Assessment of contamination and misclassification biases in a randomized controlled trial of a social network peer education intervention to reduce HIV risk behaviors among drug users and risk partners in Philadelphia, PA and Chiang Mai, Thailand.

Controlled trials of HIV prevention and care interventions are susceptible to contamination. In a randomized controlled trial of a social network peer education intervention among people who inject drugs and their risk partners in Philadelphia, PA and Chiang Mai, Thailand, we tested a contamination measure based on recall of intervention terms. We assessed the recall of test, negative and positive control terms among intervention and control arm participants and compared the relative odds of recall of test versus negative control terms between study arms. The contamination measures showed good discriminant ability among participants in Chiang Mai. In Philadelphia there was no evidence of contamination and little evidence of diffusion. In Chiang Mai there was strong evidence of diffusion and contamination. Network structure and peer education in Chiang Mai likely led to contamination. Recall of intervention materials can be a useful method to detect contamination in experimental interventions.

A multisite study of the prevalence of HIV with rapid testing in mental health settings.

OBJECTIVES: We estimated HIV prevalence and risk factors among persons receiving mental health treatment in Philadelphia, Pennsylvania, and Baltimore, Maryland, January 2009 to August 2011. METHODS: We used a multisite, cross-sectional design stratified by clinical setting. We tested 1061 individuals for HIV in university-based inpatient psychiatric units (n = 287), intensive case-management programs (n = 273), and community mental health centers (n = 501). RESULTS: Fifty-one individuals (4.8%) were HIV-infected. Confirmed positive HIV tests were 5.9% (95% confidence interval [CI] = 3.7%, 9.4%) for inpatient units, 5.1% (95% CI = 3.1%, 8.5%) for intensive case-management programs, and 4.0% (95% CI = 2.6%, 6.1%) for community mental health centers. Characteristics associated with HIV included Black race, homosexual or bisexual identity, and HCV infection. CONCLUSIONS: HIV prevalence for individuals receiving mental health services was about 4 times as high as in the general population. We found a positive association between psychiatric symptom severity and HIV infection, indicating that engaging persons with mental illness in appropriate mental health treatment may be important to HIV prevention. These findings reinforce recommendations for routine HIV testing in all clinical settings to ensure that HIV-infected persons receiving mental health services are identified and referred to timely infectious disease care.

Exploring barriers and facilitators to participation of male-to-female transgender persons in preventive HIV vaccine clinical trials.

Observed seroincidence and prevalence rates in male-to-female (MTF) transgender individuals highlight the need for effective targeted HIV prevention strategies for this community. In order to develop an effective vaccine that can be used by transgender women, researchers must understand and address existing structural issues that present barriers to this group's participation in HIV vaccine clinical trials. Overcoming barriers to participation is important for ensuring HIV vaccine acceptability and efficacy for the MTF transgender community. To explore barriers and facilitators to MTF transgender participation in preventive HIV vaccine clinical trials, the HIV Vaccine Trials Network conducted focus groups among transgender women in four urban areas (Atlanta, Boston, Philadelphia, and San Francisco). Barriers and facilitators to engagement of transgender women in preventive HIV vaccine clinical trials led to the following recommendations: (a) transgender cultural competency training, (b) creating trans-friendly environments, (c) true partnerships with local trans-friendly organizations and health care providers, (d) protocols that focus on transgender specific issues, and (e) data collection and tracking of transgender individuals. These results have implications for the conduct of HIV vaccine trials, as well as engagement of transgender women in research programs in general.

"I Think That I Have a Good Understanding of How to Protect Myself": A Qualitative Study About HIV Risk Perceptions Among Men and Gender Diverse Individuals Who Have Sex With Men.

This qualitative study aimed to determine how men and gender diverse individuals who have sex with men describe their perceived risk of HIV and what factors influence this risk assessment. We conducted in-depth, virtual interviews with 18 HIV-negative individuals from Philadelphia, eligible for or taking PrEP. The interviews assessed the participants' understanding of their HIV risk, using thematic analysis to deductively code and extract themes. Three themes emerged: (1) participants expressed both deliberative and affective risk perception before and after sexual encounters; (2) participants linked HIV knowledge to risk perception and stigma; (3) participants connected intrinsic and extrinsic factors to risk perception differently. Participants endorsed low overall risk perception, while also describing moments of high affective risk perception after sexual encounters in which they were not able to implement their preferred prevention strategies. Future research should explore helping individuals transform affective risk perception into empowerment around sexual health.

Prior Sexually Transmitted Infection and Human Immunodeficiency Virus Risk Perception in a Diverse At-Risk Population of Men Who Have Sex with Men and Transgender Individuals.

Prior sexually transmitted infections (STIs) are associated with higher rates of subsequent human immunodeficiency virus (HIV) infection, but the influence of prior STIs on perceived vulnerability to HIV remains unclear. We aimed to assess this relationship, hypothesizing that a prior STI diagnosis is associated with higher self-assessed vulnerability to HIV. We performed a cross-sectional study of men and transgender individuals who have sex with men screening for HIV prevention trials in Philadelphia. An unadjusted regression analysis found no significant association between prior STI and HIV risk perception (p = 0.71) or HIV anxiety (p = 0.32). Multivariate logistic regression models that controlled for predetermined potential cofounders known to impact HIV risk-such as condom use, preexposure prophylaxis use, and demographics-also failed to show statistically significant associations between prior STI and HIV risk perception (p = 0.87) or HIV anxiety (p = 0.10). Furthermore, there was no effect modification by HIV preventive behaviors on the relationship between prior STI and HIV vulnerability. These data suggest that a gap exists between how clinicians may attribute individual HIV risk and how individuals view their own vulnerability at a given moment in time. Future research should focus on the dynamic relationship between perceived HIV vulnerability, STI diagnosis, and adoption of preventive behavior to determine better, individualized targets for HIV prevention interventions.

Prior Exposure to Intimate Partner Violence Associated With Less HIV Testing Among Young Women.

Low-income minority women are disproportionately represented among those living with HIV in the United States. They are also at risk for the SAVA (substance abuse, violence, and HIV/AIDS) syndemic issues. Women who have recently given birth are at high risk for substance use and intimate partner violence (IPV), and HIV testing is not routinely administered during the postpartum visit. We explored the relationship between substance use, IPV, and HIV testing among low-income young adult women attending Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), a federally supported nutrition program. A survey assessed substance use, relationships in particular with violence exposure, and HIV testing behavior in the past 6 months among a convenience sample of 100 women aged 18 to 30. The survey was conducted at several WIC offices in an urban setting in the Mid-Atlantic region between June and December 2015. Physical violence was the only IPV variable significantly associated (p = .022) with not being tested for HIV in the past 6 months, remaining significant even after adjusting for demographic and other significant variables (adjusted odds ratio [AOR] = 0.02; 95% confidence interval [CI] = [0.00, 0.41]). Women exposed to physical IPV or psychological IPV in the past year were significantly more likely to have ever used an illicit drug (physical IPV: 34% vs. 59%, p = .052; psychological IPV: 22% vs. 53%. p = .002). These findings between physical IPV and HIV testing history highlight the need to further understand how the context of violence affects HIV testing behaviors. Providing convenient, safe, and accessible HIV testing sites in spaces like WIC may increase HIV testing rates overall and specifically among women experiencing IPV.

Relationships between social norms, social network characteristics, and HIV risk behaviors in Thailand and the United States.

OBJECTIVE: Social norms have been associated with a wide range of health behaviors. In this study, the authors examined whether the social norms of HIV risk behaviors are clustered within social networks and whether the norms of network members are linked to the risk behaviors of their social network members. DESIGN: Data were collected from the baseline assessment of 354 networks with 933 participants in a network-oriented HIV prevention intervention targeting injection drug users in Philadelphia, United States, and Chiang Mai, Thailand. MAIN OUTCOME MEASURES: Four descriptive HIV risk norms of sharing needles, cookers, and cotton and front- or back-loading among friends who inject were assessed. RESULTS: Three of 4 injection risk norms (sharing needle, cookers, and cotton) were found to be significantly clustered. In Philadelphia, 1 network member's (the index participant) norms of sharing needles and front- or back-loading were found to be significantly associated with the network members' risk behaviors, and the norm of sharing cotton was marginally associated. CONCLUSION: The results of this study suggest that among injection drug users, social norms are clustered within networks; social networks are a meaningful level of analyses for understanding how social norms lead to risk behaviors, providing important data for intervening to reduce injection-related HIV risks.

The efficacy of a network intervention to reduce HIV risk behaviors among drug users and risk partners in Chiang Mai, Thailand and Philadelphia, USA.

This HIV Prevention Trials Network study assessed the efficacy of a network-oriented peer education intervention promoting HIV risk reduction among injection drug users and their drug and sexual network members in Chiang Mai, Thailand and Philadelphia, USA. The study was designed to test impact on HIV infection, but the infection rate was low and the study was terminated early. This paper reports efficacy on outcomes of self-reported HIV risk behaviors. We enrolled 414 networks with 1123 participants. The experimental intervention consisted of six small group peer educator training sessions and two booster sessions delivered to the network index only. All participants in both arms received individual HIV counseling and testing. Follow-up visits occurred every six months for up to 30 months. There were 10 HIV seroconversions, 5 in each arm. The number of participants reporting injection risk behaviors dropped dramatically between baseline and follow-up in both arms at both sites. Index members in the intervention arm engaged in more conversations about HIV risk following the intervention compared to control indexes. There was no evidence of change in sexual risk as a result of the intervention. Reductions in injection risk behaviors were observed: 37%, 20%, and 26% reduction in odds of sharing cottons, rinse water and cookers, respectively, and 24% reduction in using a syringe after someone else. Analysis of the individual sites suggested a pattern of reductions in injection risk behaviors in the Philadelphia site. In both sites, the intervention resulted in index injection drug users engaging in the community role of discussing reduction in HIV injection risk behaviors. The intervention did not result in overall reductions in self-reported sexual risk behaviors, and although reductions in injection risk behaviors were observed, the overall efficacy in reducing risk was not established.

Going social: Success in online recruitment of men who have sex with men for prevention HIV vaccine research.

OBJECTIVE: To compare the use of four different social media sites to recruit men who have sex with men (MSM) and transgender women to a phase 2b HIV prevention vaccine trial, HVTN 505. DESIGN: Retrospective, observational study. METHODS: The University of Pennsylvania HIV Vaccine Trials Unit (Penn HVTU) employed street outreach and online recruitment methods to recruit participants for HVTN 505 using a combination of national recruitment images/messages with Philadelphia-specific language and imagery. We compared the efficiency (number of enrolled participants per number of completed phone screens) and effectiveness (number of enrolled participants per time interval employed) of each strategy, as well as the demographics and risk behaviors of the populations. RESULTS: Online recruitment strategies populated 37% (71/191) of trial participants at our site. Among the four social media strategies employed, 45.1% (32/71) were enrolled through Facebook, 16.9% (12/71) through Craigslist, 15.5% (11/71) through a web-based marketing company (WBMC), and 22.5% (16/71) via GRINDR. The number of participants enrolled per month of strategy and the months the strategy was employed were Facebook - 32(33months), Craigslist - 12(33months), WBMC - 11(6months), and GRINDR - 16(0.56months). In-person and online recruitment strategies yielded participants of similar demographics and levels of risk behavior. CONCLUSION: Use of several social media recruitment modalities produced large numbers of MSM engaging in high risk behavior and willing to participate in an HIV prevention vaccine trial. In comparison to other social media and online strategies, recruitment via GRINDR was the most effective.

Racial disparities in HIV prevalence and risk behaviors among injection drug users and members of their risk networks.

In the United States, racial differences in the prevalence and incidence of HIV infection and AIDS diagnoses are dramatic. These differences are large, have been recognized for nearly 20 years, and are as yet not well investigated. These disparities show no signs of diminishing and, in fact, are widening, particularly among drug users and women. Most observers of the racial disparities in prevalence and incidence of HIV infections and AIDS diagnoses in the United States have concluded that these disparities exist because prevention messages, supplies, and/or interventions do not effectively reach those at greatest risk of infection. In essence, such interpretations suggest that Blacks and Latinos continue to practice more risk behaviors than Whites. There are much data to suggest that this is, in fact, not true. Evidence from 232 'index' injection drug users and 465 of their drug and sexual network members participating in HIV Prevention Trials Network 037 is presented. These data describe lower use and/or access to drug treatment and needle exchange programs by Black injectors. In addition, data indicate the coexistence of increased prevalence of HIV in the networks of uninfected Black drug users and fewer associated risk behaviors in the networks of Black and Latino indices compared with networks of White indices. Understanding racial disparities in HIV is a critical challenge; yet, risk behaviors alone do not explain observed disparities in infection rates.

Profiles of self-reported HIV-risk behaviors among injection drug users in methadone maintenance treatment, detoxification, and needle exchange programs.

OBJECTIVE: Injection drug use has accounted for more than one third of acquired immune deficiency syndrome cases in the United States. The purpose of this study was to compare the demographic characteristics, types, and frequency of human immunodeficiency virus (HIV)-risk behaviors among injection drug users (IDUs) recruited from a needle exchange program (NEP), methadone maintenance treatment (MMT), and detoxification (detox) program. DESIGN: A cross-sectional, correlational design was used to determine whether the selected HIV-risk behaviors and demographic characteristics of IDUs varied by site of recruitment. SAMPLE AND MEASUREMENTS: Confidential questionnaires were completed by 445 IDUs in Philadelphia, Pennsylvania. RESULTS: Data analysis revealed that HIV sexual and injection-risk behavior varied by recruitment site. Subjects recruited from the NEP were more likely to engage in HIV-risk behaviors than subjects recruited from the MMT or detox sites. CONCLUSIONS: Interventions occurring in program and treatment sites need to be sensitive to various demographic characteristics and behaviors if they are to reach those at highest risk of HIV infection. Targeting HIV prevention interventions based upon risk group membership alone (e.g. IDUs) fails to address the distinct risk behaviors and demographic characteristics of enrollees in different programs.

Sociodemographic and behavioral characteristics associated with timeliness and retention in a 6-month follow-up study of high-risk injection drug users.

Timeliness and retention in a 6-month follow-up study were analyzed by subjects' baseline characteristics in a seroincidence study of 263 injection drug users at high risk of human immunodeficiency virus infection. Subjects were recruited from September 1997 to June 1998 in community settings in Philadelphia, Pennsylvania. Of these subjects, 93% were completers: 11% before the targeted date, 38% at the targeted date, 32% within 1 month of delay, and 12% beyond 1 month. Late completers were more likely than other completers to be younger and to live farther away from the study center, less likely to have stayed in a shelter or a welfare residence during the past year, more likely to have a lower income, and more likely to have shared rinse water, cotton, or cooker. By contrast, loss to follow-up was not associated with these variables. Subjects lost to follow-up were more likely than those retained to have a high school diploma and to have moved during the past year; their source of needles was less likely to be a needle exchange program and more likely to be a shooting gallery. None of the drug-related behaviors that increase the risk of human immunodeficiency virus infection was associated with timeliness or retention, suggesting that the study might be minimally biased.