseline data from a multi-site, randomized controlled study (INSPIRE), we categorized 999 HIV-positive IDUs into three groups based on serostatus of their sex partners. Our data provide some evidence for serosorting occurring in our sample; about 40% of the sample had sex exclusively with HIV-positive partners, and about half of them reported having unprotected sex with these partners. Twenty per cent had sex exclusively with HIV-negative partners; their sexual behaviors tended to be least risky with about two-thirds reporting their sex was protected. However, we also found that another 40% had at least one partner of unknown HIV status and sexual and drug risk was the highest among them. They were also least empowered, showing attributes that may undermine HIV prevention. Some of these findings are consistent with findings from MSM studies, suggesting that partner selection practices are similar between primarily heterosexual IDUs and MSM.