Showing papers in "Aids and Behavior in 2018"
TL;DR: This review of PrEP implementation identified barriers to PrEP and interventions to match those barriers and recommended multilevel interventions targeting barriers at multiple socioecological domains.
Abstract: There are many challenges to accessing PrEP and thus low uptake in the United States. This review (2007–2017) of PrEP implementation identified barriers to PrEP and interventions to match those barriers. The final set of articles (n = 47) included content on cognitive aspects of HIV service providers and individuals at risk for infection, reviews, and case studies. Cognitive barriers and interventions regarding patients and providers included knowledge, attitudes, and beliefs about PrEP. The “purview paradox” was identified as a key barrier—HIV specialists often do not see HIV-negative patients, while primary care physicians, who often see uninfected patients, are not trained to provide PrEP. Healthcare systems barriers included lack of communication about, funding for, and access to PrEP. The intersection between PrEP-stigma, HIV-stigma, transphobia, homophobia, and disparities across gender, racial, and ethnic groups were identified; but few interventions addressed these barriers. We recommend multilevel interventions targeting barriers at multiple socioecological domains.
135 citations
TL;DR: Key steps of the pre-exposure prophylaxis (PrEP) cascade are characterized and correlates of retention in care are identified and comprehensive retention efforts for men with STIs are crucial to optimize the benefits of PrEP.
Abstract: In a community-based clinic serving men who have sex with men in San Francisco, California, this study characterized key steps of the pre-exposure prophylaxis (PrEP) cascade and identified correlates of retention in care. In total, 344 patients were evaluated for PrEP. Three-fourths (78%) of those who sought PrEP services initiated PrEP. The overall cumulative incidence of discontinuing PrEP at 13 months was 38%. Men with a sexually transmitted infection (STI) were 44% less likely to be retained (adjusted hazard ratio [aHR] 0.56, 95% confidence interval [0.33-0.95]). Comprehensive retention efforts for men with STIs are crucial to optimize the benefits of PrEP.
128 citations
TL;DR: A moderate acceptability of PrEP is identified among men who have sex with men (MSM) worldwide, where self-perceived low efficacy, concern about side effects, adherence, affordability, and stigma were main barriers.
Abstract: Pre-exposure prophylaxis (PrEP) is a new biomedical intervention for HIV prevention. This study systematically reviews the acceptability of PrEP among men who have sex with men (MSM) worldwide. We searched major English databases to identify English-language articles published between July 2007 and July 2016, which reported the acceptability of PrEP and associated population characteristics. Meta-analysis was conducted to estimate a pooled acceptability, and meta-regression and subgroup analysis were used to analyse heterogeneities. The estimated acceptance from included sixty-eight articles was 57.8% (95% confidence internal 52.4–63.1%). MSM who were younger (4/5 studies, range of adjusted odds ratio (aOR) = 1.39–3.47), better educated (aOR = 1.49–7.70), wealthier (aOR = 1.31–13.03) and previously aware of PrEP (aOR = 1.33–3.30) showed significantly higher acceptance. Male sex workers (84.0% [26.3–98.7%] were more likely to accept PrEP than general MSM. Self-perceived low efficacy, concern about side effects, adherence, affordability, and stigma were main barriers. This review identifies a moderate acceptability of PrEP in MSM. Efficacy, perception of HIV risk and experienced stigma determine its acceptance.
124 citations
TL;DR: More research is needed to inform interventions on how GBM can continue taking PrEP during changes to employment that effect insurance coverage and cost and on the reasons why GBM discontinue PrEP.
Abstract: Literature concerning pre-exposure prophylaxis (PrEP) among gay and bisexual identifying men (GBM) has explored facilitators and barriers to uptake and adherence. Far less reported are the reasons why GBM discontinue PrEP use. A national sample of 1071 GBM completed surveys about PrEP use and discontinuation. Participants who were still taking PrEP the 24-month follow up were compared to those that had stopped. Eighteen percent (n = 31) of GBM who reported ever using PrEP discontinued use. Younger (AOR = 0.96; 95% CI 0.92–1.00), and unemployed (AOR = 4.58; 95% CI 1.43–14.70) GBM were more likely to discontinue PrEP than their counterparts. Those that discontinued provided details on why via a free response question. The most common reasons for discontinuation were lower perceived HIV risk (50%) and cost/insurance (30%). Reasons for potential re-initiation included higher-risk sexual activities and changes to structural related barriers. More research is needed to inform interventions on how GBM can continue taking PrEP during changes to employment that effect insurance coverage and cost.
118 citations
TL;DR: Overall, this literature review found that this diverse group of participants generally performed HST correctly with a few exceptions, were accepting of the test if available at a relatively low cost, and preferred the oral-based HST over the blood-based test.
Abstract: HIV self-test kits may have the potential to increase testing rates around the globe, and thereby lead to reductions in HIV-related incidence and mortality. However, the effectiveness of these self-test kits and the issues surrounding self-testing have been greatly debated in recent years. We conducted a literature review on the acceptability, feasibility, and effectiveness of HIV self-testing (HST) around the world. Of the 28 articles abstracted, several themes of HST were explored, including behavioral risk compensation, presence of counseling, uses of HST, ability to perform the self-test, sensitivity and specificity, concordance with confirmatory testing, perceptions surrounding HST, instruction and supervision, and cost. Overall, this literature review found that this diverse group of participants generally performed HST correctly with a few exceptions, were accepting of the test if available at a relatively low cost, and preferred the oral-based HST over the blood-based test.
113 citations
TL;DR: Primary concerns for poor retention include substance use and physical health factors, which are also found to be relevant in developed countries and developing countries.
Abstract: A systematic literature review was conducted to identify predictors of poor adult retention in HIV medical care in developed and developing countries. An electronic search was conducted with MEDLINE (OVID), PubMED, EBSCO, SCOPUS, and Cochrane databases, as well as manual searches. Original, quantitative, adult studies in English, published between 1995 and 2015 were included. Only those with a focus on predictors of retention in care were reported on. Of the 345 articles identified, thirty were included following an independent assessment by two raters. In developed countries, the most frequently cited predictors of poor retention were active substance use and demographic factors. In developing countries, physical health factors were most frequently associated with poor retention in care. The results from this review suggests primary concerns for poor retention include substance use and physical health factors. Other psychosocial factors, such as psychiatric illness and social/welfare factors, were also found to be relevant.
99 citations
TL;DR: Among a nationally representative sample of Black individuals, few high risk individuals were willing to use PrEP, and interventions to increase risk awareness, PrEP knowledge and access to care are necessary to improve PrEP uptake.
Abstract: This study explores willingness to use PrEP among Black individuals in the US. From February to April 2016, an online survey was administered to a nationally representative sample of Black individuals. 855 individuals who were HIV negative by self-report participated [mean age: 33.6 (SD 9.2); 45.5% male]. Among all respondents, 14.5% were aware of, and 26.0% would be willing to use PrEP. Among high-risk individuals (N = 327), 19.8% knew about and 35.1% would be willing to use PrEP. The most common reason for lack of willingness among high-risk individuals was low self-perceived risk (65.1%). In multivariate analysis, individuals reporting single marital status [OR 1.8 (1.2, 2.5), p = 0.002], depressive symptoms [OR 1.6 (1.2, 2.2), p = 0.0054], arrest history [OR 1.7(1.2, 2.4), p = 0.0003], PrEP knowledge [OR 1.5 (1.0, 2.3), p = 0.0247] and belief in HIV conspiracies [OR 1.3 (1.1, 1.5), p = 0.0075] were more willing to use PrEP. Participants who saw a health care provider less frequently were less willing to use PrEP [OR 0.5 (0.4, 0.8), p = 0.0044]. Among a nationally representative sample of Black individuals, few high risk individuals were willing to use PrEP. Interventions to increase risk awareness, PrEP knowledge and access to care are necessary to improve PrEP uptake.
85 citations
TL;DR: An innovative home-based HIV self-testing service that included mailing of a free HIVST kit, and providing online real-time instructions and pre-test/post-test counseling has a strong potential in increasing prevalence of HIV testing and reducing sexual risk behaviors.
Abstract: We developed an innovative home-based HIV self-testing (HIVST) service that included mailing of a free HIVST kit, and providing online real-time instructions and pre-test/post-test counseling (HIVST-OIC). The present parallel-group and non-blinded randomized controlled trial was conducted to evaluate the efficacy of promoting HIVST-OIC in increasing HIV testing rate among 430 men who have sex with men (MSM), with access to online live-chat applications in Hong Kong. At month 6, as compared to the control group, the intervention group reported significantly higher prevalence of HIV testing of any type (89.8 vs. 50.7%; relative risk (RR): 1.77; p < 0.001). Among those who have taken up any HIV testing in the last six months, significant between-group difference was found in multiple male sex partnerships (34.2 vs. 47.7%, RR: 0.72; p = 0.021). HIVST-OIC has a strong potential in increasing prevalence of HIV testing and reducing sexual risk behaviors. Implementation research is warranted.
84 citations
TL;DR: The HSCL-25 is a reliable and valid measure of mental health amongPLHIV in rural Uganda and in cultural contexts where somatic complaints are commonly elicited when screening for symptoms of depression, it may be undesirable to exclude somatic items from depression symptom checklists administered to PLHIV.
Abstract: Depression and anxiety are highly comorbid among people living with HIV (PLHIV), but few instruments for screening or measurement have been validated for use in sub-Saharan Africa. The objective of this study was to determine the reliability, validity, and factor structure of the 25-item Hopkins Symptom Checklist (HSCL) in a population-based sample of PLHIV in rural Uganda. This study was nested within an ongoing population-based cohort of all residents living in Nyakabare Parish, Mbarara District, Uganda. All participants who identified as HIV-positive by self-report were included in this analysis. We performed parallel analysis on the scale items and estimated the internal consistency of the identified sub-scales using ordinal alpha. To assess construct validity we correlated the sub-scales with related constructs, including subjective well being (happiness), food insecurity, and health status. Of 1814 eligible adults in the population, 158 (8.7%) self-reported being HIV positive. The mean age was 41 years, and 68% were women. Mean HSCL-25 scores were higher among women compared with men (1.71 vs. 1.44; t = 3.6, P < 0.001). Parallel analysis revealed a three-factor structure that explained 83% of the variance: depression (7 items), anxiety (5 items), and somatic symptoms (7 items). The ordinal alpha statistics for the sub-scales ranged from 0.83 to 0.91. Depending on the sub-scale, between 27 and 41% of the sample met criteria for caseness. Strong evidence of construct validity was shown in the estimated correlations between sub-scale scores and happiness, food insecurity, and self-reported overall health. The HSCL-25 is a reliable and valid measure of mental health among PLHIV in rural Uganda. In cultural contexts where somatic complaints are commonly elicited when screening for symptoms of depression, it may be undesirable to exclude somatic items from depression symptom checklists administered to PLHIV.
84 citations
TL;DR: A comprehensive care approach, incorporating mental health and psychosocial assessments with more traditional clinical assessments, will be needed to improve health outcomes for the aging HIV-positive population.
Abstract: We conducted a cross-sectional study among HIV-positive adults age ≥ 50 in San Francisco to evaluate the frequency of loneliness, characteristics of those who reported loneliness, and the association of loneliness with functional impairment and health-related quality of life (HRQoL). Participants (N = 356) were predominately male (85%); 57% were white; median age was 56. 58% reported any loneliness symptoms with 24% reporting mild, 22% moderate and 12% severe loneliness. Lonely participants were more likely to report depression, alcohol and tobacco use, and have fewer relationships. In unadjusted models, loneliness was associated with functional impairment and poor HRQoL. In adjusted models, low income and depression remained associated with poor HRQoL, while low income, higher VACS index and depression were associated with functional impairment. A comprehensive care approach, incorporating mental health and psychosocial assessments with more traditional clinical assessments, will be needed to improve health outcomes for the aging HIV-positive population.
81 citations
TL;DR: It is concluded that research around HIVST in SSA is still in its infancy, and further implementation research and interventions are required to improve acceptability of HIVST among diverse study populations, failing which policy adoption and scale-up may be hindered.
Abstract: Several HIV testing models have been implemented in sub-Saharan Africa (SSA) to improve access to HIV testing, but uptake remains poor. HIV Self-Testing (HIVST) is now available, and may serve to overcome barriers of current testing models which include stigma, discrimination and non-confidential testing environments. A scoping study was conducted to provide an overview of the current literature in SSA, as well as identify future research needs to scale-up HIVST and increase HIV testing uptake. The outcome of the review indicated only 11 reported studies to date, showing variable acceptability (22.3-94%) of HIVST, with acceptability of HIVST higher among men than women in SSA. We conclude that research around HIVST in SSA is still in its infancy, and further implementation research and interventions are required to improve acceptability of HIVST among diverse study populations, failing which policy adoption and scale-up may be hindered.
TL;DR: It was found that psychosocial interventions for PLWH had a small positive effect on mental health, and a systematic review and meta-analysis suggests that psychOSocial interventions have a beneficial effect forPLWH with mental health problems.
Abstract: In this systematic review and meta-analysis we investigated the effectiveness of different psychosocial treatments for people living with HIV (PLWH) and mental health problems. Additionally, characteristics that may influence the effectiveness of a treatment (e.g., treatment duration) were studied. PubMed, PsycINFO and Embase were searched for randomized controlled trials on psychosocial interventions for PLWH. Depression, anxiety, quality of life, and psychological well-being were investigated as treatment outcome measures. Sixty-two studies were included in the meta-analysis. It was found that psychosocial interventions for PLWH had a small positive effect on mental health (ĝ = 0.19, 95% CI [0.13, 0.25]). Furthermore, there was evidence for publication bias. Six characteristics influenced the effectiveness of a treatment for depression. For example, larger effects were found for studies with psychologists as treatment providers. To conclude, this systematic review and meta-analysis suggests that psychosocial interventions have a beneficial effect for PLWH with mental health problems.
TL;DR: Light is shed on transgender women living in New York City’s perceived and actual challenges to using PrEP and potential strategies to overcome them and about barriers and facilitators to PrEP in transgender women.
Abstract: Transgender women may face a disparate risk for HIV/AIDS compared to other groups. In 2012, Truvada was approved for daily use as HIV pre-exposure prophylaxis (PrEP). However, there is a dearth of research about barriers and facilitators to PrEP in transgender women. This paper will shed light on transgender women living in New York City’s perceived and actual challenges to using PrEP and potential strategies to overcome them. After completing an initial screening process, four 90-min focus groups were completed with n = 18 transgender women. Participants were asked what they like and dislike about PrEP. Participants identified the following barriers: uncomfortable side effects, difficulty taking pills, stigma, exclusion of transgender women in advertising, and lack of research on transgender women and PrEP. Facilitators included: reducing pill size, increasing the types of available HIV prevention products, and conducting scientific studies to evaluate PrEP in transgender women.
TL;DR: A qualitative sub-study including focus groups and in-depth interviews was conducted among men who have sex with men participating in New York City to understand their experience with PrEP and study dosing schedules, highlighting the need to understand and address multidimensional stigma related to PrEP use.
Abstract: The HPTN 067/Alternative Dosing to Augment Pre-Exposure Prophylaxis Pill Taking (ADAPT) study evaluated daily and non-daily dosing schedules for oral pre-exposure prophylaxis (PrEP) to prevent HIV. A qualitative sub-study including focus groups and in-depth interviews was conducted among men who have sex with men participating in New York City to understand their experience with PrEP and study dosing schedules. The 37 sub-study participants were 68% black, 11% white, and 8% Asian; 27% were of Hispanic/Latino ethnicity. Mean age was 34 years. Themes resulting from qualitative analysis include: PrEP is a significant advance for HIV prevention; non-daily dosing of PrEP is congruent with HIV risk; and pervasive stigma connected to HIV and risk behavior is a barrier to PrEP adherence, especially for non-daily dosing schedules. The findings underscore how PrEP intersects with other HIV prevention practices and highlight the need to understand and address multidimensional stigma related to PrEP use.
TL;DR: Youth who reported their physicians had initiated discussion about their sexual orientation were significantly more likely to have received HIV/STI preventive services and testing.
Abstract: Adolescent males who have sex with males (AMSM) are at increased risk of contracting HIV/AIDS and other sexually transmitted infections (STIs). Healthcare providers are a critical source of HIV/STI prevention, yet little is known about AMSM patient-provider sexual health communications and services. To explore this issue, we surveyed a national sample of 198 AMSM 14-17 years. Four online psychometrically validated scales indicated over half the youth avoided communicating their sexual orientation and sexual health concerns to providers due to fear of heterosexist bias, concern their sexual health information would be disclosed to parents, and a general belief that sexual minority youth do not receive equitable treatment in health care settings. Youth who reported their physicians had initiated discussion about their sexual orientation were significantly more likely to have received HIV/STI preventive services and testing. Discussion includes the importance of medical training that meets the unique sexual health needs of AMSM.
TL;DR: This rapid review of eHealth, HIV-related articles (2007–2017) focused on technology-based interventions that reported CoC-related outcomes and identified gaps in development and application of e health interventions regarding CoC.
Abstract: National HIV prevention goals call for interventions that address Continuum of HIV Care (CoC) for persons living with HIV. Electronic health (eHealth) can leverage technology to rapidly develop and disseminate such interventions. We conducted a qualitative review to synthesize (a) technology types, (b) CoC outcomes, (c) theoretical frameworks, and (d) behavior change mechanisms. This rapid review of eHealth, HIV-related articles (2007-2017) focused on technology-based interventions that reported CoC-related outcomes. Forty-five studies met inclusion criteria. Mobile texting was the most commonly reported technology (44.4%, k = 20). About 75% (k = 34) of studies showed proven or preliminary efficacy for improving CoC-related outcomes. Most studies (60%, k = 27) focused on medication adherence; 20% (k = 9) measured virologic suppression. Many eHealth interventions with preliminary or proven efficacy relied on mobile technology and integrated knowledge/cognition as behavior change mechanisms. This review identified gaps in development and application of eHealth interventions regarding CoC.
TL;DR: Of the 197 participants who had used PrEP in the past 6 months, 65 discontinued use, with primary reasons for PrEP discontinuation included trouble getting to doctor’s appointments and issues related to insurance coverage or loss.
Abstract: Understanding pre-exposure prophylaxis (PrEP) discontinuation is key to maximizing its effectiveness at the individual and population levels. Data came from the RADAR cohort study of MSM aged 16–29 years, 2015–2017. Participants included those who reported past 6-month PrEP use and discontinued its use by the interview date. Of the 197 participants who had used PrEP in the past 6 months, 65 discontinued use. Primary reasons for PrEP discontinuation included trouble getting to doctor’s appointments (14, 21.5%) and issues related to insurance coverage or loss (13, 20.0%). Few (21%) who discontinued spoke to their doctor first, which has important implications for future long acting formulations.
TL;DR: This work examined the prevalence and types of PrEP stigma and injunctive norm beliefs among YMSM and transgender women and associated individual and geospatial factors and indicated lower stigma among White, compared to Black and Latino participants, and among participants not identifying as male.
Abstract: Increasing the uptake of pre-exposure prophylaxis (PrEP) to prevent HIV acquisition among at-risk populations, such as young men who have sex with men (YMSM), is of vital importance to slowing the HIV epidemic. Stigma and negative injunctive norms, such as the so called “Truvada Whore” phenomenon, hamper this effort. We examined the prevalence and types of PrEP stigma and injunctive norm beliefs among YMSM and transgender women and associated individual and geospatial factors. A newly created measure of PrEP Stigma and Positive Attitudes was administered to 620 participants in an ongoing longitudinal cohort study. Results indicated lower stigma among White, compared to Black and Latino participants, and among participants not identifying as male. Prior knowledge about PrEP was associated with lower stigma and higher positive attitudes. PrEP stigma had significant geospatial clustering and hotspots were identified in neighborhoods with high HIV incidence and concentration of racial minorities, whereas coldspots were identified in areas with high HIV incidence and low LGBT stigma. These results provide important information about PrEP attitudes and how PrEP stigma differs between individuals and across communities.
TL;DR: Dating websites and apps may be effective channels to reach a diverse group of MSM with HIV prevention messages and can be canales efectivos for alcanzar un grupo diverso of HSH with mensajes for the prevención of the VIH.
Abstract: This study explored the frequency of dating website and app usage among MSM to understand sub-group differences in use. Web-based survey data (N = 3105) were analyzed to assess the use of dating websites and apps. More than half (55.7%) of MSM in this sample were frequent users of dating websites and apps. Two-thirds (66.7%) of frequent users had casual partners only in the past 12 months and reported a high average number of casual sexual partners in the past 12 months (Mdn = 5.0) compared to never users (Mdn = 0.0; χ
2(2) = 734.94, adj. p < .001). The most frequently used dating website or app was Grindr, with 60.2% of the sample reporting some or frequent use. Adam4Adam (23.5%), Jack’d (18.9%) and Scruff (18.7%) were also frequently used. Dating websites and apps may be effective channels to reach a diverse group of MSM with HIV prevention messages.
TL;DR: Women with 12-month behavioral health disorders were significantly more likely than their counterparts to engage in subsequent sexual and substance use HIV risk behaviors, and likelihood of disorders was associated with women’s race/ethnicity, employment status, and income.
Abstract: We used the World Health Organization’s Composite International Diagnostic Interview to determine the prevalence, comorbidity, and correlates of lifetime and 12-month behavioral health disorders in a multisite cohort of 1027 women living with HIV in the United States. Most (82.6%) had one or more lifetime disorders including 34.2% with mood disorders, 61.6% with anxiety disorders, and 58.3% with substance use disorders. Over half (53.9%) had at least one 12-month disorder, including 22.1% with mood disorders, 45.4% with anxiety disorders, and 11.1% with substance use disorders. Behavioral health disorder onset preceded HIV diagnosis by an average of 19 years. In multivariable models, likelihood of disorders was associated with women’s race/ethnicity, employment status, and income. Women with 12-month behavioral health disorders were significantly more likely than their counterparts to engage in subsequent sexual and substance use HIV risk behaviors. We discuss the complex physical and behavioral health needs of women living with HIV.
TL;DR: Results inform and justify a future randomised controlled trial of task-shifted PST-AD, and show promising change at 6-months follow-up was seen in electronic adherence, viral load suppression and depression.
Abstract: Using a pilot trial design in an HIV care clinic in Zimbabwe, we randomised 32 adults with poor adherence to antiretroviral therapy and at least mild depression to either six sessions of Problem-Solving Therapy for adherence and depression (PST-AD) delivered by an adherence counsellor, or to Enhanced Usual Care (Control). Acceptability of PST-AD was high, as indicated by frequency of session attendance and through qualitative analyses of exit interviews. Fidelity was >80% for the first two sessions of PST-AD but fidelity to the adherence component of PST-AD dropped by session 4. Contamination occurred, in that seven patients in the control arm received one or two PST-AD sessions before follow-up assessment. Routine health records proved unreliable for measuring HIV viral load at follow-up. Barriers to measuring adherence electronically included device failure and participant perception of being helped by the research device. The study was not powered to detect clinical differences, however, promising change at 6-months follow-up was seen in electronic adherence, viral load suppression (PST-AD arm 9/12 suppressed; control arm 4/8 suppressed) and depression (Patient Health Questionnaire-4.7 points in PST-AD arm vs. control, adjusted p value = 0.01). Results inform and justify a future randomised controlled trial of task-shifted PST-AD.
TL;DR: Research on correlates of PrEP uptake is reviewed and findings organized within an Information-Motivation-Behavioral Skills (IMB) model framework are presented and an adaptation of the IMB model for Pr EP uptake is proposed and discussed.
Abstract: Despite documented effectiveness of pre-exposure prophylaxis (PrEP), PrEP uptake remains low among at-risk populations. The 2015 CDC report estimates that about 1.2 million people in the US have indications for PrEP. However, only 49,158 or 4% of the targeted population are currently using PrEP. Efforts to optimize uptake of PrEP may be facilitated by the development of a comprehensive theoretical framework which can be used to understand reasons for poor uptake and to develop interventions to maximize PrEP uptake and adherence. This article reviews research on correlates of PrEP uptake and presents findings organized within an Information-Motivation-Behavioral Skills (IMB) model framework. In the context of PrEP uptake, the IMB model asserts that to the extent that at-risk groups are well-informed about PrEP, motivated to act on their knowledge, and have necessary behavioral skills to seek out and initiate PrEP regimen, they will successfully overcome obstacles to initiate and adhere to PrEP. The article proposes an adaptation the IMB model for PrEP uptake, provides empirical support for the adapted IMB model extracted from related research, and discusses its application in PrEP uptake interventions.
TL;DR: Peer interventions may improve retention in primary care among subgroups of people living with HIV from racial/ethnic minority communities, although such improved retention may not increase viral load suppression.
Abstract: Racial/ethnic minorities living with HIV and behavioral health co-morbidities are more likely to be disengaged from HIV primary care. Peer programs have been effective in HIV outreach and prevention but effectiveness of such programs for retention in care and viral suppression is understudied. Subjects (n = 348) were randomized in equal allocation to a peer navigation and education intervention versus standard clinical care at three urban clinics in the United States. The intervention group received seven structured interventions plus weekly contact to address medical and social needs. Primary outcomes included time-to-first 4-month gap in HIV care and viral suppression up to 12 months of follow-up. Intention-to-treat analysis showed no difference between groups on 4-month gap in HIV primary care, but subgroup analysis showed a suggestive effect of the peer intervention in reducing gaps in care among stably housed subjects. Fully compliant subjects in the peer intervention experienced significantly fewer 4-month gaps in HIV primary care (p < 0.0001). Those in the peer group who had more clinical face-to-face encounters in the first 3 months were also significantly more likely to have better retention in care (p = 0.04). There were no significant differences between any study subgroups in viral suppression at 12 months. Peer interventions may improve retention in primary care among subgroups of people living with HIV from racial/ethnic minority communities, although such improved retention may not increase viral load suppression. Attending and completing structured educational sessions along with early, intensive contact with peers could improve retention in HIV primary care for patients. Future peer programs should consider training on housing referral systems to help increase retention for patients who are not stably housed. clinicaltrials.gov registration number: NCT01616940.
TL;DR: In this article, a survey study of 115 US medical students examined associations between biases (racism and heterosexism) and PrEP clinical decision-making and explored prior PrEP education as a potential buffer.
Abstract: Social biases among healthcare providers could limit PrEP access. In this survey study of 115 US medical students, we examined associations between biases (racism and heterosexism) and PrEP clinical decision-making and explored prior PrEP education as a potential buffer. After viewing a vignette about a PrEP-seeking MSM patient, participants reported anticipated patient behavior (condomless sex, extra-relational sex, and adherence), intention to prescribe PrEP to the patient, biases, and background characteristics. Minimal evidence for racism affecting clinical decision-making emerged. In unadjusted analyses, heterosexism indirectly affected prescribing intention via all anticipated behaviors, tested as parallel mediators. Participants expressing greater heterosexism more strongly anticipated increased risk behavior and adherence problems, which were associated with lower prescribing intention. The indirect effect via condomless sex remained significant adjusting for background characteristics. Prior PrEP education did not buffer any indirect effects. Heterosexism may compromise PrEP provision to MSM and should be addressed in PrEP-related medical education.
TL;DR: A systematic review of peer-reviewed published articles and content analysis of online posts about PrEP identified salient and novel information about barriers to and facilitators of PrEP use among US MSM.
Abstract: Pre-exposure prophylaxis (PrEP) remains an under-utilized HIV prevention tool among men who have sex with men (MSM). To more comprehensively elucidate barriers and facilitators to PrEP use among US MSM, we conducted a systematic review of peer-reviewed published articles and content analysis of online posts about PrEP. We searched peer-reviewed databases (Medline, Web of Science, Google Scholar) using MESH headings and keywords about PrEP and/or HIV prevention from 2005 to 2015. We included original studies among MSM in the US that reported on barriers, facilitators, or other factors related to PrEP use. We also searched online posts and associated comments (news articles, opinion pieces, blogs and other social media posts) in diverse venues (Facebook, Slate Outward, Huffington Post Gay Voices, Queerty, and My PrEP Experience blog) to identify posts about PrEP. We used content analysis to identify themes and compare potential differences between the peer-reviewed literature and online posts. We identified 25 peer-reviewed articles and 28 online posts meeting inclusion criteria. We identified 48 unique barriers and 46 facilitators to using PrEP. These 94 themes fit into six overarching categories: (1) access (n = 14), (2) attitudes/beliefs (n = 24), (3) attributes of PrEP (n = 13), (4) behaviors (n = 11), (5) sociodemographic characteristics (n = 8), and (6) social network (n = 6). In all categories, analysis of online posts resulted in identification of a greater number of unique themes. Thirty-eight themes were identified in the online posts that were not identified in the peer-reviewed literature. We identified barriers and facilitators to PrEP in online posts that were not identified in a systematic review of the peer-reviewed literature. By incorporating data both from a systematic review of peer-reviewed articles and from online posts, we have identified salient and novel information about barriers to and facilitators of PrEP use. Traditional research approaches may not comprehensively capture current factors important for designing and implementing PrEP related interventions.
TL;DR: Across sub-Saharan Africa, masculinity appears to play an important role in men’s decision to test for HIV and further research and interventions are needed to address this link.
Abstract: Men living with HIV/AIDS in sub-Saharan Africa are less likely to test for HIV than women. We conducted a scoping review in May of 2016 to identify how masculine norms influence men's HIV testing in sub-Saharan Africa. Our review yielded a total of 13 qualitative studies from 8 countries. Masculine norms create both barriers and facilitators to HIV testing. Barriers included emotional inexpression, gendered communication, social pressures to be strong and self-reliant, and the fear that an HIV positive result would threaten traditional social roles (i.e., husband, father, provider, worker) and reduce sexual success with women. Facilitators included perceptions that HIV testing could restore masculinity through regained physical strength and the ability to re-assume the provider role after accessing treatment. Across sub-Saharan Africa, masculinity appears to play an important role in men's decision to test for HIV and further research and interventions are needed to address this link.
TL;DR: As condomless anal sex may increase following PrEP uptake, adherence counseling and efforts to retain patients in PrEP care, especially during periods of non-condom use, are important as PrEP is more widely implemented.
Abstract: We describe changes in sexual behaviors among men who have sex with men (MSM) following initiation of pre-exposure prophylaxis (PrEP) in a clinic-based sample of MSM initiating PrEP in Providence, Rhode Island. Data were collected at baseline, 3, and 6 months following PrEP initiation including total number of anal sex partners and condom use. A longitudinal mixed effects model assessed changes in number of partners and condom use over time, adjusting for age, race, and education. There was no statistically significant difference in total number of partners over time. There was a significant increase in number of condomless anal sex partners at the 6-month visit compared to baseline (mean change +1.31 partners, 95% confidence interval 0.09-2.53, P = 0.035). As condomless anal sex may increase following PrEP uptake, adherence counseling and efforts to retain patients in PrEP care, especially during periods of non-condom use, are important as PrEP is more widely implemented.
TL;DR: Interventions addressing economic insecurity have the potential to bolster health outcomes, such as HIV viral suppression, by improving ART adherence among vulnerable adolescents living in low-resource environments by improving the intersections of financial security and HIV treatment.
Abstract: To assess the effect of a savings-led economic empowerment intervention on viral suppression among adolescents living with HIV. Using data from Suubi + Adherence, a longitudinal, cluster randomized trial in southern Uganda (2012–2017), we examine the effect of the intervention on HIV RNA viral load, dichotomized between undetectable (< 40 copies/ml) and detectable (≥ 40 copies/ml). Cluster-adjusted comparisons of means and proportions were used to descriptively analyze changes in viral load between study arms while multi-level modelling was used to estimate treatment efficacy after adjusting for fixed and random effects. At 24-months post intervention initiation, the proportion of virally suppressed participants in the intervention cohort increased tenfold (ΔT2−T0 = + 10.0, p = 0.001) relative to the control group (ΔT2−T0 = + 1.1, p = 0.733). In adjusted mixed models, simple main effects tests identified significantly lower odds of intervention adolescents having a detectable viral load at both 12- and 24-months. Interventions addressing economic insecurity have the potential to bolster health outcomes, such as HIV viral suppression, by improving ART adherence among vulnerable adolescents living in low-resource environments. Further research and policy dialogue on the intersections of financial security and HIV treatment are warranted.
TL;DR: In adults with HIV, high resilience was related to a lower prevalence of depression, anxiety, and problems with ADLs, and it may be necessary to consider resilience when exploring the well-being of adults ageing with HIV.
Abstract: Resilience has been related to improved physical and mental health, and is thought to improve with age. No studies have explored the relationship between resilience, ageing with HIV, and well-being. A cross sectional observational study performed on UK HIV positive (N = 195) and HIV negative adults (N = 130). Associations of both age and ‘time diagnosed with HIV’ with resilience (RS-14) were assessed, and the association of resilience with depression, anxiety symptoms (PHQ-9 and GAD-7), and problems with activities of daily living (ADLs) (Euroqol 5D-3L). In a multivariable model, HIV status overall was not related to resilience. However, longer time diagnosed with HIV was related to lower resilience, and older age showed a non-significant trend towards higher resilience. In adults with HIV, high resilience was related to a lower prevalence of depression, anxiety, and problems with ADLs. It may be necessary to consider resilience when exploring the well-being of adults ageing with HIV.
TL;DR: The need to intervene with drug-using women taking antiretroviral therapy to maintain effective adherence is highlighted, as the effects of self-reported substance use on suboptimal adherence in the Women’s Interagency HIV Study are examined.
Abstract: Research is scant regarding differential effects of specific types of recreational drugs use on antiretroviral therapy adherence among women, particularly to single-tablet regimens (STR). This is increasingly important in the context of marijuana legalization. We examined the effects of self-reported substance use on suboptimal (<95%) adherence in the Women’s Interagency HIV Study, 2003–2014. Among 1799 HIV-infected women, the most prevalent substance used was marijuana. In multivariable Poisson GEE regression, substance use overall was significantly associated with suboptimal adherence (adjusted prevalence ratio, aPR = 1.20, 95% CI 1.10–1.32), adjusting for STR use, socio-demographic, behavioral, and clinical factors. Among STR users, compared to no drug use, substance use overall remained detrimental to ART adherence (aPR = 1.61, 95% CI 1.24–2.09); specifically, both marijuana (aPR = 1.48, 95% CI: 1.11–1.97) and other drug use (aPR = 1.87, 95% CI 1.29–2.70) predicted suboptimal adherence. These findings highlight the need to intervene with drug-using women taking antiretroviral therapy to maintain effective adherence.