Engagement in care promotes durable viral suppression among persons newly diagnosed with HIV infection.

We characterize the association between engagement in care and durable viral suppression among persons newly diagnosed with HIV infection. Persons newly diagnosed with HIV with unsuppressed viral loads when they initiated care at one of six HIV clinics in the US were observed for up to 24 months. We describe the percentage who achieved durable viral suppression and number of days to achieve durable viral suppression. These outcomes were examined by the proportion of scheduled primary care appointments kept and demographic variables. Overall, 62% of patients achieved durable viral suppression and it took 174 days for 50% of patients to reach the beginning of the event. As the proportion of kept medical appointments increased, the proportion who achieved durable viral suppression increased, with 84% of patients who kept >75% of their appointments achieving the outcome. Higher adherence to appointments shortened the time to the beginning of durable viral suppression. Age, race/ethnicity, and risk factor for acquiring HIV infection were correlated with the outcomes. Adherence to primary care appointments is strongly associated with achieving durable viral suppression in persons newly diagnosed with HIV. Identifying and addressing patient barriers and unmet needs may increase the number who achieve durable viral suppression.

Occupational mobility and cognitive ability: A commentary on Betthäuser, Bourne and Bukodi.

This commentary critiques Betthäuser, Bourne and Bukodi's (2020) paper which finds that cognitive ability does not substantially mediate class of origin effects on educational and occupational outcomes. From these results, they conclude that cognitive ability is only of minor importance for social stratification, reasserting their view of the primacy of class origins for social stratification. The central issue surrounding cognitive ability in social stratification is its effects on socioeconomic attainments vis-à-vis socioeconomic origins, not the extent that cognitive ability mediates classorigin effects. Their analytical strategy of estimating the extent that cognitive ability mediates class origineffects is misleading because: it ignores the only moderate associations of socioeconomic origins with educational and occupational outcomes; the stronger direct effects of cognitive ability; the associations of parents' ability with their own socioeconomic attainments; and the genetic transmission of cognitive ability and other traits relevant to social stratification from parents to their children.

Characterising HIV transmission risk among US patients with HIV in care: a cross-sectional study of sexual risk behaviour among individuals with viral load above 1500 copies/mL.

OBJECTIVES: Viral load and sexual risk behaviour contribute to HIV transmission risk. High HIV viral loads present greater transmission risk than transient viral 'blips' above an undetectable level. This paper therefore characterises sexual risk behaviour among patients with HIV in care with viral loads>1500 copies/mL and associated demographic characteristics. METHODS: This cross-sectional study was conducted at six HIV outpatient clinics in USA. The study sample comprises 1315 patients with HIV with a recent viral load >1500 copies/mL. This study sample was drawn from a larger sample of individuals with a recent viral load >1000 copies/mL who completed a computer-assisted self-interview (CASI) regarding sexual risk practices in the last 2 months. The study sample was 32% heterosexual men, 38% men who have sex with men (MSM) and 30% women. RESULTS: Ninety per cent of the sample had their viral load assay within 60 days of the CASI. Thirty-seven per cent reported being sexually active (vaginal or anal intercourse) in the last 2 months. Most of the sexually active participants reported always using condoms (56.9%) or limiting condomless sex to seroconcordant partners (serosorting; 29.2% overall and 42.9% among MSM). Among sexually active participants who reported condomless anal or vaginal sex with an at-risk partner (14%), most had viral loads>10 000 copies/mL (62%). CONCLUSIONS: A relatively small number of patients with HIV in care with viral loads above 1500 copies/mL reported concurrent sexual transmission risk behaviours. Most of the individuals in this small group had markedly elevated viral loads, increasing the probability of transmission. Directing interventions to patients in care with high viral loads and concurrent risk behaviour could strengthen HIV prevention and reduce HIV infections. TRIAL REGISTRATION NUMBER: NCT02044484, completed.

Evaluation of a computer-based and counseling support intervention to improve HIV patients' viral loads.

We sought to integrate a brief computer and counseling support intervention into the routine practices of HIV clinics and evaluate effects on patients' viral loads. The project targeted HIV patients in care whose viral loads exceeded 1000 copies/ml at the time of recruitment. Three HIV clinics initiated the intervention immediately, and three other HIV clinics delayed onset for 16 months and served as concurrent controls for evaluating outcomes. The intervention components included a brief computer-based intervention (CBI) focused on antiretroviral therapy adherence; health coaching from project counselors for participants whose viral loads did not improve after doing the CBI; and behavioral screening and palm cards with empowering messages available to all patients at intervention clinics regardless of viral load level. The analytic cohort included 982 patients at intervention clinics and 946 patients at control clinics. Viral loads were assessed at 270 days before recruitment, at time of recruitment, and +270 days later. Results indicated that both the control and intervention groups had significant reductions in viral load, ending with approximately the same viral level at +270 days. There was no evidence that the CBI or the targeted health coaching was responsible for the viral reduction in the intervention group. Results may stem partially from statistical regression to the mean in both groups. Also, clinical providers at control and intervention clinics may have taken action (e.g., conversations with patients, referrals to case managers, adherence counselors, mental health, substance use specialists) to help their patients reduce their viral loads. In conclusion, neither a brief computer-based nor targeted health coaching intervention reduced patients' viral loads beyond levels achieved with standard of care services available to patients at well-resourced HIV clinics.

The Contribution of Genes and the Environment to Educational and Socioeconomic Attainments in Australia.

This article analyzes the contribution of genetics and the environment to educational attainment, occupational status, and income using data from over 1,100 monozygotic and 400 dizygotic Australian twin pairs aged from 18 to 99. The respective heritability estimates were 0.54, 0.37, and 0.18. The bivariate heritabilities were 0.71 for educational attainment and occupational status, 0.37 for education and income, and 0.61 for occupational status and income. There were no gender and cohort differences in the heritabilities for education and occupation, but for income, contrary to expectations, the heritabilities were significantly higher among women and for the older cohort (aged 50 or older). The sizable contribution of genes to these socioeconomic outcomes suggests that standard sociological and economic theories on the socioeconomic career require substantial modification to accommodate the role of genetics.

Durable Viral Suppression and Transmission Risk Potential Among Persons With Diagnosed HIV Infection: United States, 2012-2013.

BACKGROUND: We examined durable viral suppression, cumulative viral load (VL) burden, and transmission risk potential among human immunodeficiency virus (HIV)-diagnosed persons in care. METHODS: Using data from the National HIV Surveillance System from 17 jurisdictions with complete reporting of VL test results, we determined the percentage of persons in HIV care who achieved durable viral suppression (all VL results <200 copies/mL) and examined viremia copy-years and time spent above VL levels that increase the risk of HIV transmission during 2012-2013. RESULTS: Of 265 264 persons in HIV care in 2011, 238 641 had at least 2 VLs in 2012-2013. The median number of VLs per individual during the 2-year period was 5. Approximately 62% had durable viral suppression. The remaining 38% had high VL burden (geometric mean of viremia copy-years, 7261) and spent an average of 438 days, 316 days, and 215 days (60%, 43.2%, and 29.5% of the 2-year period) above 200, 1500, and 10 000 copies/mL. Women, blacks/African Americans, Hispanics/Latinos, persons with HIV infection attributed to transmission other than male-to-male sexual contact, younger age groups, and persons with gaps in care had higher viral burden and transmission risk potential. CONCLUSIONS: Two-thirds of persons in HIV care had durable viral suppression during a 2-year period. One-third had high VL burden and spent substantial time above VL levels with increased risk of onward transmission. More intervention efforts are needed to improve retention in care and medication adherence so that more persons in HIV care achieve durable viral suppression.

Social and psychological correlates of unprotected anal intercourse among Hispanic-American women: implications for STI/HIV prevention.

Heterosexual anal intercourse is associated with increased risk for HIV and other sexually transmitted infections. Research on the social and psychological risk factors associated with heterosexual unprotected anal intercourse among Hispanic women in the USA is limited. We examined demographic, mental health, relationship power, sexual self-efficacy, self-esteem, acculturation and HIV knowledge as correlates of unprotected anal intercourse among 514 HIV-negative Hispanic women, 18 to 59 years of age, residing in one urban county in southern Florida. In both unadjusted and adjusted results, the likelihood of engaging in unprotected anal intercourse was associated with food insecurity in the past 30 days (adjusted odds ratio [AOR] = 1.57, 95% confidence interval [CI] 1.03, 2.40) and more interpersonal power attributed to the male partner (AOR = 1.63, 95%CI 1.08, 2.45). Not significant, yet of possible importance, were ever having engaged in exchange sex (AOR = 1.96, 95%CI = 0.97, 3.98) and lower HIV knowledge (AOR = 0.80, 95%CI = 0.63, 1.01). Interventions aimed at reducing heterosexual unprotected anal intercourse risk for HIV infection among Hispanic women may benefit by addressing socioeconomic and interpersonal issues, and assessing HIV knowledge and comprehension.

Respondent-Driven Sampling in a Multi-Site Study of Black and Latino Men Who Have Sex with Men.

PURPOSE: Respondent-driven sampling (RDS) was used to recruit four samples of Black and Latino men who have sex with men (MSM) in three metropolitan areas to measure HIV prevalence and sexual and drug use behaviors. We compared demographic and behavioral risk characteristics of participants across sites, assessed the extent to which the RDS statistical adjustment procedure provides estimates that differ from the crude results, and summarized our experiences using RDS. METHODS: From June 2005 to March 2006 a total of 2,235 MSM were recruited and interviewed: 614 Black MSM and 516 Latino MSM in New York City, 540 Black MSM in Philadelphia, and 565 Latino MSM in Los Angeles County. Crude point estimates for demographic characteristics, behavioral risk factors and HIV prevalence were calculated for each of the four samples. RDS Analysis Tool was used to obtain population-based estimates of each sampled population's characteristics. RESULTS: RDS adjusted estimates were similar to the crude estimates for each study sample on demographic characteristics such as age, income, education and employment status. Adjusted estimates of the prevalence of risk behaviors were lower than the crude estimates, and for three of the study samples, the adjusted HIV prevalence estimates were lower than the crude estimates. However, even the adjusted HIV prevalence estimates were higher than what has been previously estimated for these groups of MSM in these cities. Each site faced unique circumstances in implementing RDS. CONCLUSIONS: Our experience in using RDS among Black and Latino MSM resulted in diverse recruitment patterns and uncertainties in the estimated HIV prevalence and risk behaviors by study site.

The declining influence of family background on educational attainment in Australia: The role of measured and unmeasured influences.

The paper examines changes in the influence of family background, including socioeconomic and social background variables on educational attainment in Australia for cohorts born between 1890 and 1982. We test hypotheses from modernization theory on sibling data using random effects models and find: (i) substantial declines in the influence of family background on educational attainment (indicated by the sibling intraclass correlations); (ii) declines in the effects of both economic and cultural socioeconomic background variables; (iii) changes in the effects of some social background variables (e.g., family size); (iv) and declines in the extent that socioeconomic and social background factors account for variation in educational attainment. Unmeasured family background factors are more important, and proportionally increasingly so, for educational attainment than the measured socioeconomic and social background factors analyzed. Fixed effects models showed steeper declines in the effects of socioeconomic background variables than in standard analyses suggesting that unmeasured family factors associated with socioeconomic background obscure the full extent of the decline.

Enhanced personal contact with HIV patients improves retention in primary care: a randomized trial in 6 US HIV clinics.

BACKGROUND: The aim of the study was to determine whether enhanced personal contact with human immunodeficiency virus (HIV)-infected patients across time improves retention in care compared with existing standard of care (SOC) practices, and whether brief skills training improves retention beyond enhanced contact. METHODS: The study, conducted at 6 HIV clinics in the United States, included 1838 patients with a recent history of inconsistent clinic attendance, and new patients. Each clinic randomized participants to 1 of 3 arms and continued to provide SOC practices to all enrollees: enhanced contact with interventionist (EC) (brief face-to-face meeting upon returning for care visit, interim visit call, appointment reminder calls, missed visit call); EC + skills (organization, problem solving, and communication skills); or SOC only. The intervention was delivered by project staff for 12 months following randomization. The outcomes during that 12-month period were (1) percentage of participants attending at least 1 primary care visit in 3 consecutive 4-month intervals (visit constancy), and (2) proportion of kept/scheduled primary care visits (visit adherence). RESULTS: Log-binomial risk ratios comparing intervention arms against the SOC arm demonstrated better outcomes in both the EC and EC + skills arms (visit constancy: risk ratio [RR], 1.22 [95% confidence interval {CI}, 1.09-1.36] and 1.22 [95% CI, 1.09-1.36], respectively; visit adherence: RR, 1.08 [95% CI, 1.05-1.11] and 1.06 [95% CI, 1.02-1.09], respectively; all Ps < .01). Intervention effects were observed in numerous patient subgroups, although they were lower in patients reporting unmet needs or illicit drug use. CONCLUSIONS: Enhanced contact with patients improved retention in HIV primary care compared with existing SOC practices. A brief patient skill-building component did not improve retention further. Additional intervention elements may be needed for patients reporting illicit drug use or who have unmet needs. CLINICAL TRIALS REGISTRATION: CDCHRSA9272007.

Homophobia is associated with sexual behavior that increases risk of acquiring and transmitting HIV infection among black men who have sex with men.

We investigated whether the experience of homophobic events increases the odds of engaging in unprotected anal intercourse (UAI) among black men who have sex with men (MSM) and whether social integration level buffered the association. Participants (N = 1,154) reported homophobic events experienced in the past 12 months. Social integration measures included social support, closeness with family members and friends, attachment to the black gay community, openness about sexuality within religious communities, and MSM social network size. Logistic regression analyses indicated that experiencing homophobia was associated with (1) UAI among men not previously diagnosed with HIV and (2) sexual HIV transmission risk behavior among men who knew they were HIV-infected. None of the social integration measures buffered these associations. Homophobia may promote acquisition and transmission of HIV infection among black MSM. Interventions are needed to reduce homophobia experienced by black MSM.

Interventions to promote linkage to and utilization of HIV medical care among HIV-diagnosed persons: a qualitative systematic review, 1996-2011.

This qualitative systematic review examined interventions that promote linkage to or utilization of HIV care among HIV-diagnosed persons in the United States. We conducted automated searches of electronic databases (i.e., MEDLINE, EMBASE, PsycINFO, CINAHL) and manual searches of journals, reference lists, and listservs. Fourteen studies from 19 published reports between 1996 and 2011 met our inclusion criteria. We developed a three-tier approach, based on strength of study design, to evaluate 6 findings on linkage to care and 18 findings on HIV care utilization. Our review identified similar strategies for the two outcomes, including active coordinator's role in helping with linking to or utilizing HIV care; offering information and education about HIV care; providing motivational or strengths-based counseling; accompanying clients to medical appointments and helping with appointment coordination. The interventions focused almost exclusively on individual-level factors. More research is recommended to examine interventions that address system and structural barriers.

"A man's gonna do what a man wants to do": African American and Hispanic women's perceptions about heterosexual relationships: a qualitative study.

BACKGROUND: HIV prevention efforts have given limited attention to the relational schemas and scripts of adult heterosexual women. These broader schemas and scripts of romantic and other sexual liaisons, partner selection, relationship dynamics, and power negotiations may help to better understand facilitators and barriers to HIV risk-reduction practices. METHODS: We conducted exploratory qualitative interviews with 60 HIV-uninfected heterosexual African-American women from rural counties in North Carolina and Alabama, and Hispanic women from an urban county in southern Florida. Data were collected for relationship expectations; relationship experiences, and relationship power and decision-making. Interview transcripts underwent computer-assisted thematic analysis. RESULTS: Participants had a median age of 34 years (range 18-59), 34% were married or living as married, 39% earned an annual income of $12,000 or less, 12% held less than a high school education, and 54% were employed. Among the Hispanic women, 95% were foreign born. We identified two overarching relationship themes: contradictions between relationship expectations and desires and life circumstances that negated such ideals, and relationship challenges. Within the contradictions theme, we discovered six subthemes: a good man is hard to find; sex can be currency used to secure desired outcomes; compromises and allowances for cheating, irresponsible, and disrespectful behavior; redefining dating; sex just happens; needing relationship validation. The challenges theme centered on two subthemes: uncertainties and miscommunication, and relationship power negotiation. Gender differences in relationship intentions and desires as well as communication styles, the importance of emotional and financial support, and the potential for relationships to provide disappointment were present in all subthemes. In examining HIV risk perceptions, participants largely held that risk for HIV-infection and the need to take precautions were problems of women who differed from them (i.e., abuse drugs, are promiscuous, exchange sex). CONCLUSION: Underlying women's relational schemas was a belief that relationship priorities differed for men and women. Consequently, expectations and allowances for partner infidelity and negligent behaviors were incorporated into their scripts. Moreover, scripts endorsed women's use of sex as currency in relationship formation and endurance, and did not emphasize HIV risk. Both couple- and gender-specific group-level interventions are needed to deconstruct (breakdown) and reconstruct (rewrite) relationship scripts.

Has Cognitive Ability Become More Important for Education and the Labor Market? A Comparison of the Project Talent and 1979 National Longitudinal Survey of Youth Cohorts.

Modernization and meritocratic theories contend that with modernization, socioeconomic background (SES) becomes less important for educational and socioeconomic attainments, while cognitive ability becomes more important. However, the evidence is mixed. This study investigates if the effects of SES and cognitive ability on educational and labor market outcomes have changed in the US by comparing two longitudinal cohort studies: the 1960 Project Talent and the 1979 National Longitudinal Survey of Youth. For all outcomes-grades-at-school, educational and occupational attainment, and income-cognitive ability clearly has stronger effects than a composite and broad measure of SES. The effects of cognitive ability for grades-at-school and income are notably stronger in the more recent cohort, whereas its effects on educational and occupational attainment are similar. SES effects, net of ability, for educational and occupational attainment are only moderate and for school grades and income are very small (ß < 0.10). However, for each outcome SES effects are stronger in the more recent NLSY79 cohort. This is attributed to ability being a stronger influence on the educational and socioeconomic attainments of NLSY79 parents compared to Project Talent parents. These analyses suggest that in the US, cognitive ability has long been an important, and SES a much weaker, influence on educational and subsequent socioeconomic outcomes.

A low-effort, clinic-wide intervention improves attendance for HIV primary care.

BACKGROUND: Retention in care for human immunodeficiency virus (HIV)-infected patients is a National HIV/AIDS Strategy priority. We hypothesized that retention could be improved with coordinated messages to encourage patients' clinic attendance. We report here the results of the first phase of the Centers for Disease Control and Prevention/Health Resources and Services Administration Retention in Care project. METHODS: Six HIV-specialty clinics participated in a cross-sectionally sampled pretest-posttest evaluation of brochures, posters, and messages that conveyed the importance of regular clinic attendance. 10,018 patients in 2008-2009 (preintervention period) and 11,039 patients in 2009-2010 (intervention period) were followed up for clinic attendance. Outcome variables were the percentage of patients who kept 2 consecutive primary care visits and the mean proportion of all primary care visits kept. Stratification variables were: new, reengaging, and active patients, HIV RNA viral load, CD4 cell count, age, sex, race or ethnicity, risk group, number of scheduled visits, and clinic site. Data were analyzed by multivariable log-binomial and linear models using generalized estimation equation methods. RESULTS: Clinic attendance for primary care was significantly higher in the intervention versus preintervention year. Overall relative improvement was 7.0% for keeping 2 consecutive visits and 3.0% for the mean proportion of all visits kept (P < .0001). Larger relative improvement for both outcomes was observed for new or reengaging patients, young patients and patients with elevated viral loads. Improved attendance among the new or reengaging patients was consistent across the 6 clinics, and less consistent across clinics for active patients. CONCLUSION: Targeted messages on staying in care, which were delivered at minimal effort and cost, improved clinic attendance, especially for new or reengaging patients, young patients, and those with elevated viral loads.

Routine brief risk-reduction counseling with biannual STD testing reduces STD incidence among HIV-infected men who have sex with men in care.

BACKGROUND: We evaluated whether routine biannual sexually transmitted disease (STD) testing coupled with brief risk-reduction counseling reduces STD incidence and high-risk behaviors. METHODS: The SUN study is a prospective observational HIV cohort study conducted in 4 US cities. At enrollment and every 6 months thereafter, participants completed a behavioral survey and were screened for STDs, and if diagnosed, were treated. Medical providers conducted brief risk-reduction counseling with all patients. Among men who have sex with men (MSM), we examined trends in STD incidence and rates of self-reported risk behaviors before and after exposure to the risk-reduction intervention. The "preintervention" visit was the study visit that was at least 6 months after enrollment STD screening and treatment and at which the participant was first exposed to the intervention. The "postintervention" visit was 12 months later. RESULTS: Among 216 MSM with complete STD and behavioral data, median age was 44.5 years; 77% were non-Hispanic white; 83% were on highly active antiretroviral treatment; 84% had an HIV RNA level <400 copies/mL and the median CD4 (cluster of differentiation 4) count was 511 cells/mm. Twelve months after first exposure to the risk-reduction intervention, STD incidence declined from 8.8% to 4.2% (P = 0.041). Rates of unprotected receptive or insertive anal intercourse with HIV-positive partners increased (19% to 25%, P = 0.024), but did not change with HIV-negative partners or partners of unknown HIV status (24% to 22%, P = 0.590). CONCLUSIONS: STD incidence declined significantly among HIV-infected MSM after implementing frequent, routine STD testing coupled with risk-reduction counseling. These findings support adoption of routine STD screening and risk-reduction counseling for HIV-infected MSM.

Interventions to improve retention in HIV primary care: a systematic review of U.S. studies.

Retaining HIV-diagnosed persons in care is a national priority, but little is known on what intervention strategies are most effective for promoting retention in care. We conducted a systematic search and qualitatively reviewed 13 published studies and three recent conference presentations to identify evidence-informed retention strategies. We extracted information on study design, methods, and intervention characteristics. Strengths-based case management that encourages clients to recognize and use their own internal abilities to access resources and solve problems offered strong evidence for retention in care. Other evidence-informed strategies included peer navigation, reducing structural- and system-level barriers, including peers as part of a health care team, displaying posters and brochures in waiting rooms, having medical providers present brief messages to patients, and having clinics stay in closer contact with patients across time. Opportunities for additional intervention strategies include using community-based organizations as a setting for engaging HIV-infected persons about the importance of regular care and involving patients' significant others in retention in care interventions.

Having supportive social relationships is associated with reduced risk of unrecognized HIV infection among black and Latino men who have sex with men.

We examined the hypothesis that black and Latino men who have sex with men (MSM) who have supportive social relationships with other people are less likely to have unrecognized HIV infection compared with MSM of color who report lower levels of social support. We interviewed 1286 black and Latino MSM without known HIV infection in three metropolitan areas who were recruited using respondent driven sampling. Participants completed a computer-administered questionnaire and were tested for HIV. Unrecognized HIV infection was found in 118 men (9.2%). MSM who scored higher on the supportive relationship index had significantly lower odds of testing HIV-positive in the study. The mediation analysis identified two possible behavioral pathways that may partially explain this association: men who had strong supportive relationships were more likely to have had a test for HIV infection in the past 2 years and less likely to have recently engaged in high-risk sexual behavior. The findings illuminate the protective role of social relationships among MSM of color in our sample.