Homelessness at diagnosis is associated with death among people with HIV in a population-based study of a US city.

OBJECTIVE: San Francisco, California, has experienced a 44% reduction in new HIV diagnoses since 2013 supported by its 'Getting to Zero' initiative; however, the age-adjusted mortality rate in people with HIV (PWH) has not decreased. We sought to identify factors associated with death among PWH in San Francisco. DESIGN: Population-based incidence-density case-control study. METHODS: Among PWH in the San Francisco HIV surveillance registry, a random sample of 48 decedents from 1 July 2016 to 31 May 2017 were each matched to two to three controls who were alive at the date of death (108 controls matched on age and time since diagnosis). Covariates included demographics, substance use, housing status, medical conditions, and care indicators from the study population. We used matched-pair conditional logistic regression to examine factors associated with mortality. RESULTS: Of the 156 PWH in the study, 14% were African-American, 14% Latino, and 8% female sex. In adjusted analysis, factors associated with higher odds of death included: homelessness at HIV diagnosis [adjusted odds ratio (AOR) = 27.4; 95% confidence interval (CI) = 3.0-552.1], prior-year IDU (AOR = 10.2; 95% CI = 1.7-128.5), prior-year tobacco use (AOR = 7.2; 95% CI = 1.7-46.9), being off antiretroviral therapy at any point in the prior year (AOR = 6.8; 95% CI = 1.1-71.4), and being unpartnered vs. married/partnered (AOR = 4.7; 95% CI = 1.3-22.0). CONCLUSION: People homeless at HIV diagnosis had 27-fold higher odds of death compared with those with housing; substance use and retention on antiretroviral therapy in the prior year are other important intervenable factors. New strategies to address these barriers, and continued investment in supportive housing and substance use treatment, are needed.

Assessing receipt of medical care and disparity among persons with HIV/AIDS in San Francisco, 2006-2007.

We used data from HIV/AIDS surveillance case registry to assess the timing of entry into medical care, level of care received after HIV diagnosis, and to identify characteristics associated with delayed and insufficient care among persons diagnosed with HIV/AIDS between 2006 and 2007 in San Francisco. Laboratory reports of HIV viral load and CD4 test results were used as a marker for receipt of medical care. The time from HIV diagnosis to entry into care was estimated using Kaplan-Meier product limit method and independent predictors of delayed entry into care were determined using the proportional hazards model. Insufficient care was defined as less than an average of two viral load/CD4 tests per person-year of follow-up. Predictors of insufficient care were evaluated using a logistic regression model. An estimated 85% of persons diagnosed with HIV/AIDS entered care within three months after HIV diagnosis; the proportion increased to 95% within 12 months after diagnosis. Persons who were born outside of the USA and those tested at the public counseling and testing sites were more likely to delay care. Nineteen percent of persons were determined to have received insufficient care. Younger persons and those diagnosed at a hospital were more likely to receive insufficient care. A high proportion of persons diagnosed with HIV/AIDS in San Francisco established timely and adequate care after HIV diagnosis. However, delays for some individuals in entry into care and markers of insufficient care suggest that there remains a need to improve access to and sustainability of HIV-specific medical care.

Efficacy of personalized cognitive counseling in men of color who have sex with men: secondary data analysis from a controlled intervention trial.

In a previous report, we demonstrated the efficacy of a cognitively based counseling intervention compared to standard counseling at reducing episodes of unprotected anal intercourse (UAI) among men who have sex with men (MSM) seeking HIV testing. Given the limited number of efficacious prevention interventions for MSM of color (MOC) available, we analyzed the data stratified into MOC and whites. The sample included 196 white MSM and 109 MOC (23 African Americans, 36 Latinos, 22 Asians, eight Alaskan Natives/Native Americans/Hawaiian/Pacific Islander, and 20 of mixed or other unspecified race). Among MOC in the intervention group, the mean number of episodes of UAI declined from 5.1 to 1.6 at six months and was stable at 12 months (1.8). Among the MOC receiving standard counseling, the mean number of UAI episodes was 4.2 at baseline, 3.9 at six months and 2.1 at 12 months. There was a significant treatment effect overall (relative risk 0.59, 95% confidence interval 0.35-0.998). These results suggest that the intervention is effective in MOC.

Informing interventions: the importance of contextual factors in the prediction of sexual risk behaviors among transgender women.

This study identifies contextual factors that predict risky sexual behavior among 153 transgender women who participated in a structured survey soliciting information on demographics, substance use, HIV status, risk behaviors, and other health and psychosocial factors. Multivariate logistic regression models were used to determine predictors. Inconsistent condom use was associated with stimulant use, unstable housing, and recruitment site. Substance use during sex was associated with unstable housing and stimulant use. Sex work was associated with hormone use, gender confirming surgeries, and younger age. When developing interventions for transgender women, it may be useful to focus on predictors of risk behavior rather than predictors of current HIV status (i.e., race/ethnicity as "risk factor"), because these behaviors are the target of interventions aimed at sexual risk reduction. Implications include potential benefits of context-specific interventions, structural interventions addressing barriers to housing and health care, and culturally specific substance abuse treatment programs for transgender women.

The Bolger conference on PDE-5 inhibition and HIV risk: implications for health policy and prevention.

INTRODUCTION: Recent reports have linked the use of phosphodiesterase type 5 (PDE-5) inhibitors with increased rates of high-risk sexual behavior and HIV transmission in some individuals. AIM: A National Institute of Mental Health (NIMH)-funded, multidisciplinary conference was convened to evaluate scientific research, clinical and ethical considerations, and public policy implications of this topic. MAIN OUTCOME MEASURES: Published and unpublished findings on effects of PDE-5 inhibitors on sexual behavior; published guidelines and management recommendations. METHODS: Leading investigators in relevant disciplines (e.g., public health, epidemiology, medical ethics, urology, psychology) participated in a 2-day meeting, including representatives of government, scientific, and regulatory agencies (the Centers for Disease Control, Food and Drug Administration, NIMH, and the National Institute on Drug Abuse). Panelists provided critical reviews of substantive areas of research, followed by question and answer sessions on each topic. On the second day, working groups were convened to identify critical gaps and priorities in three major areas: (i) research and evaluation needs; (ii) prevention strategies and clinical management issues; and (iii) policy and prevention implications. RESULTS: Research needs and priorities were categorized into four specific areas: (i) basic and clinical/laboratory research; (ii) epidemiology and risk factors; (iii) social-behavioral processes and interventions; and (iv) prevention/policy and educational needs. Identified gaps in the available data include populations at risk (e.g., risk among heterosexuals, risk profiles among subpopulations of men who have sex with men) and the specific role of PDE-5 inhibitors in HIV seroconversion. Specific areas of emphasis were the need for safer sex counseling, comprehensive sexually transmitted infection (STI) screening and follow-up when indicated, avoidance of potentially dangerous drug interactions, and potential benefits of testosterone replacement for HIV-positive men with decreased androgen and other symptoms of hypogonadism. Conclusions. A conference was convened on the topic of PDE-5 inhibition and HIV risk. This "white paper" summarizes the findings of the conference and recommendations for future research.