S U P P L E M E N T A R T I C L E
Linkage to Care for HIV-Infected Heterosexual
Men in the United States
Nickolas D. Zaller,1,2Jeannia J. Fu,2Amy Nunn,1,2and Curt G. Beckwith1,2
1Alpert Medical School, Brown University, and2Division of Infectious Diseases, Miriam Hospital, Providence, Rhode Island
In the United States, the human immunodeficiency virus (HIV) epidemic among heterosexual men
disproportionately affects individuals involved with the criminal justice system, injection drug and other
substance users, and racial and ethnic minorities. These overlapping populations confront similar social and
structural disparities that contribute to HIV risk and limit access to HIV testing, treatment, and care. In this
review, we discuss barriers to linkage to comprehensive HIV care for specific subpopulations of heterosexual
men and examine approaches for enhancing linkage to care for this diverse population.
In 1997, 78% of all AIDS cases in the United States were
among men . A decade later, the human immuno-
deficiency virus (HIV)/AIDS epidemic remains dispro-
portionately concentrated among men, who represent
nearly three-fourths of all HIV/AIDS cases and new HIV
infections among adults and adolescents . HIV-in-
fectedmen are also morelikelytoreceive adiagnosis late
in the course of infection  and have lower CD4 cell
counts when care is initiated . In 2007, 46% of men
infected through heterosexual contact progressed to
HIV-infected population . Significant racial and
ethnic disparities in HIV infection persist. In2007,black
and Hispanic men comprised 57% of all HIV/AIDS
diagnoses among men, and black men experienced the
highest rate of new HIV infections of any demographic
group (115.7/100,000 population) . Racial and ethnic
minorities are also disproportionately represented
among late diagnoses and are significantly more likely to
experience delayed linkage to care [5–11].
Modes of HIV transmission among men have
changed during the last decade [1, 2]. Male-to-male
sexual contact remains the primary mode of trans-
mission among men in the United States; however, 16%
sex and 12% through injection drug use (IDU) in 2007
. Whereas the number of new HIV/AIDS cases
among men resulting from IDU has declined during the
past 2 decades and stabilized since 2004, infections at-
tributable to heterosexual sex have increased . In-
creasing rates of heterosexual HIV transmission
underscore the potential for a more generalized het-
erosexual HIV epidemic, and studies in Washington,
DC, and Baltimore, Maryland, have identified this tra-
jectory in marginalized urban communities [12, 13].
Figure 1 depicts the proportion of heterosexual men
among the total number of persons with HIV infection
in the United States between 2000 and 2007 [2, 14–20].
In the United States, the HIV epidemic among het-
erosexual men disproportionately affects individuals
involved with the criminal justice system, injection drug
users (IDUs), other substance users, and racial and
ethnic minorities. These overlapping populations con-
front similar social and structural disparities that con-
tribute to HIV risk and limit access to HIV testing,
treatment, and care. In describing these disparities and
risks, clinicians and researchers need to be particularly
cautious about protecting sensitive health information,
such as drug use and sexual risk-taking behaviors. Some
Correspondence: Nickolas D. Zaller, MD, 164 Summit Ave, Providence, RI, 02909
Clinical Infectious Diseases
? The Author 2011. Published by Oxford University Press on behalf of the
Infectious Diseases Society of America. All rights reserved. For Permissions,
please e-mail: email@example.com.
Linkage to HIV Care: Heterosexual Men
d CID 2011:52 (Suppl 2)
researchers have used peer-based interventions and employed
research staff of the same race and/or cultural background as the
study participants to enhance participants’ comfort with the
research and to bolster the quality of data collected [21, 22].
Other studies have used technology such as audio computer-
assisted self-interviews to improve rates of reporting of sensitive
behaviors and to reduce socially desirable responding [23–26].
In this review, we discuss barriers to linking specific sub-
populations of heterosexual men to comprehensive HIV care
and examine approaches for enhancing the linkage to care for
this diverse population.
EMERGING SUBPOPULATIONS AT RISK
During the past 2 decades, there has been a significant decline in
IDU-related HIV infections [27–29], probably in partbecause of
increases in HIV prevention programs targeted to IDUs, in-
cluding syringe exchange programs [30, 31]. Despite these de-
clines, IDU-related HIV transmission continues to affect racial
and ethnic minorities at disproportionate rates, particularly
African American men . Recent data from the Centers for
Disease Control and Prevention indicate that between 2004 and
2007, 62% of incident IDU-associated HIV infections were
among men and 58% of those infected through IDU were black
. In addition, 40% of HIV-infected IDUs received late HIV
diagnoses, defined as receiving an AIDS diagnosis within 12
months of HIV diagnosis . Among African Americans in
high-risk communities in Houston, Texas, Risser et al found
that individuals reporting both IDU and heterosexual anal in-
tercourse had 6.2 times the odds of being HIV infected . In
a sample of 3555 drug users and neighborhood controls, McCoy
et al found that IDUs and those reporting both IDU and crack
cocaine smoking were 9.8 and 5.27 times, respectively, more
likely to be HIV infected . These findings demonstrate the
need for coordinated efforts between researchers, policymakers,
and outreach and community-based organizations to address
late HIV diagnoses among IDUs and to target interventions to
the needs of specific IDU subpopulations.
Nonparenteral Substance Users
Despite the overall decline in IDU-related HIV infections, the
association between nonparenteral substance use and HIV in-
fection has been increasingly demonstrated. In some areas of the
United States, HIV prevalence among crack cocaine smokers
may be comparable to or greater than among IDUs . Booth
et al found that crack cocaine smokers and crack cocaine–
smoking IDUs were more likely to report having multiple sexual
partners and exchanging sex for drugs or money than those who
only injected . McCoy et al found that, compared with
neighborhood controls, crack cocaine smokers were 2.2 times
more likely to be infected with HIV . Adimora et al also
found a statistically significant association between sexual con-
currency and crack cocaine smoking in a sample of rural African
Americans with recent heterosexually acquired HIV infection
. Alcohol use has also been shown to be an important me-
diator of high-risk sexual behavior among men [38, 39], with
Table 1.Linkage to Care among Heterosexual Men with Human Immunodeficiency Virus Infection: Barriers and Facilitators
Barriers or ChallengesSuccessful Strategies
Incarceration Communication between correctional and community providers; comprehensive discharge
planning and case management; availability of substance use treatment within and outside
Substance dependenceDirectly administered antiretroviral therapy; integrated opiate replacement and antiretroviral
therapy; case management; integration or colocation of medical care and supportive services
Stigma and distrustPeer engagement and outreach; sustained engagement with target population
Structural or environmental barriersCase management and colocation of services; linkage to health insurance; access to stable
housing; job training and placement programs
infection among males in the United States, by transmission category,
2000–2007. Source: Centers for Disease Control and Prevention annual
HIV/AIDS surveillance reports [2,14–20].aUnknown indicates other or risk
factor not reported or identified.
Estimated proportion of human immunodeficiency virus (HIV)
d CID 2011:52 (Suppl 2)
d Zaller et al.
additional studies finding strong associations between alcohol
use and HIV incidence [40, 41]. Methamphetamine use is yet
another emerging risk factor for HIV infection among hetero-
sexual men [42, 43].
Men Who Have Sex With Men and Women
Understanding risk factors among men who have sex with men
and women (MSMW) and adapting effective prevention inter-
ventions should be priorities, given the potential of MSMW to
bridge the epidemics between sexes. Lichtenstein found that
bisexual activity is often unprotected among black MSMW ,
and Williams et al identified high rates of IDU and crack use
among MSMW . In a sample of mostly low-income, un-
employed, minority MSMW, Gorbach et al found that sexual
and drug use networks were highly interconnected .
Another characteristic of the changing HIV epidemic among
heterosexual males in the United States is the increasing number
of HIV-infected persons who are foreign born . This in-
seekers. The regulatory change in 2009 that removed HIV in-
fection from the list of communicable diseases of public health
significance among foreign immigrants may affect the pro-
portion of foreign-born HIV-infected persons in the United
Statesinthe comingyears.Before thischange,HIV-infected
immigrants were inadmissible to the country without a govern-
ment waiver.Heterosexual riskisthe predominant modeof HIV
transmission among many foreign-born populations [49, 50];
however, relatively little is known about the epidemiology of
HIV infection inthesepopulations and theextenttowhich these
individuals engage in HIV care after arrival in the United States.
LINKAGE TO CARE
Large numbers of HIV-infected individuals pass through cor-
rectional facilities each year. In 2006, 1 in 7 HIV-positive in-
dividuals in the United States were incarcerated . Access and
adherence to antiretroviral treatment can often be most difficult
in the period immediately after release from incarceration. Re-
cently released individuals are at elevated risk for relapse to drug
use and sexual and drug-related risk behaviors [52–58] and have
difficulty securing stable housing and employment [59–61].
These stressors during community reentry may disrupt en-
gagement in care and lead to worsened virologic outcomes as
well as increase the risk of secondary HIV transmission [62–64].
Newly released African American and Latino inmates in par-
ticular have difficulty accessing antiretroviral treatment (ART)
in the community .
The majority of correctional facilities provide some type of
discharge planning for HIV-positive inmates (T. M. Hammett,
S. Kennedy, S. Kuck, unpublished data, 2007), and studies have
found that inmates who receive such assistance are more likely
to engage in HIV treatment and care in the community [61, 66].
However, Grinstead et al found that staff responsible for dis-
charge planning may not be informed of inmates’ HIV status or
have knowledge of HIV-related services in the community ,
indicating that education of discharge planning staff and co-
ordination with community providers could probably be im-
Because recently released HIV-infected inmates confront
a multitude of challenges during community reentry, initiating
and remaining engaged in community-based care often requires
intensive and sustained assistance that addresses barriers such as
substance dependence, mental illness, unstable housing, un-
employment, and lack of health insurance. Intensive case
management can be successful in engaging recently released
HIV-infected prisoners into medical care and providing linkage
to social services . Newly released HIV-infected individuals
are also more likely to fill a prescription for ART within 10, 30,
or 60 days of release if they receive assistance from a community
caseworker in completing the AIDS Drug Assistance Program
application . However, fewer than half of state and federal
correctional facilities and only 39% of city and county systems
provide referrals to case management services for HIV-infected
inmates during discharge planning (T. M. Hammett, S. Ken-
nedy, S. Kuck, unpublished data, 2007). Organized discharge
planning and intensive case management are critical to facili-
tating successful linkage to and retention in care within this
population and should be implemented on a wide scale.
Substance use frequently undermines the medical management
of HIV among HIV-infected substance users , who are also
and have limited health care access and utilization [68–70]. In
a systematic review of 41 studies examining the relationship
between substance use and adherence to ART, Malta et al found
that active substance use was widely associated with poor ART
adherence . In turn, these associations may create reluctance
among physicians to initiate combination ART in active sub-
stance users .
Involvement with the criminal justice system further com-
plicates the provision of HIV care for substance users. Kerr et al
found that incarceration was the strongest predictor for dis-
continuation of ART among HIV-infected IDUs, with in-
dividuals reporting recent incarceration having 5-fold higher
odds of discontinuing highly active ART (95% confidence in-
terval [CI], 1.2–18.7) . Furthermore, because of the limited
provision of substance-dependence treatment such as opiate
replacement therapy (ORT) in correctional facilities , sub-
Linkage to HIV Care: Heterosexual Men
d CID 2011:52 (Suppl 2)
buprenorphine or methadone in the community may not be
able to continue treatment while incarcerated . As a result,
they may undergo withdrawal and be less inclined to reinitiate
treatment after release , which may increase their risk of
relapse to drug use and significantly affect their ability to engage
in HIV treatment and care. Recently, studies in several cities
have demonstrated the feasibility and effectiveness of linking
prisoners toORT during incarceration and after release [76–84].
Despite the challenges to engaging and retaining this pop-
ulation in care, a number of different treatment interventions
targeted to HIV-infected substance users have achieved favor-
able clinical outcomes. Smith-Rohrberg et al conducted a ran-
domized, controlled trial of directly administered ART for IDUs
and found improved virologic and immunologic outcomes as
well as improved adherence . Integrating substance de-
pendence and HIV treatment is an approach to engaging sub-
stance users in care that directly addresses substance use and its
associated complications. The efficacy of integrating ORT and
HIV treatment has been increasingly examined and models that
integrate treatment with buprenorphine-naloxone into HIV
primary care have recently been successfully piloted [68, 86–89].
Medication-assisted treatment is also available for individuals
dependent on cocaine, methamphetamine, or alcohol, although
more work is needed to explore the potential for integrating
these therapies with ART and HIV care .
Case management and colocation of services can also enhance
linkage to care for substance users , although interventions
using case management alone may be less effective than direct
linkage to substance-dependence treatment in this population
. In their study, Smith-Rohrberg et al assessed the impact of
colocated medical, case management, and referral to substance
abuse services among drug users undergoing directly adminis-
tered ART and found that greater utilization of onsite medical
and case management services was independently associated
with improved virologic outcomes . The impact of case
management on engagement and retention in care has also been
demonstrated among substance-using homeless populations
[93, 94]. Broadhead et al confirmed the feasibility of using peer
health advocates to engage HIV-infected drug users in care and
described this social support structure as a more accessible al-
ternative inthe context oflimitedaccesstointegrated substance-
dependence treatment and HIV care. The intervention involved
weekly provision of peer support and counseling and the pro-
vision of nominal monetary rewards to health advocates for
successfully promoting their peers’ engagement in care .
African-American and Latino Populations
HIV-infected African American and Latino persons are signifi-
cantly more likely than HIV-infected white persons to be di-
agnosed and initiated on treatment late in the course of HIV
infection. In a modeling analysis using data from the national
HIV Research Network to describe HIV survival disparities
among specific racial and ethnic groups, Losina et al found that
late initiation and early discontinuation of ART were most
pronounced among Hispanic subjects, with an additional 3.9
years of life lost from late initiation and early discontinuation of
ART compared with 3.5 years of life lost for the entire study
population . In a retrospective cohort study, Ulett et al
found 2.45 higher odds (95% CI, 1.60–3.74) of delayed linkage
to HIV care among African American patients at an HIV/AIDS
clinic . Racial and ethnic minorities experience greater
marginalization from the health care system and are more likely
than their white counterparts to receive lower quality medical
care [7, 9, 10, 98–104]. Distrust of the health care system can
pose an additional barrier to engaging HIV-infected African
American and Latino persons in treatment and care [105–107].
The complex interplay between social, cultural, and economic
barriers to care among African American and Latino pop-
ulations isnot fullyunderstood.However,sociallyandculturally
sensitive linkage interventions have been developed in a manner
consistent with the adaptation of culturally sensitive and client-
centered HIV prevention interventions [108, 109]. Peer and
outreach-based interventions that address structural barriers to
care have demonstrated effectiveness in linking marginalized
racial and ethnic minorities to treatment. The California Bridge
Project used peer-based staff in outreach to locate out-of-
treatment HIV-infected individuals . Nearly a third of the
325 predominantly African American and Latino clients who
reported no history of HIV treatment were linked to care. Af-
rican American and Latino clients had 2.3 and 3.7 greater odds,
respectively, of being linked to care than did white clients; the
authors hypothesized that this difference was probably due to
the use of outreach staff who reflected the client population
demographically. An average of 15.4 contacts were reported
among those who were successfully linked compared with 7.1
among those who were not, demonstrating the sustained effort
required to engage marginalized individuals in care . Ra-
underserved African American and Latino HIV-positive in-
dividuals at 7 sites of the Health Resources and Services Ad-
of outreach programs that contributed to engagement and re-
tention in HIV care by these populations . Outreach staff
improved access to care through locating physicians and clinics,
linking clients to health insurance, accompanying them to
medical appointments, and facilitating communication with
providers. Staff support enhanced clients’ self-efficacy and ca-
pacity to cope with the HIV diagnosis, and participants were
providedwithservices suchastransportation,food,and housing
that addressed structural barriers to care. Forty-five percent of
participants achieved undetectable viral loads by 12 months
. In another analysis of this multisite study, Cabral et al
d CID 2011:52 (Suppl 2)
d Zaller et al.
found that participants reporting >9 contacts with outreach
staff were half as likely as those with fewer contacts to have
Randomized, controlled trials are needed to assess the effect of
outreach-based interventions on initiating and retaining disad-
vantaged minority populations in care . The feasibility of
integrating outreach interventions with substance-dependence
treatment should also be explored [70, 108, 112].
Interventions that incorporate case management have also
been successful in enhancing linkage to care among racial and
ethnic minorities. The Antiretroviral Treatment Access Study
(ARTAS) was a brief strengths-based case management in-
terventionimplementedinhealthdepartments and community-
based organizations that involved client identification of
strengths and abilities and the development of a personalized
plan to acquire needed resources. ARTAS successfully linked
79% of recently diagnosed participants (497/626) to a primary
HIV care provider within 6 months. Hispanic subjects were
more likely to be engaged in HIV care than other racial and
ethnic groups (odds ratio, 2.14; 95% CI, 1.03– 4.43) .
in 4 states, comparing the efficacy of passive referral to a case
management intervention in linking persons recently diagnosed
to care. Individuals receiving the strengths-based case manage-
ment intervention were 41% more likely to see a medical pro-
vider in consecutive 6-month intervals than those receiving
passive referral to care (relative risk, 1.41; 95% CI, 1.1–1.6). The
intervention had a stronger impact on Hispanic participants
(relative risk, 2.16; 95% CI, 1.40–3.35) than on participants of
other ethnicities .
Colocationofmedicalcareandothersupport serviceshas also
been shown to be an important factor in engaging marginalized
in the ARTAS intervention at a site colocated with HIV medical
care providers were more likely to be linked to care . In
a program designed to facilitate HIV health care utilization
among mostly minority populations in Bronx, New York,
through colocation of case management, support groups,
mental health, and harm reduction services, Cunningham et al
found that case management and HIV support group visits were
associated with 1.9 and 2.3 greater odds, respectively, of quar-
terly medical visits among participants .
In summary, factors such as substance use, poverty, un-
employment, lack of educational opportunities, and marginali-
zation from the health care system constitute multilevel barriers
to care for vulnerable subpopulations of HIV-infected hetero-
sexual men. Consequently, interventions that address social and
structural barriers to care through case management, colocation
of services, and outreach have been shown to enhance linkage to
care across these subpopulations. Despite the broad efficacy of
these interventions, those involved with the criminal justice
system, substance users, and disadvantaged racial and ethnic
minorities face distinct challenges to accessing care that also
require more targeted strategies. Correctional facilities have the
capacity to improve the health of HIV-infected individuals be-
yond incarceration, where they are arguably most vulnerable, by
providing organized and coordinated discharge planning and
linkage to intensive case management after release. Although
substance-dependent populations are especially challenging to
link to and retain in care, the emergence of integrated substance
use and HIV treatment offers new possibilities to engage this
population. The efficacy of peer- and outreach-based inter-
ventions in linking racial and ethnic minorities to care dem-
onstrates the importance of socially and culturally sensitive
interventions that foster trust in providers and provide means of
overcoming structural barriers to care.
Future work is urgently needed to scale up successful models
of linkage to care and to adapt these models to local contexts.
This will require additional resources, but, most importantly, it
will require collaboration across agencies and institutions and
the innovative use of existing resources and capacities. In-
tegration of services is an important example of improving ef-
ficiency in delivering comprehensive HIV care. The challenge
and complexity of linking HIV-infected heterosexual men to
care require renewed efforts to adapt interventions to the needs
of diverse subpopulations.
this manuscript, but support for related work is provided by the National
Institutes of Health (NIH), Center for AIDS Research (grant number P30-
AI-42853); the Center for Drug Abuse and AIDS Research (grant number
P30DA013868); and the National Institute on Drug Abuse, NIH (grant
Supplement sponsorship.This article was published as part of a supple-
by Bristol-Myers Squibb, Positive Charge Initiative. Editorial support for the
Myers Squibb, Positive Charge.
Potential conflicts of interest.A.N. has received consulting fees from
Mylan. All other authors: no conflicts.
The authors received no direct financial support for
1. Centers for Disease Control and Prevention. HIV/AIDS surveillance
report 1997; 9:1–43. Available at: http://www.cdc.gov/hiv/topics/
reports/pdf/hivsur92.pdf. Accessed 7 June 2010.
2. Centers for Disease Control and Prevention. HIV/AIDS surveillance
report 2007; 19:1–63. Available at: http://www.cdc.gov/hiv/topics/
.pdf. Accessed 7 June 2010.
3. Castilla J, Sobrino P, De La Fuente L, Noguer I, Guerra L, Parras F.
Late diagnosis of HIV infection in the era of highly active anti-
retroviral therapy: consequences for AIDS incidence. AIDS 2002;
Linkage to HIV Care: Heterosexual Men
d CID 2011:52 (Suppl 2)
4. Samet JH, Freedberg KA, Savetsky JB, Sullivan LM, Stein MD. Un-
derstanding delay to medical care for HIV infection: the long-term
non-presenter. AIDS 2001; 15:77–85.
5. WohlDA, ShainL, AdamianM, etal. HIVtransmissionrisk behaviors
among HIV-infected individuals released from prison [abstract 36].
In: Program and Abstracts of the 10th Conference on Retroviruses
and Opportunistic Infections 10–14 February 2003. Boston.
6. Hu DJ, Byers R Jr., Fleming PL, Ward JW. Characteristics of persons
with late AIDS diagnosis in the United States. Am J Prev Med 1995;
7. Oramasionwu CU, Brown CM, Lawson KA, Ryan L, Frei CR. Evalu-
ating HIV/AIDS disparities for blacks in the United States: a review of
8. Oramasionwu CU, Brown CM, Ryan L, Lawson KA, Hunter JM, Frei
CR. HIV/AIDS disparities: the mounting epidemic plaguing US
blacks. J Natl Med Assoc 2009; 101:1196–204.
9. Oramasionwu CU, Skinner J, Ryan L, Frei CR. Disparities in anti-
retroviral prescribing for blacks and whites in the United States. J Natl
Med Assoc 2009; 101:1140–4.
10. Moore RD, Stanton D, Gopalan R, Chaisson RE. Racial differences in
the use of drug therapy for HIV disease in an urban community.
N Engl J Med 1994; 330:763–8.
11. Wohl AR, Tejero J, Frye DM. Factors associated with late HIV testing
for Latinos diagnosed with AIDS in Los Angeles. AIDS Care 2009;
12. Magnus M, Kuo I, Shelley K, et al. Risk factors driving the emergence
of a generalized heterosexualHIV epidemicin Washington, District of
Columbia networks at risk. AIDS 2009; 23:1277–84.
13. Towe VL, Sifakis F, Gindi RM, et al. Prevalence of HIV infection and
sexual risk behaviors among individuals having heterosexual sex in
low income neighborhoods in Baltimore, MD: the BESURE study.
J Acquir Immune Defic Syndr 2010; 53:522–8.
14. Centers for Disease Control and Prevention. HIV/AIDS surveillance
report 2000; 12:1–44. Available at: http://www.cdc.gov/hiv/topics/
surveillance/resources/reports/pdf/hasr1202.pdf. Accessed 7 June 2010.
15. Centers for Disease Control and Prevention. HIV/AIDS surveillance
report 2001; 13:1–44. Available at: http://www.cdc.gov/hiv/topics/
year-end.pdf. Accessed 7 June 2010.
16. Centers for Disease Control and Prevention. HIV/AIDS surveillance
report 2002; 14:1–50. Available at: http://www.cdc.gov/hiv/topics/
pdf. Accessed 7 June 2010.
17. Centers for Disease Control and Prevention. HIV/AIDS surveillance
report 2003; 15:1–46. Available at: http://www.cdc.gov/hiv/topics/
pdf. Accessed 7 June 2010.
18. Centers for Disease Control and Prevention. HIV/AIDS surveillance
report 2004; 16:1–46. Available at: http://www.cdc.gov/hiv/topics/
pdf. Accessed 7 June 2010.
19. Centers for Disease Control and Prevention. HIV/AIDS surveillance
report 2005; 17:1–54. Available at: http://www.cdc.gov/hiv/topics/
pdf. Accessed 7 June 2010.
20. Centers for Disease Control and Prevention. HIV/AIDS surveillance
report 2006; 18:1–55. Available at: http://www.cdc.gov/hiv/topics/
pdf. Accessed 7 June 2010.
21. Bartholomew LK, Parcel GS, Kok G, Gottlieb NH. Planning health
promotion programs: an intervention mapping approach. San Fran-
cisco: Jossey-Bass, 2006.
22. Purcell DW, McCree DH. Recommendations from a research con-
sultation to address intervention strategies for HIV/AIDS preven-
tion focused on African Americans. Am J Public Health 2009;
23. Metzger DS, Koblin B, Turner C, et al. Randomized controlled trial of
audio computer-assisted self-interviewing: utility and acceptability in
longitudinal studies. HIVNET Vaccine Preparedness Study Protocol
Team. Am J Epidemiol 2000; 152:99–106.
24. Perlis TE, Des Jarlais DC, Friedman SR, Arasteh K, Turner CF. Audio-
computerized self-interviewing versus face-to-face interviewing for
research data collection at drug abuse treatment programs. Addiction
25. Ghanem KG, Hutton HE, Zenilman JM, Zimba R, Erbelding EJ.
Audio computer assisted self interview and face to face interview
modes in assessing response bias among STD clinic patients. Sex
Transm Infect 2005; 81:421–5.
26. Macalino GE, Celentano DD, Latkin C, Strathdee SA, Vlahov D. Risk
behaviors by audio computer-assisted self-interviews among HIV-
seropositive and HIV-seronegative injection drug users. AIDS Educ
Prev 2002; 14:367–78.
27. Tempalski B, Lieb S, Cleland CM, Cooper H, Brady JE, Friedman SR.
HIV prevalence rates among injection drug users in 96 large US
metropolitan areas, 1992–2002. J Urban Health 2009; 86:132–54.
28. Des Jarlais DC, Perlis T, Arasteh K, et al. HIV incidence among in-
jection drugusers in New York City, 1990 to 2002:use of serologic test
algorithm to assess expansion of HIV prevention services. Am J Public
Health 2005; 95:1439–44.
29. Santibanez SS, Garfein RS, Swartzendruber A, Purcell DW, Paxton
LA, Greenberg AE. Update and overview of practical epidemiologic
aspects of HIV/AIDS among injection drug users in the United States.
J Urban Health 2006; 83:86–100.
30. Des JarlaisDC, SemaanS.HIVpreventionfor injectingdrugusers: the
first 25 years and counting. Psychosom Med 2008; 70:606–11.
31. Beckwith CG, Moreira CC, Aboshady HM, Zaller N, Rich JD, Flani-
gan TP. A success story: HIV prevention for injection drug users in
Rhode Island. Subst Abuse Treat Prev Policy 2006; 1:34.
32. Centers for Disease Control and Prevention. HIV infection among
injection-drug users - 34 states, 2004–2007. MMWR Morb Mortal
Wkly Rep 2009; 58:1291–5.
33. Risser JM, Padgett P, Wolverton M, Risser WL. Relationship between
heterosexual anal sex, injection drug use and HIV infection among
black men and women. Int J STD AIDS 2009; 20:310–4.
34. McCoy C, Lai S, Metsch L, Messiah S, Zhao W. Injection drug use and
crack cocaine smoking: independent and dual risk behaviors for HIV
infection. Ann Epidemiol 2004; 14:535–42.
35. Williams ML, Elwood WN, Weatherby NL, et al. An assessment of
the risks of syphilis and HIV infection among a sample of not-
in-treatment drug users in Houston, Texas. AIDS Care 1996;
36. Booth RE, Kwiatkowski CF, Chitwood DD. Sex related HIV risk be-
haviors: differential risks among injection drug users, crack smokers,
and injection drug users who smoke crack. Drug Alcohol Depend
37. Adimora AA, Schoenbach VJ, Martinson FE, Donaldson KH, Stancil
TR, Fullilove RE. Concurrent partnerships among rural African
Americans with recently reported heterosexually transmitted HIV
infection. J Acquir Immune Defic Syndr 2003; 34:423–9.
38. Rees V, Saitz R, Horton NJ, Samet J. Association of alcohol con-
sumption with HIV sex- and drug-risk behaviors among drug users.
J Subst Abuse Treat 2001; 21:129–34.
39. Kalichman SC, Cain D, Zweben A, Swain G. Sensation seeking, al-
cohol use and sexual risk behaviors among men receiving services at
a clinic for sexually transmitted infections. J Stud Alcohol 2003;
40. Shuper PA, Neuman M, Kanteres F, Baliunas D, Joharchi N, Rehm J.
Causal considerations on alcohol and HIV/AIDS—a systematic re-
view. Alcohol Alcohol 2010; 45:159–66.
41. Baliunas D, Rehm J, Irving H, Shuper P. Alcohol consumption and
risk of incident human immunodeficiency virus infection: a meta-
analysis. Int J Public Health 2010; 55:159–66.
d CID 2011:52 (Suppl 2)
d Zaller et al.
42. Rondinelli AJ, Ouellet LJ, Strathdee SA, et al. Young adult injection
drug users in the United States continue to practice HIV risk be-
haviors. Drug Alcohol Depend 2009; 104:167–74.
43. Cheng WS, Garfein RS, Semple SJ, Strathdee SA, Zians JK, Patterson
TL. Binge use and sex and drug use behaviors among HIV(-), het-
erosexual methamphetamine users in San Diego. Subst Use Misuse
44. Lichtenstein B. Secret encounters: black men, bisexuality, and AIDS in
Alabama. Med Anthropol Q 2000; 14:374–93.
45. Williams CT, Mackesy-Amiti ME, McKirnan DJ, Ouellet LJ. Differ-
ences in sexual identity, risk practices, and sex partners between bi-
sexual men and other men among a low-income drug-using sample.
J Urban Health 2009; 86:93–106.
46. Gorbach PM, Murphy R, Weiss RE, Hucks-Ortiz C, Shoptaw S.
Bridging sexual boundaries: men who have sex with men and women
in a street-based sample in Los Angeles. J Urban Health 2009; 86:63–76.
47. Kent JB. Impact of foreign-born persons on HIV diagnosis rates
among blacks in King County, Washington. AIDS Educ Prev 2005;
48. Centers for Disease Control and Prevention. Medical examination of
aliens: removal of human immunodeficiency virus (HIV) infection
from definition ofcommunicablediseaseof publichealthsignificance.
Fed Regist 2009; 74:56547–62.
49. Beckwith CG, DeLong AK, Desjardins SF, et al. HIV infection in
refugees: a case-control analysis of refugees in Rhode Island. Int J
Infect Dis 2009; 13:186–92.
50. KeraniRP, KentJB,SidesT, etal.HIV amongAfrican-bornpersonsin
the United States: a hidden epidemic? J Acquir Immune Defic Syndr
51. Spaulding AC, Seals RM, Page MJ, Brzozowski AK, Rhodes W,
Hammett TM. HIV/AIDS among inmates of and releasees from US
correctional facilities, 2006: declining share of epidemic but persistent
public health opportunity. LoS One 2009; 4:e7558.
52. Valera P, Epperson M, Daniels J, Ramaswamy M, Freudenberg N.
Substance use and HIV-risk behaviors among young men involved in
the criminal justice system. Am J Drug Alcohol Abuse 2009; 35:43–7.
53. Grinstead OA, Faigeles B, Comfort M, et al. HIV, STD, and hepatitis
risk to primary female partners of men being released from prison.
Women Health 2005; 41:63–80.
54. Khan MR, Wohl DA, Weir SS, et al. Incarceration and risky sexual
partnerships in a southern US city. J Urban Health 2008; 85:100–13.
55. Kidder DP, Wolitski RJ, Pals SL, Campsmith ML. Housing status and
HIV risk behaviors among homeless and housed persons with HIV.
J Acquir Immune Defic Syndr 2008; 49:451–5.
56. Morrow KM. HIV, STD, and hepatitis risk behaviors of young men
before and after incarceration. AIDS Care 2009; 21:235–43.
57. Khan MR, Doherty IA, Schoenbach VJ, Taylor EM, Epperson MW,
Adimora AA. Incarceration and high-risk sex partnerships among
men in the United States. J Urban Health 2009; 86:584–601.
58. Margolis AD, MacGowan RJ, Grinstead O, Sosman J, Kashif I,
Flanigan TP. Unprotected sex with multiple partners: implications for
HIV prevention among young men with a history of incarceration.
Sex Transm Dis 2006; 33:175–80.
59. Rich JD, Holmes L, Salas C, et al. Successful linkage of medical care
and community services for HIV-positive offenders being released
from prison. J Urban Health 2001; 78:279–89.
60. Harzke AJ, Ross MW, Scott DP. Predictors of post-release primary
care utilization among HIV-positive prison inmates: a pilot study.
IDS Care 2006; 18:290–301.
61. Wang EA, White MC, Jamison R, Goldenson J, Estes M, Tulsky JP.
Discharge planning and continuity of health care: findings from the
San Francisco County Jail. Am J Public Health 2008; 98:2182–4.
62. Clements-Nolle K, Marx R, Pendo M, Loughran E, Estes M, Katz M.
Highly active antiretroviral therapy use and HIV transmission risk
behaviors among individuals who are HIV infected and were recently
released from jail. Am J Public Health 2008; 98:661–6.
63. Springer SA, Pesanti E, Hodges J, Macura T, Doros G, Altice FL.
Effectiveness of antiretroviral therapy among HIV-infected prisoners:
reincarceration and the lack of sustained benefit after release to the
community. Clin Infect Dis 2004; 38:1754–60.
64. White MC, Tulsky JP, Estes M, Jamison R, Long HL. Health and
health behaviors in HIV-infected jail inmates, 1999 and 2005. AIDS
Patient Care STDS 2008; 22:221–31.
65. Baillargeon J, Borucki MJ, Zepeda S, Jenson HB, Leach CT. Anti-
retroviral prescribing patterns in the Texas prison system. Clin Infect
Dis 2000; 31:1476–81.
66. Baillargeon JG, Giordano TP, Harzke AJ, Baillargeon G, Rich JD, Paar
DP. Enrollment in outpatient care among newly released prison in-
mates with HIV infection. Public Health Rep 2010; 125:64–71.
67. Grinstead O, Seal DW, Wolitski R, et al. HIV and STD testing in
prisons: perspectives of in-prison service providers. AIDS Educ Prev
68. Bruce RD, Kresina TF, McCance-Katz EF. Medication-assisted
treatment and HIV/AIDS:aspects in treating HIV-infected drug users.
AIDS 2010; 24:331–40.
69. Celentano DD, Galai N, Sethi AK, et al. Time to initiating highly
active antiretroviral therapy among HIV-infected injection drug
users. AIDS 2001; 15:1707–15.
70. Rumptz MH, Tobias C, Rajabiun S, et al. Factors associated with
engaging socially marginalized HIV-positive persons in primary care.
AIDS Patient Care STDS 2007; 21:S30–9.
71. Malta M, Strathdee SA, Magnanini MM, Bastos FI. Adherence to
antiretroviral therapy for human immunodeficiency virus/acquired
immune deficiency syndrome among drug users: a systematic review.
Addiction 2008; 103:1242–57.
72. Altice FL, Maru DS, Bruce RD, Springer SA, Friedland GH. Superi-
ority of directly administered antiretroviral therapy over self-admin-
istered therapy among HIV-infected drug users: a prospective,
randomized, controlled trial. Clin Infect Dis 2007; 45:770–8.
73. Kerr T, Marshall A, Walsh J, et al. Determinants of HAART discon-
tinuation among injection drug users. AIDS Care 2005; 17:539–49.
74. Nunn A, Zaller N, Dickman S, Trimbur C, Nijhawan A, Rich JD.
Methadone and buprenorphine prescribing and referral practices in
US prison systems: results from a nationwide survey. Drug Alcohol
Depend 2009; 105:83–8.
75. Mitchell SG, Kelly SM, Brown BS, et al. Incarceration and opioid
withdrawal: the experiences of methadone patients and out-of-treat-
ment heroin users. J Psychoactive Drugs 2009; 41:145–52.
76. Kinlock TW, Gordon MS, Schwartz RP, Fitzgerald TT, O’Grady KE. A
randomized clinical trial of methadone maintenance for prisoners:
results at 12 months postrelease. J Subst Abuse Treat 2009; 37:277–85.
77. Kinlock TW, Gordon MS, Schwartz RP, O’Grady K, Fitzgerald TT,
Wilson M. A randomized clinical trial of methadone maintenance for
prisoners: results at 1-month post-release. Drug Alcohol Depend
78. Kinlock TW, Gordon MS, Schwartz RP, O’Grady KE. A study of
methadone maintenance for male prisoners: 3-month postrelease
outcomes. Crim Justice Behav 2008; 35:34–47.
79. Kinlock TW, Gordon MS, Schwartz RP, Fitzgerald TT. Developing
and implementing a new prison-based buprenorphine treatment
program. J Offender Rehabil 2010; 49:91–109.
80. Green T, Zaller ND, Parikh A, et al. Initiation of buprenorphine
during incarceration and linkage to treatment upon release [abstract
WEPE0187]. In: Program of the XVIII International AIDS Conference
18–23 July 2010; Vienna.
81. Zaller ND, Mckenzie M, Green T, et al. Initiation of methadone
during incarceration and linkage to treatment upon release: results of
a randomized control trial [abstract THPDX103]. In: Program of the
XVII International AIDS Conference 18–23 July 2010; Vienna.
82. Magura S, Lee JD, Hershberger J, et al. Buprenorphine and metha-
done maintenance in jail and post-release: a randomized clinical trial.
Drug Alcohol Depend 2009; 99:222–30.
Linkage to HIV Care: Heterosexual Men
d CID 2011:52 (Suppl 2)
83. Springer SA, Chen S, Altice FL. Improved HIV and substance abuse
treatment outcomes for released HIV-infected prisoners: the impact
of buprenorphine treatment.. J Urban Health 2010; 87:592–602.
84. McKenzie M, Nunn A, Zaller ND, Bazazi AR, Rich JD. Overcoming
implications for policy and practice. J Opioid Manag 2009; 5:219–27.
85. Smith-Rohrberg D, Mezger J, Walton M, Bruce RD, Altice FL. Impact
of enhanced services on virologic outcomes in a directly administered
antiretroviral therapy trial for HIV-infected drug users. J Acquir
Immune Defic Syndr 2006; 43:S48–53.
86. Basu S, Smith-Rohrberg D, Bruce RD, Altice FL. Models for in-
tegrating buprenorphine therapy into the primary HIV care setting.
Clin Infect Dis 2006; 42:716–21.
87. Sullivan LE, Bruce RD, Haltiwanger D, et al. Initial strategies for
integrating buprenorphine into HIV care settings in the United States.
Clin Infect Dis 2006; 43:S191–6.
88. Khalsa J, Vocci F, Altice F, Fiellin D, Miller V. Buprenorphine and
HIV primary care: new opportunities for integrated treatment. Clin
Infect Dis 2006; 43:S169–72.
89. Lum PJ, Tulsky JP. The medical management of opioid dependence in
HIV primary care settings. Curr HIV/AIDS Rep 2006; 3:195–204.
90. Bruce R. Medical interventions for addictions in the primary care
setting. Top HIV Med 2010; 18:8–12.
91. Mizuno Y, Wilkinson JD, Santibanez S, et al. Correlates of health care
utilization among HIV-seropositive injection drug users. AIDS Care
92. Lucas G, Chaudhry A, Hsu J, et al. Clinic-based treatment of opiod-
dependentHIV-infected patientsversusreferraltoanopiod treatment
program. Ann Intern Med 2010; 152:704–11.
93. Kushel MB, Colfax G, Ragland K, Heineman A, Palacio H, Bangsberg
DR. Case management is associated with improved antiretroviral
adherence and CD41 cell counts in homeless and marginally housed
individuals with HIV infection. Clin Infect Dis 2006; 43:234–42.
94. Bristow DP, Herrick CA. Emergency department case management:
the dyad team of nurse case manager and social worker improve
discharge planning and patient and staff satisfaction while decreasing
inappropriate admissions and costs: a literature review. Lippincotts
Case Manag 2001; 7:243–51.
95. Broadhead RS, Heckathorn DD, Altice FL, et al. Increasing drug users’
adherence to HIV treatment: results of a peer-driven intervention
feasibility study. Soc Sci Med 2002; 55:235–46.
96. Losina E, Schackman BR, Sadownik SN, et al. Racial and sex dis-
parities in life expectancy losses among HIV-infected persons in the
United States: impact of risk behavior, late initiation, and early dis-
continuation of antiretroviral therapy. Clin Infect Dis 2009;
97. Ulett KB, Willig JH, Lin HY, et al. The therapeutic implications of
timely linkage and early retention in HIV care. AIDS Patient Care
STDS 2009; 23:41–9.
98. Wells K, Klap R, Koike A, Sherbourne C. Ethnic disparities in unmet
need for alcoholism, drug abuse, and mental health care. Am J Psy-
chiatry 2001; 158:2027–32.
99. Porter J. The street/treatment barrier: treatment experiences of Puerto
Rican injection drug users. Subst Use Misuse 1999; 34:1951–75.
100. Office of Minority Health, U.S. Department of Health and Human
Services. Assessment of state minority health infrastructure and ca-
pacity to address issues of health disparity. Washington, DC: US
Department of Health and Human Services, 2000. Available at: http://
ityFRSept00.pdf. Accessed 7 June 2010.
101. Lundgren LM, Amodeo M, Ferguson F, Davis K. Racial and ethnic
differences in drug treatment entry of injection drug users in Mas-
sachusetts. J Subst Abuse Treat 2001; 21:145–53.
102. Gebo KA, Fleishman JA, Conviser R, et al. Racial and gender dis-
parities in receipt of highly active antiretroviral therapy persist in
a multistate sample of HIV patients in 2001. J Acquir Immune Defic
Syndr 2005; 38:96–103.
103. Smedley BD, Stith AY, Nelson AR. Committee on Understanding and
Eliminating Racial and Ethnic Disparities in Health Care. Unequal
treatmentconfronting racial and ethnic disparities in health care.
Washington, DC: National Academies Press, 2003.
104. Zaller ND, Bazazi AR, Velazquez L, Rich JD. Attitudes toward
methadone among out-of-treatment minority injection drug users:
implications for health disparities. Int J Environ Res Public Health
105. Musa D, Schulz R, Harris R, Silverman M, Thomas SB. Trust in the
health care system and the use of preventive health services by older
black and white adults. Am J Public Health 2009; 99:1293–9.
106. Dovidio JF, Penner LA, Albrecht TL, Norton WE, Gaertner SL,
Shelton JN. Disparities and distrust: the implications of psychological
processes for understanding racial disparities in health and health
care. Soc Sci Med 2008; 67:478–86.
107. Armstrong K, Ravenell KL, McMurphy S, Putt M. Racial/ethnic dif-
ferences in physician distrust in the United States. Am J Public Health
108. Bradford JB. The promise of outreach for engaging and retaining out-
of-care persons in HIV medical care. AIDS Patient Care STDS 2007;
109. McKleroy VS, Galbraith JS, Cummings B, et al. Adapting evidence-
based behavioral interventions for new settings and target pop-
ulations. AIDS Educ Prev 2006; 18:59–73.
110. Molitor F, Waltermeyer J, Mendoza M, et al. Locating and linking to
medical care HIV-positive persons without a history of care: findings
from the California Bridge Project. AIDS Care 2006; 18:456–9.
111. Rajabiun S, Mallinson RK, McCoy K, et al. ‘‘Getting me back on
track’’: the role of outreach interventions in engaging and retaining
people living with HIV/AIDS in medical care. AIDS Patient Care
STDS 2007; 21:S209.
112. Naar-King S, Bradford J, Coleman S, Green-Jones M, Cabral H,
Tobias C. Retention in care of persons newly diagnosed with HIV:
outcomes of the Outreach Initiative. AIDS Patient Care STDS 2007;
113. Cabral HJ, Tobias C, Rajabiun S, et al. Outreach program contacts: do
they increase the likelihood of engagement and retention in HIV
primary care for hard-to-reach patients? AIDS Patient Care STDS
114. Gardner LI, Metsch LR, Anderson-Mahoney P, et al. Efficacy of a brief
case management intervention to link recently diagnosed HIV-
infected persons to care. AIDS 2005; 19:423–31.
115. Gardner LI, Marks G, Metsch LR, et al. Psychological and behavioral
correlates of entering care for HIV infection: the Antiretroviral Treat-
116. Cunningham CO, Sanchez JP, Li X, Heller D, Sohler NL. Medical and
support service utilization in a medical program targeting marginal-
ized HIV-infected individuals. J Health Care Poor Underserved 2008;
d CID 2011:52 (Suppl 2)
d Zaller et al.