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ABSTRACT: BACKGROUND: An international randomized clinical trial (RCT) on pre-exposure prophylaxis (PrEP) as an human immunodeficiency virus (HIV)-prevention intervention found that taken on a daily basis, PrEP was safe and effective among men who have sex with men (MSM) and male-to-female transgender women. Within the context of the HIV epidemic in the United States (US), MSM and transgender women are the most appropriate groups to target for PrEP implementation at the population level; however, their perspectives on evidenced-based biomedical research and the results of this large trial remain virtually unknown. In this study, we examined the acceptability of individual daily use of PrEP and assessed potential barriers to community uptake. METHODS: We conducted semi-structured interviews with an ethnoracially diverse sample of thirty HIV-negative and unknown status MSM (n = 24) and transgender women (n = 6) in three California metropolitan areas. Given the burden of disease among ethnoracial minorities in the US, we purposefully oversampled for these groups. Thematic coding and analysis of data was conducted utilizing an approach rooted in grounded theory. RESULTS: While participants expressed general interest in PrEP availability, results demonstrate: a lack of community awareness and confusion about PrEP; reservations about PrEP utilization, even when informed of efficacious RCT results; and concerns regarding equity and the manner in which a PrEP intervention could be packaged and marketed in their communities. CONCLUSIONS: In order to effectively reduce HIV health disparities at the population level, PrEP implementation must take into account the uptake concerns of those groups who would actually access and use this biomedical intervention as a prevention strategy. Recommendations addressing these concerns are provided.
Implementation Science 11/2012; 7(1):116. · 3.10 Impact Factor
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ABSTRACT: Abstract The delivery of HIV risk assessment and behavioral counseling by clinicians in HIV clinical settings is one component in a comprehensive "positive prevention" strategy to help patients reduce their transmission risk behavior. Clinicians engage in behavioral prevention inconsistently, however, depending on whether patients are new to a practice or are established in regular care and on their attitudes and characteristics of their practices. We analyzed clinician reports of behavioral prevention delivered before and after participation in a large federal demonstration project of positive prevention interventions. The interventions that were part of this project were successful in increasing behavioral prevention among both new and returning patients. Prior to study interventions, clinicians reported counseling 69% of new patients and 52% of returning patients. In follow-up interviews 12 months after receiving training, clinicians reported delivering prevention messages to 5% more new patients and 9% of returning patients (both p<0.01). After 12 months, clinicians were more likely to engage in behavioral prevention if other providers in their sites were also involved. Clinicians agreeing that behavioral prevention was part of the clinic's mission were more likely to conduct it. The interventions were successful in mitigating the influence of provider attitudes precluding prevention delivery. Intervention strategies can help clinicians more consistently deliver behavioral prevention messages to their HIV-infected patients.
AIDS Care 09/2012; · 1.60 Impact Factor
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ABSTRACT: In the United States, HIV prevention services are increasingly being offered in the context of healthcare settings. This includes prioritizing prevention services for people living with HIV (PLWH), otherwise known as "prevention with positives." We conducted sixty in-depth interviews to explore patients' perceptions of clinic-based HIV prevention interventions targeting people living with HIV. The majority of patients were receptive to the prevention interventions. Patients described experiencing feeling fulfilled by communicating about issues related to HIV prevention when the conversations were specific to their situation and with an interventionist who was objective, yet empathic and non-judgmental. Provider-delivered interventions opened up new areas of prevention discussions with patients. Specialist-delivered interventions, specifically group-level interventions, provided opportunities to integrate participants into social networks that in turn provided social support and a reduction in social isolation. HIV prevention counseling benefited patients regardless of risk status.
AIDS education and prevention: official publication of the International Society for AIDS Education 08/2012; 24(4):295-308. · 1.51 Impact Factor
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Peter R. Kerndt,
Robert Dubrow,
Getahun Aynalem,
Kenneth H. Mayer,
Curt Beckwith,
Robert H. Remien,
Hong-Ha M. Truong,
Apurva Uniyal,
Michael Chien,
Ronald A. Brooks,
Ofilio R. Vigil,
Wayne T. Steward,
Michael Merson,
Mary Jane Rotheram-Borus, Stephen F. Morin
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ABSTRACT: Acute/early HIV infection plays a critical role in onward HIV transmission. Detection of HIV infections during this period
provides an important early opportunity to offer interventions which may prevent further transmission. In six US cities, persons
with acute/early HIV infection were identified using either HIV RNA testing of pooled sera from persons screened HIV antibody
negative or through clinical referral of persons with acute or early infections. Fifty-one cases were identified and 34 (68%)
were enrolled into the study; 28 (82%) were acute infections and 6 (18%) were early infections. Of those enrolled, 13 (38%)
were identified through HIV pooled testing of 7,633 HIV antibody negative sera and 21 (62%) through referral. Both strategies
identified cases that would have been missed under current HIV testing and counseling protocols. Efforts to identify newly
infected persons should target specific populations and geographic areas based on knowledge of the local epidemiology of incident
infections.
AIDS and Behavior 04/2012; 13(6):1037-1045. · 3.49 Impact Factor
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ABSTRACT: Questions remain regarding the clinical utility of psychological interventions for HIV-positive persons because randomized
controlled trials have utilized stringent inclusion criteria and focused extensively on gay men. The present randomized controlled
trial examined the efficacy of a 15-session, individually delivered cognitive-behavioral intervention (n=467) compared to a wait-list control (n=469) in a diverse sample of HIV-positive persons who reported HIV transmission risk behavior. Five intervention sessions
that dealt with executing effective coping responses were delivered between baseline and the 5months post-randomization.
Additional assessments were completed through 25months post-randomization. Despite previously documented reductions in HIV
transmission risk, no intervention-related changes in psychosocial adjustment were observed across the 25-month investigation
period. In addition, there were no intervention effects on psychosocial adjustment among individuals who presented with mild
to moderate depressive symptoms. More intensive mental health interventions may be necessary to improve psychosocial adjustment
among HIV-positive individuals.
AIDS and Behavior 04/2012; 13(3):555-563. · 3.49 Impact Factor
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Robert H. Remien,
Theresa Exner,
Robert M. Kertzner,
Anke A. Ehrhardt,
Mary Jane Rotheram-Borus,
Mallory O. Johnson,
Lance S. Weinhardt,
Lauren E. Kittel,
Rise B. Goldstein,
Rogério M. Pinto, Stephen F. Morin,
Margaret A. Chesney,
Marguerita Lightfoot,
Cheryl Gore-Felton,
Brian Dodge,
Jeffrey A. Kelly,
NIMH Healthy Living Project Trial Group
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ABSTRACT: Objective: An enhanced stress and coping model was used to explain depression among HIV-positive women in healthcare and community settings where highly active anti-retroviral treatment (HAART) was commonplace. Method: HIV-infected women in four cities (N=978) were assessed, cross-sectionally, for mental and physical health, stress, social support, and other background factors. Results: Self-reported level of depressive symptomatology was high. Number of physical symptoms, illness intrusiveness, and perceived stress were positively associated with depressed mood, while coping self-efficacy and social support were negatively associated. Stress mediated the effect of health status on depression and coping self-efficacy mediated the effect of psychosocial resources on depression. Our enhanced stress and coping model accounted for 52% of variance in depressive symtpomatology. Conclusions: Interventions focused on improving coping self-efficacy, bolstering social supports, and decreasing stress in the lives of HIV-positive women may help to reduce the negative effects of HIV disease on mood.
American Journal of Community Psychology 04/2012; 38(3):275-285. · 1.74 Impact Factor
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J. Hampton Atkinson,
Jenny A. Higgins,
Ofilio Vigil,
Robert Dubrow,
Robert H. Remien,
Wayne T. Steward,
Corinna Young Casey,
Kathleen J. Sikkema,
Jackie Correale,
Chris Ake,
J. Allen McCutchan,
Peter R. Kerndt, Stephen F. Morin,
Igor Grant
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ABSTRACT: Acute/early HIV infection is a period of high risk for HIV transmission. Better understanding of behavioral aspects during
this period could improve interventions to limit further transmission. Thirty-four participants with acute/early HIV infection
from six US cities were assessed with the Mini International Diagnostic Interview, Beck Depression Inventory II, State-Trait
Anxiety Inventory, Brief COPE, and an in-depth interview. Most had a pre-HIV history of alcohol or substance use disorder
(85%); a majority (53%) had a history of major depressive or bipolar disorder. However, post-diagnosis coping was predominantly
adaptive, with only mild to moderate elevations of anxious or depressive mood. Respondents described challenges managing HIV
in tandem with pre-existing substance abuse problems, depression, and anxiety. Integration into medical and community services
was associated with adaptive coping. The psychiatric context of acute/early HIV infection may be a precursor to infection,
but not necessarily a barrier to intervention to reduce forward transmission of HIV among persons newly infected.
AIDS and Behavior 04/2012; 13(6):1061-1067. · 3.49 Impact Factor
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ABSTRACT: Retaining high-risk individuals is critical for HIV prevention trials. The current analyses examined predictors of trial dropout
among HIV-infected men and women in a multi-site HIV prevention trial. Results indicated that dropouts (n=74) were more likely to be younger, depressed, and not taking antiretroviral therapy (ART) than those who continued (n=815). No other background, substance use, or transmission risk differences were found, suggesting no direct evidence of
dropout bias on key outcomes. Efforts may be warranted for early detection and treatment of depression and for improving retention
of younger participants and those not on ART.
AIDS and Behavior 04/2012; 12(6):974-977. · 3.49 Impact Factor
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ABSTRACT: Disclosure of HIV serostatus by HIV-infected individuals is considered a prevention strategy, under the assumption that disclosure will prompt risk reduction practices among sex partners. We examined patients' self-reports regarding disclosure messages they found relevant as part of prevention with positives (PwP) interventions in clinical settings. We conducted 52 in-depth interviews with patients participating in 13 PwP interventions. We found that the opportunity to reflect about living with HIV, explore fears of stigma and rejection, develop communication skills and strategies to disclose, and explore a sense of responsibility influenced patients' intention to disclose and their disclosure practices. PwP interventions need to include a combination of messages about disclosure strategies, stigma, and communication, as well as helping patients frame disclosure as a process that includes situations and interactions to consider post-disclosure. PwP disclosure counseling can help influence a shift in patients' risk towards safer sex practices.
AIDS education and prevention: official publication of the International Society for AIDS Education 04/2012; 24(2):179-92. · 1.51 Impact Factor
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ABSTRACT: Despite high rates of patient satisfaction with emergency department (ED) HIV testing, acceptance varies widely. It is thought that patients who decline may be at higher risk for HIV infection, thus we sought to better understand patient acceptance and refusal of ED HIV testing.
In-depth interviews with fifty ED patients (28 accepters and 22 decliners of HIV testing) in three ED HIV testing programs that serve vulnerable urban populations in northern California.
Many factors influenced the decision to accept ED HIV testing, including curiosity, reassurance of negative status, convenience, and opportunity. Similarly, a number of factors influenced the decision to decline HIV testing, including having been tested recently, the perception of being at low risk for HIV infection due to monogamy, abstinence or condom use, and wanting to focus on the medical reason for the ED visit. Both accepters and decliners viewed ED HIV testing favorably and nearly all participants felt comfortable with the testing experience, including the absence of counseling. While many participants who declined an ED HIV test had logical reasons, some participants also made clear that they would prefer not to know their HIV status rather than face psychosocial consequences such as loss of trust in a relationship or disclosure of status in hospital or public health records.
Testing for HIV in the ED as for any other health problem reduces barriers to testing for some but not all patients. Patients who decline ED HIV testing may have rational reasons, but there are some patients who avoid HIV testing because of psychosocial ramifications. While ED HIV testing is generally acceptable, more targeted approaches to testing are necessary for this subgroup.
BMC Public Health 01/2012; 12:3. · 2.00 Impact Factor
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ABSTRACT: A recent clinical trial demonstrated that a daily dose tenofovir disoproxil fumarate and emtricitabrine (TDF-FTC) can reduce HIV acquisition among men who have sex with men (MSM) and transgender (TG) women by 44%, and up to 90% if taken daily. We explored how medical and service providers understand research results and plan to develop clinical protocols to prescribe, support and monitor adherence for patients on PrEP in the United States.
Using referrals from our community collaborators and snowball sampling, we recruited 22 healthcare providers in San Francisco, Oakland, and Los Angeles for in-depth interviews from May-December 2011. The providers included primary care physicians seeing high numbers of MSM and TG women, HIV specialists, community health clinic providers, and public health officials. We analyzed interviews thematically to produce recommendations for setting policy around implementing PrEP. Interview topics included: assessing clinician impressions of PrEP and CDC guidance, considerations of cost, office capacity, dosing schedules, and following patients over time.
Little or no demand for PrEP from patients was reported at the time of the interviews. Providers did not agree on the most appropriate patients for PrEP and believed that current models of care, which do not involve routine frequent office visits, were not well suited for prescribing PrEP. Providers detailed the need to build capacity and were concerned about monitoring side effects and adherence. PrEP was seen as potentially having impact on the epidemic but providers also noted that community education campaigns needed to be tailored to effectively reach specific vulnerable populations.
While PrEP may be a novel and clinically compelling prevention intervention for MSM and TG women, it raises a number of important implementation challenges that would need to be addressed. Nonetheless, most providers expressed optimism that they eventually could prescribe and monitor PrEP in their practice.
PLoS ONE 01/2012; 7(7):e40603. · 4.09 Impact Factor
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BMJ (Clinical research ed.). 01/2012; 345:e5412.
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ABSTRACT: As community-level interventions become more common in HIV prevention, processes such as community mobilization (CM) are increasingly utilized in public health programs and research. Project Accept, a multi-site community randomized controlled trial, is testing the hypothesis that CM coupled with community-based mobile voluntary counseling and testing and post-test support services will alter community norms and reduce the incidence of HIV. By using a multiple-case study approach, this qualitative study identifies seven major community mobilization strategies used in Project Accept, including stakeholder buy-in, formation of community coalitions, community engagement, community participation, raising community awareness, involvement of leaders, and partnership building, and describes three key elements of mobilization success.
AIDS and Behavior 08/2011; 16(5):1217-26. · 3.49 Impact Factor
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JAIDS Journal of Acquired Immune Deficiency Syndromes 05/2011; 57(3):175-80. · 4.43 Impact Factor
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ABSTRACT: The 2006 Centers for Disease Control and Prevention (CDC) HIV testing guidelines recommend screening for HIV infection in all healthcare settings, including the emergency department (ED). In urban areas with a high background prevalence of HIV, the ED has become an increasingly important site for identifying HIV infection. However, this public health policy has been operationalized using different models. We sought to describe the development and implementation of HIV testing programs in three EDs, assess factors shaping the adoption and evolution of specific program elements, and identify barriers and facilitators to testing.
We performed a qualitative evaluation using in-depth interviews with fifteen 'key informants' involved in the development and implementation of HIV testing in three urban EDs serving sizable racial/ethnic minority and socioeconomically disadvantaged populations. Testing program HIV prevalence ranged from 0.4% to 3.0%.
Three testing models were identified, reflecting differences in the use of existing ED staff to offer and perform the test and disclose results. Factors influencing the adoption of a particular model included: whether program developers were ED providers, HIV providers, or both; whether programs took a targeted or non-targeted approach to patient selection; and the extent to which linkage to care was viewed as the responsibility of the ED. A common barrier was discomfort among ED providers about disclosing a positive HIV test result. Common facilitators were a commitment to underserved populations, the perception that testing was an opportunity to re-engage previously HIV-infected patients in care, and the support and resources offered by the medical setting for HIV-infected patients.
ED HIV testing is occurring under a range of models that emerge from local realities and are tailored to institutional strengths to optimize implementation and overcome provider barriers.
Implementation Science 03/2011; 6:30. · 3.10 Impact Factor
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Adam W Carrico,
Elise D Riley,
Mallory O Johnson,
Edwin D Charlebois,
Torsten B Neilands,
Robert H Remien,
Marguerita A Lightfoot,
Wayne T Steward,
Lance S Weinhardt,
Jeffrey A Kelly,
Mary Jane Rotheram-Borus, Stephen F Morin,
Margaret A Chesney
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ABSTRACT: In the era of antiretroviral therapy (ART), depression and substance use predict hastened HIV disease progression, but the underlying biological or behavioral mechanisms that explain these effects are not fully understood.
Using outcome data from 603 participants enrolled in a randomized controlled trial of a behavioral intervention, binary logistic and linear regression were employed to examine whether inconsistent patterns of ART utilization partially mediated the effects of depression and substance use on higher HIV viral load over a 25-month follow-up.
Elevated affective symptoms of depression independently predicted ART discontinuation [adjusted odds ratio = 1.39, 95% confidence interval (CI) = 1.08 to 1.78], and use of stimulants at least weekly independently predicted intermittent ART utilization (adjusted odds ratio = 2.62, 95% CI = 1.45 to 4.73). After controlling for the average self-reported percentage of ART doses taken and baseline T-helper (CD4) count, elevated depressive symptoms predicted a 50% higher mean viral load, and weekly stimulant use predicted a 137% higher mean viral load. These effects became nonsignificant after accounting for inconsistent patterns of ART utilization, providing evidence of partial mediation.
Inconsistent patterns of ART utilization may partially explain the effects of depression and stimulant use on hastened HIV disease progression.
JAIDS Journal of Acquired Immune Deficiency Syndromes 02/2011; 56(2):146-50. · 4.43 Impact Factor
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ABSTRACT: To support expanded prevention services for people living with HIV, the US Health Resources and Services Administration (HRSA) sponsored a 5-year initiative to test whether interventions delivered in clinical settings were effective in reducing HIV transmission risk among HIV-infected patients. Across 13 demonstration sites, patients were randomized to one of four conditions. All interventions were associated with reduced unprotected vaginal and/or anal intercourse with persons of HIV-uninfected or unknown status among the 3,556 participating patients. Compared to the standard of care, patients assigned to receive interventions from medical care providers reported a significant decrease in risk after 12 months of participation. Patients receiving prevention services from health educators, social workers or paraprofessional HIV-infected peers reported significant reduction in risk at 6 months, but not at 12 months. While clinics have a choice of effective models for implementing prevention programs for their HIV-infected patients, medical provider-delivered methods are comparatively robust.
AIDS and Behavior 03/2010; 14(3):483-92. · 3.49 Impact Factor
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W Scott Comulada,
Mary Jane Rotheram-Borus,
Willo Pequegnat,
Robert E Weiss,
Katherine A Desmond,
Elizabeth Mayfield Arnold,
Robert H Remien, Stephen F Morin,
Lance S Weinhardt,
Mallory O Johnson,
Margaret A Chesney
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ABSTRACT: Relationships between mental health symptoms (anxiety and depression) or a positive state of mind and behavior associated with HIV transmission (substance use and risky sexual behavior) were explored in a longitudinal study of persons living with HIV (PLH; N = 936) who were participants in a transmission-prevention trial. Bivariate longitudinal regressions were used to estimate the correlations between mental health symptoms and HIV-related transmission acts for 3 time frames: at the baseline interview, over 25 months, and from assessment to assessment. At baseline, mental health symptoms were associated with transmission acts. Elevated levels of mental health symptoms at baseline were associated with decreasing alcohol or marijuana use over 25 months. Over 25 months, an increasingly positive state of mind was associated with decreasing alcohol or marijuana use; an increasingly positive state of mind in the immediate intervention condition and increasing depressive symptoms in the lagged condition were related to increasing risky sexual behavior. Our findings suggest that mental health symptoms precede a decrease in substance use and challenge self-medication theories. Changes in mental health symptoms and sexual behavior occur more in tandem.
Psychology of Addictive Behaviors 03/2010; 24(1):109-18. · 2.09 Impact Factor
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ABSTRACT: Internalized heterosexism (IH), or the internalization of societal antihomosexual attitudes, has been consistently linked to depression and low self-esteem among gay men, and it has been inconclusively associated with substance use and sexual risk in gay and bisexual men. Using structural equation modeling, the authors tested a model framed in social action theory (C. K. Ewart, 1991, 2004) in which IH is associated with HIV transmission risk and poor adherence to HIV antiretroviral therapy (ART) through the mechanisms of negative affect and stimulant use. Data from a sample of 465 gay-identified men interviewed as part of an HIV risk reduction behavioral trial were used to test the fit of the model. Results support the hypothesized model in which IH was associated with unprotected receptive (but not insertive) anal intercourse with HIV-negative or unknown HIV status partners, and with ART nonadherence indirectly via increased negative affect and more regular stimulant use. The model accounted for 15% of the variance in unprotected receptive anal intercourse and 17% of the variance in ART nonadherence. Findings support the potential utility of addressing IH in HIV prevention and treatment with HIV-positive gay men.
Journal of Consulting and Clinical Psychology 11/2008; 76(5):829-39. · 4.85 Impact Factor
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ABSTRACT: Unprotected sexual intercourse remains a primary mode of HIV transmission in the United States. We found that receipt of services to reduce HIV transmission-risk behaviors was low among 3787 HIV-infected individuals and that men who have sex with men were especially unlikely to receive these services even though they were more likely to report unprotected sexual intercourse with seronegative and unknown serostatus casual partners. Greater efforts should be made to ensure that prevention counseling is delivered to all HIV-infected persons, especially men who have sex with men.
American Journal of Public Health 07/2008; 98(6):1011-4. · 3.93 Impact Factor
