Torsten B Neilands

Centre for HIV/Aids Prevention Studies, Johannesburg, Gauteng, South Africa

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Publications (181)498.62 Total impact

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    ABSTRACT: This article draws on ethnographic, qualitative, and survey data with transwomen in Puerto Rico to discuss the social context of lay injection with hormone and silicone - common practices within this community. The study describes specific practices of hormone and silicone injection, the actors that govern them, the market for the sale and distribution of syringes, and the networks of lay specialists who provide services to a population that is neglected by and largely excluded from biomedical settings. Our data derive from ethnographic observations, sociodemographic questionnaires, surveys, and semi-structured interviews conducted with a diverse group of transwomen in metropolitan San Juan, Puerto Rico. Our analysis focuses on four domains of social context that shape the practices of lay silicone and hormone injection among transwomen. We conclude with a discussion of the kinds of intervention and policy targets that would respond to that factors that most endanger transwomen's health.
    Full-text · Article · Jun 2016
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    ABSTRACT: This research describes the context and health consequences of migration/mobility that accompany the search for gender transitioning procedures among Puerto Rican transgender/transsexual women. We term migration/mobility for gender transitioning trans-migration. We conducted an ethnographic study focusing on trans-migration, including participant observation and semi-structured interviews with 39 transgender/transsexual women in Puerto Rico. Our analysis highlights three main processes that profoundly shape trans-migration among Puerto Rican transwomen: (1) institutionalized discrimination; (2) barriers to work; and (3) involvement in survival sex work. Patterns of trans-migration are examined as products of social exclusion, discrimination, and resilience. The analysis informs recommendations to support transwomen’s health.
    Full-text · Article · Jun 2016

  • No preview · Article · Jan 2016 · Prevention Science
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    ABSTRACT: Social benefits likely play a role in young adult tobacco use. The Social Prioritization Index (SPI) was developed to measure the degree to which young adults place a great importance on their social lives. We examined the usefulness of this measure as a potential predictor of tobacco use controlling for demographics and tobacco-related attitudes. Young adults completed cross-sectional surveys between 2012 and 2014 in bars in seven U.S. cities (N = 5,503). The SPI is a 13-item scale that includes personality items and information on how frequently participants attend bars and how late they stay out. Three step-by-step multinomial regression models were run using the SPI as a predictor of smoking status (nondaily and daily smoking vs. nonsmoking): (1) SPI as the sole predictor, (2) SPI and demographics, and (3) SPI, demographics, and tobacco-related attitude variables. Next, we conducted an exploratory factor analysis to examine if the number of items in SPI could be reduced and retain its strong relationship with smoking. Higher scores on the SPI were related to an increased probability of being a Nondaily Smoker (odds ratio = 1.09, 95% confidence interval [1.04, 1.14], p < .001) or Daily Smoker (odds ratio = 1.14, 95% confidence interval [1.07, 1.22], p < .0001) compared to a Nonsmoker, controlling for demographics and other tobacco-related attitudes. The SPI and reduced SPI were independently related to young adult tobacco use. The measure's brevity, ease of use, and strong association with tobacco use may make it useful to tobacco and other prevention researchers.
    No preview · Article · Dec 2015 · Health Education & Behavior
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    ABSTRACT: Specialized training for healthcare professionals (HCP) in order to reduce HIV/AIDS related stigma must be part of a public health model for HIV/AIDS. Tested interventions to reduce HIV/AIDS related stigma among HCP have been mostly absent from these efforts. A qualitative approach was used to assess stigma reduction within a traditional randomized controlled design in order to better understand how our current stigma intervention worked and was understood by 2nd year medical students. After conducting a quantitative follow up survey one year post intervention we conducted 20 in-depth qualitative interviews with a subsample of our intervention group participants as part of the overall evaluation process. Once the interviews were finished, we transcribed them and used NVivo (v.8) to organized the qualitative data. In the process of analyzing the qualitative data we identified core intervention areas participants described as useful for their training and development: 1) acquiring more HIV/AIDS-related knowledge, 2) increased skills for management of high stigma situations, and 3) the ability to identify socio-structural factors that foster HIV infection among clients. The gathered information is important in order to have a deep understanding of how attitudinal change happens as part of our intervention strategies.
    Full-text · Article · Dec 2015 · Qualitative Report
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    ABSTRACT: Background: Improving the implementation of the global response to HIV requires understanding retention after starting antiretroviral therapy, but loss to follow-up undermines assessment of the magnitude of and reasons for stopping care. Methods: We evaluated adults starting ART over 2.5 years in 14 clinics Uganda, Tanzania and Kenya. We traced a random sample of patients lost to follow-up and incorporated updated information in weighted competing risks estimates of retention. Reasons for non-return were surveyed. Results: Among 18,081 patients, 3150 (18%) were lost to follow-up and 579 (18%) were traced. Of 497 (86%) with ascertained vital status, 340 (69%) were alive and in 278 (82%) cases, updated care status was obtained. Among all patients initiating ART, weighted estimates incorporating tracing outcomes found that two years after ART, 69% were in care at original clinic, 14% transferred (4% official and 10% unofficial), 6% were alive but out of care, 6% died in care (< 60 days after last visit), and 6% died out of care (>= 60 days after last visit). Among lost patients found in care elsewhere, structural barriers (e.g., transportation) were most prevalent (65%), followed by clinic-based (e.g., waiting times) (33%) and psychosocial (e.g., stigma) (27%). Among patients not in care elsewhere, psychosocial barriers were most prevalent (76%) followed by structural (51%) and clinic-based (15%). Conclusion: Accounting for outcomes among the lost yields a more informative assessment of retention. Structural barriers contribute most to silent transfers whereas psychological and social barriers tend to result in longer-term care discontinuation.
    No preview · Article · Dec 2015 · Clinical Infectious Diseases
  • Sara Kalkhoran · James L. Padilla · Torsten B. Neilands · Pamela M. Ling
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    ABSTRACT: Introduction: Use of non-cigarette tobacco products is common, and e-cigarette use is increasing among young adults. We aimed to identify use of other tobacco products among young adult bar patrons in the context of a bar-based intervention to decrease cigarette smoking. Methods: 2,291 cross-sectional surveys were collected from young adults in bars in Albuquerque, New Mexico using time-location sampling between 2011 and 2013 (N=1142 in 2011, N=1149 in 2012-2013), 2 and 3years into an intervention to reduce cigarette use, and analyzed in 2014-2015. Participants reported current (i.e. past 30-day) use of cigarettes, snus, dip, cigarillos, hookah, and e-cigarettes, demographics, and tobacco-related attitudes. Multiple imputation was used to account for planned missing data. Logistic regression determined correlates of multiple tobacco product use. Results: Cigarette smoking in the population decreased during the intervention from 43% to 37%. Over 60% of current cigarette smokers reported poly-use, most frequently with e-cigarettes (46%) and hookah (44%), followed by cigarillos (24%), dip (15%), and snus (14%) in 2012-2013. Among cigarette smokers, current e-cigarette use increased, while use of other products decreased during the intervention. Odds of poly-use (versus smoking cigarettes only) were greater among males and those reporting past 30-day binge drinking, and lower in those who strongly believed secondhand smoke exposure is harmful. Conclusions: Among young adult bar patrons in Albuquerque, New Mexico, most cigarette smokers reported currently using at least one other tobacco product. Public health interventions should address use of all tobacco products, use of which may rise despite decreased cigarette use.
    No preview · Article · Dec 2015 · Preventive Medicine
  • John J Chin · Torsten B Neilands
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    ABSTRACT: Objectives: We examined Chinese immigrant religious institutions' views on teaching about preventing sexual transmission of HIV and the consistency of their views with public health best practices in HIV prevention. Methods: We used 2009 to 2011 survey data from 712 members of 20 New York City-based Chinese immigrant religious institutions to analyze their views on (1) teaching adolescents about condoms, (2) discussing homosexuality nonjudgmentally, and (3) promoting abstinence until marriage. Results: Religion type was a significant predictor of views in the 3 domains, with Evangelical Protestants in least agreement with public health best practices, Buddhists in most agreement, and mainline Protestants between them. Greater HIV knowledge was significantly associated with agreement with best practices in all 3 domains. The frequency of prayer, meditation, or chanting and the level of acculturation were significant predictors of views on teaching adolescents about condoms and promoting abstinence until marriage. Conclusions: The best practice messages about HIV prevention that Chinese immigrant religious institutions find acceptable vary according to religion type and several other key factors, including HIV knowledge; frequency of prayer, meditation, or chanting; and level of acculturation. (Am J Public Health. Published online ahead of print November 12, 2015: e1-e9. doi:10.2105/AJPH.2015.302924).
    No preview · Article · Nov 2015 · American Journal of Public Health
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    ABSTRACT: Scientific literature has systematically documented the negative effects of social stigma for people living with HIV/AIDS (PLWHA). HIV/AIDS stigma has the potential to negatively impact self-care strategies for those already affected, and simultaneously hinder prevention efforts to deter the emergence of new infections. When health professionals manifest these negative attitudes access to quality health-care and prevention strategies can be seriously affected. Scientifically tested interventions to reduce HIV/AIDS stigma among health professionals are still scarce. Although the number of tested interventions has increased over the past decade, few of them target Latino health professionals or Spanish-speaking populations. Furthermore, although some of those interventions have been reported as effective for stigma reduction, more work is needed to better understand the underlying variables that account for the reduction of stigma attitudes in those efforts. The SPACES intervention has been documented as an effective HIV/AIDS stigma-reduction intervention focusing on health-care professionals in training. The intervention, which is delivered in Spanish, has been previously tested with medical students in Puerto Rico and shown significant results in addressing negative attitudes toward PLWHA. The main objective of this study was to document the underlying variables that fostered reduction of HIV/AIDS stigma due to participation in the SPACES intervention. Results evidence that health professionals in training who participated in the intervention (n = 507) had less stigmatizing attitudes toward PLWHA due to an increase in their positive emotions toward this population. In light of these results, we discuss the importance of engaging health professionals in HIV/AIDS stigma-reduction interventions that go beyond the provision of information and skills for interacting with PLWHA, and address the emotional component of HIV/AIDS stigma.
    Full-text · Article · Oct 2015 · AIDS Care
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    ABSTRACT: Objective: Engagement in care is key to successful HIV treatment in resource-limited settings; yet little is known about the magnitude and determinants of reengagement among patients out of care. We assessed patient-reported reasons for not returning to clinic, identified latent variables underlying these reasons, and examined their influence on subsequent care reengagement. Design: We used data from the East Africa International Epidemiologic Databases to Evaluate AIDS to identify a cohort of patients disengaged from care (>3 months late for last appointment, reporting no HIV care in preceding 3 months) (n = 430) who were interviewed about reasons why they stopped care. Among the 399 patients for whom follow-up data were available, 104 returned to clinic within a median observation time of 273 days (interquartile range: 165-325). Methods: We conducted exploratory and confirmatory factor analyses (exploratory factor analyses, confirmatory factor analyses) to identify latent variables underlying patient-reported reasons, then used these factors as predictors of time to clinic return in adjusted Cox regression models. Results: Exploratory factor analyses and confirmatory factor analyses findings suggested a six-factor structure that lent coherence to the range of barriers and motivations underlying care disengagement, including poverty, transport costs, and interference with work responsibilities; health system 'failures,' including poor treatment by providers; fearing disclosure of HIV status; feeling healthy; and treatment fatigue/seeking spiritual alternatives to medicine. Factors related to poverty and poor treatment predicted higher rate of return to clinic, whereas the treatment fatigue factor was suggestive of a reduced rate of return. Conclusion: Certain barriers to reengagement appear easier to overcome than factors such as treatment fatigue. Further research will be needed to identify the easiest, least expensive interventions to reengage patients lost to HIV care systems. Interpersonal interventions may continue to play an important role in addressing psychological barriers to retention. Copyright (C) 2015 Wolters Kluwer Health, Inc.
    No preview · Article · Oct 2015 · AIDS
  • Anna V Song · Lauren M Dutra · Torsten B Neilands · Stanton A Glantz
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    ABSTRACT: Importance: Smoke-free laws are associated with a lower prevalence of smoking. Objective: To quantify the effect of 100% smoke-free laws on the smoking behavior of adolescents and young adults in a longitudinal analysis. Design, setting, and participants: Pooled logistic regression and zero-inflated negative binomial regression analysis of participants in the National Longitudinal Survey of Youth 1997 (data from 1997 to 2007), with complete data on initiation of smoking (n = 4098) and number of days respondents reported smoking in the past 30 days (n = 3913). Exposures: Laws for 100% smoke-free workplaces, laws for 100% smoke-free bars, and state cigarette taxes. Main outcomes and measures: Smoking initiation (first report of smoking cigarette), current (for 30 days) smoking, and number of days respondents reported smoking in the past 30 days among current smokers. Results: Laws for 100% smoke-free workplaces, but not bars, were associated with significantly lower odds of initiating smoking (odds ratio, 0.66 [95% CI, 0.44-0.99]). Laws for 100% smoke-free bars were associated with lower odds of being a current smoker (odds ratio, 0.80 [95% CI, 0.71-0.90]) and fewer days of smoking (incidence rate ratio, 0.85 [95% CI, 0.80-0.90]) among current smokers. Taxes were associated with a lower percentage of new smokers but not current smokers among adolescents and young adults. The effect of smoke-free workplace laws on smoking initiation is equivalent to a $1.57 (in 2007 dollars) tax increase. Smoke-free bar laws are associated with lower rates of current smoking, as well as a decrease in the number of days reported smoking among current smokers. Conclusions and relevance: Smoke-free laws are an important tobacco control tool. They not only protect bystanders from secondhand smoke but also contribute to less smoking among adolescents and young adults.
    No preview · Article · Sep 2015
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    ABSTRACT: Purpose: Youth are exposed to many types of protobacco influences, including smoking in movies, which has been shown to cause initiation. This study investigates associations between different channels of protobacco media and susceptibility to smoking cigarettes, cigarette experimentation, and current tobacco use among US middle and high school students. Methods: By using data from the 2012 National Youth Tobacco Survey, structural equation modeling was performed in 2013. The analyses examined exposure to tobacco use in different channels of protobacco media on smoking susceptibility, experimentation, and current tobacco use, accounting for perceived peer tobacco use. Results: In 2012, 27.9% of respondents were never-smokers who reported being susceptible to trying cigarette smoking. Cigarette experimentation increased from 6.3% in 6th grade to 37.1% in 12th grade. Likewise, current tobacco use increased from 5.2% in 6th grade to 33.2% in 12th grade. Structural equation modeling supported a model in which current tobacco use is associated with exposure to static advertising through perception of peer use, and by exposure to tobacco use depicted on TV and in movies, both directly and through perception of peer use. Exposure to static advertising appears to directly increase smoking susceptibility but indirectly (through increased perceptions of peer use) to increase cigarette experimentation. Models that explicitly incorporate peer use as a mediator can better discern the direct and indirect effects of exposure to static advertising on youth tobacco use initiation. Conclusions: These findings underscore the importance of reducing youth exposure to smoking in TV, movies, and static advertising.
    Full-text · Article · Aug 2015 · PLoS ONE
  • Amanda Fallin · Torsten B Neilands · Jeffrey W Jordan · Pamela M Ling
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    ABSTRACT: Lesbian, gay, bisexual, and transgender (LGBT) individuals are more likely to smoke than the general population. This study evaluated a Social Branding intervention, CRUSH, which included an aspirational brand, social events, and targeted media to discourage smoking among LGBT young adults in Las Vegas, NV. Cross-sectional surveys (N = 2,395) were collected in Las Vegas LGBT bars at 2 time points 1 year apart. Multivariate logistic regressions examined associations between campaign exposure, message understanding, and current (past 30 days) smoking, controlling for demographics. LGBT individuals were significantly more likely to report current (past 30 day) smoking than heterosexual/straight, gender-conforming participants. Overall, 53% of respondents reported exposure to CRUSH; of those exposed, 60% liked the campaign, 60.3% reported they would attend a CRUSH event on a night when they usually went somewhere else, and 86.3% correctly identified that the campaign was about "partying fresh and smokefree." Current smoking was reported by 47% of respondents at Time 1 and 39.6% at Time 2. There were significant interactions between time and campaign exposure and campaign exposure and understanding the message. Among those who understood the CRUSH smokefree message, the highest level of campaign exposure was significantly associated with 37%-48% lower odds for current smoking. While longitudinal studies would better assess the impact of this intervention, CRUSH shows promise to reduce tobacco use among LGBT bar patrons. © The Author 2015. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
    No preview · Article · Aug 2015 · Nicotine & Tobacco Research
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    ABSTRACT: Since the July 2012 approval by the FDA of emtricitabine/ tenofovir disoproxil fumarate (Truvada) for use as pre-exposure prophylaxis (PrEP) against HIV, its feasibility and acceptability has been under study. HIV-discordant couples are likely targets for PrEP but little is known about how this new prevention tool impacts relationships. We examined, among gay male couples, the acceptability of individual and partner use of PrEP and intentions to use condoms with primary and outside partners in the context of PrEP use. Data are from two independent samples of couples recruited in the San Francisco bay area and New York City-a qualitative one (N=48 couples) between March and November, 2011, and a quantitative one (N=171 couples) between June, 2012 and May, 2013. Data were categorized by couple HIV status and general linear models; chi-square tests of independence were used to examine condom-use intentions with primary and outside partners, by sexual risk profile, and race. Almost half of the HIV-negative couples felt PrEP was a good HIV prevention strategy for themselves and their partner. Over half reported that they would not change their current condom use if they or their partner were taking PrEP. However, approximately 30% of HIV-negative couples reported that they would stop using condoms or use them less with primary and outside partners if they were on PrEP or if their partner was on PrEP. A large percentage of couples view PrEP positively. However, to ensure safety for both partners, future programing must consider those who intend not to use condoms while on PrEP.
    No preview · Article · Jun 2015 · AIDS patient care and STDs
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    Leyla Karimli · Fred M. Ssewamala · Torsten B. Neilands · Mary McKernan McKay
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    ABSTRACT: This study examines variations in saving behavior among poor families enrolled in a Child Savings Account program for orphaned and vulnerable school-going children in Uganda. We employ multilevel analyses using longitudinal data from a cluster-randomized experimental design. Our analyses reveal the following significant results: (1) given the average number of months during which the account was open (18 months), families saved on average, USD 54.72, which, after being matched by the program (2:1 match rate) comes to USD 164.16—enough to cover approximately five academic terms of post-primary education; (2) children’s saving behavior was not associated with quality of family relations; it was, however, significantly associated with family financial socialization; (3) family demographics were significantly associated with children’s saving behavior in the matched Child Savings Account program; and (4) children enrolled in some schools saved better compared to children enrolled in other schools within the same treatment group
    Full-text · Article · Apr 2015
  • Sara Kalkhoran · Rachel A. Grana · Torsten B. Neilands · Pamela M. Ling
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    ABSTRACT: Objectives: To evaluate predictors of dual use of cigarettes with smokeless tobacco or e-cigarettes. Methods: Adult smokers (N = 1324) completed online cross-sectional surveys. Logistic regression evaluated predictors of dual use and cigarette quit attempts. Results: Smokeless tobacco dual use was associated with past attempts to quit smoking by switching to smokeless products. E-cigarette dual use was associated with using stop-smoking medication and strong anti-tobacco industry attitudes. Ever use of stop-smoking medication was associated with quit attempts among dual e-cigarette users and cigarette-only users. Conclusions: Dual users are more likely than cigarette-only users to endorse certain cessation-related attitudes and behaviors. This may provide an opportunity for clinicians or others to discuss evidence-based strategies for smoking cessation.
    No preview · Article · Mar 2015 · American journal of health behavior
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    ABSTRACT: Research suggests that optimal couple functioning depends on adopting a "we" orientation to health. Using qualitative data from 20 male couples in which at least one partner was HIV-positive, we examined how couples viewed their health involvement and its relation to social support. One group described their health as highly interconnected; in a second group, at least one partner viewed health as a personal responsibility. Results revealed that there was not a uniform "we" approach toward health; rather, sero-concordance, sero-discordance, and coping with other chronic illnesses strongly contributed to orientations toward health. Orientations toward health were not found to determine social support. © The Author(s) 2015.
    Full-text · Article · Feb 2015 · Journal of Health Psychology
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    ABSTRACT: The massively disproportionate impact of America's prison boom on communities of color has raised questions about how incarceration may affect health disparities, including disparities in HIV. Primary partners are an important source of influence on sexual health. In this paper, we investigate sexual HIV risk among male-female couples following a man's release from prison. We draw upon data from the Relate Project, a novel cross-sectional survey of recently released men and their female partners in Oakland and San Francisco, California (N=344). Inferential analyses use the actor-partner model to explore actor and partner effects on sexual HIV risk outcomes. Dyadic analyses of sexual HIV risk among male parolees and their female partners paint a complex portrait of couples affected by incarceration and of partners' influences on each other. Findings indicate that demographic factors such as education level and employment status, individual psycho-social factors such as perception of risk, and relationship factors such as commitment and power affect sexual HIV risk outcomes. The Relate Project provides a novel dataset for the dyadic analysis of sexual risk among male parolees and their female partners, and results highlight the importance of focusing on the couple as a unit when assessing HIV risk and protective behaviors. Results also indicate potentially fruitful avenues for population-specific interventions that may help to reduce sexual health disparities among couples affected by incarceration.
    No preview · Article · Feb 2015
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    ABSTRACT: Substance use is strongly linked to HIV risk, and members of couples can have a powerful influence on each other's health behaviors. We examined whether couple-level patterns of stimulant use were differentially associated with engaging in condomless anal intercourse with primary partners and outside partners. Members of HIV serodiscordant male couples (N = 117 couples, 232 men) completed surveys, and HIV-positive men had blood drawn for viral load. Results revealed that stimulant use by only one partner in the couple was associated with a decrease in the odds of engaging in condomless anal sex with one's primary partner (AOR = 0.09, 95% CI: 0.01, 0.89). When both partners reported stimulant use, the HIV-negative partner had an increase in the odds of condomless sex with outside partners (AOR = 6.68, 95% CI: 1.09, 8.01). Understanding the role of couples' stimulant use patterns in HIV transmission risk is an important area for future research and intervention.
    Full-text · Article · Feb 2015 · JAIDS Journal of Acquired Immune Deficiency Syndromes
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    ABSTRACT: Even among HIV-infected patients who fully suppress plasma HIV RNA replication on antiretroviral therapy, genetic (e.g. CCL3L1 copy number), viral (e.g. tropism) and environmental (e.g. chronic exposure to microbial antigens) factors influence CD4 recovery. These factors differ markedly around the world and therefore the expected CD4 recovery during HIV RNA suppression may differ globally. We evaluated HIV-infected adults from North America, West Africa, East Africa, Southern Africa and Asia starting non-nucleoside reverse transcriptase inhibitorbased regimens containing efavirenz or nevirapine, who achieved at least one HIV RNA level <500/ml in the first year of therapy and observed CD4 changes during HIV RNA suppression. We used a piecewise linear regression to estimate the influence of region of residence on CD4 recovery, adjusting for socio-demographic and clinical characteristics. We observed 28 217 patients from 105 cohorts over 37 825 person-years. After adjustment, patients from East Africa showed diminished CD4 recovery as compared with other regions. Three years after antiretroviral therapy initiation, the mean CD4 count for a prototypical patient with a pre-therapy CD4 count of 150/ml was 529/ml [95% confidence interval (CI): 517–541] in North America, 494/ml (95% CI: 429–559) in West Africa, 515/ml (95% CI: 508–522) in Southern Africa, 503/ml (95% CI: 478–528) in Asia and 437/ml (95% CI: 425–449) in East Africa. CD4 recovery during HIV RNA suppression is diminished in East Africa as compared with other regions of the world, and observed differences are large enough to potentially influence clinical outcomes. Epidemiological analyses on a global scale can identify macroscopic effects unobservable at the clinical, national or individual regional level.
    Full-text · Article · Feb 2015 · International Journal of Epidemiology

Publication Stats

4k Citations
498.62 Total Impact Points

Institutions

  • 2005-2015
    • Centre for HIV/Aids Prevention Studies
      Johannesburg, Gauteng, South Africa
  • 2001-2015
    • University of California, San Francisco
      • • Center for AIDS Prevention Studies
      • • Department of Medicine
      San Francisco, California, United States
  • 2013
    • University of San Francisco
      San Francisco, California, United States
  • 2008
    • CSU Mentor
      Long Beach, California, United States
  • 2006
    • University of Alabama at Birmingham
      • Department of Psychology
      Birmingham, Alabama, United States
    • San Francisco Department of Public Health
      San Francisco, California, United States
  • 2003
    • San Francisco VA Medical Center
      San Francisco, California, United States
  • 2001-2002
    • University of Texas at Austin
      • Department of Psychology
      Austin, Texas, United States