Disclosure of HIV-serodiscordant relationships and association with viral suppression: results from the Positive Plus One study.

BACKGROUND: Little is known about the effects of disclosure of HIV-serodiscordant relationships on clinical outcomes. We aimed to evaluate the effect of relationship disclosure on HIV viral suppression, and hypothesized that disclosure by HIV-positive and HIV-negative partners would be associated with viral suppression in the HIV-positive partner. METHODS: We conducted a Canadian national online and telephone-administered survey of HIV-positive and HIV-negative partners in serodiscordant relationships. The primary outcome was self-reported viral suppression. Multivariable analyses were undertaken using Firth logistic regression. RESULTS: We recruited 540 participants in current serodiscordant relationships (n = 228 HIV-negative; n = 312 HIV-positive). Similar proportions of HIV-positive and HIV-negative partners disclosed their relationship to healthcare professionals (82% v. 76%, p = 0.13). Among HIV-positive partners, disclosure of the relationship to healthcare professionals increased the odds of viral suppression (aOR = 4.7; CI: 2.13, 10.51) after adjusting for age, education, and relationship turmoil due to HIV. Increasing age (aOR = 1.28; 95% CI = 1.07, 1.55) and education (aOR = 2.43; 95% CI = 1.15, 5.26) were also associated with viral suppression. Among HIV-negative partners, relationship disclosure was not associated with viral suppression and HIV-negative heterosexual men were less likely to report that their HIV-positive partners were virally suppressed (aOR = 0.24; CI: 0.09, 0.61). CONCLUSIONS: Disclosure of HIV-serodiscordant status by HIV-positive participants to healthcare professionals was associated with increased odds of viral suppression. Similar effects were not evident among HIV-negative participants. Future work should explore factors that empower relationship disclosure and incorporate them into supportive services for HIV-serodiscordant relationships.

A national recruitment strategy for HIV-serodiscordant partners living in Canada for the Positive Plus One study: a mixed-methods study.

BACKGROUND: With the recent shift in focus to addressing HIV risk within relationships and couple-based interventions to prevent HIV transmission, successful recruitment of individuals involved in HIV-serodiscordant relationships is crucial. This paper evaluates methods used by the Positive Plus One (PP1) study to recruit and collect data on a diverse national sample of dyads and individuals involved in current or past HIV-serodiscordant relationships, discusses the strengths and limitations of the recruitment approach, and makes recommendations to inform the interpretation of study results and the design of future studies. METHODS: PP1 used a multi-pronged approach to recruit adults involved in a current or past HIV-serodiscordant relationship in Canada from 2016 to 2018 to complete a survey and an interview. Upon survey completion, index (first recruited) partners were invited to recruit their primary current HIV-serodiscordant partner. We investigated participant enrollment by recruitment source, participant-, relationship-, and dyad-level sociodemographic characteristics, missing data, and correlates of participation for individuals recruited by their partners. RESULTS: We recruited 613 participants (355 HIV-positive; 258 HIV-negative) across 10 Canadian provinces, including 153 complete dyads and 307 individuals who participated alone, and representing 460 HIV-serodiscordant relationships. Among those in current relationships, HIV-positive participants were more likely than HIV-negative participants to learn of the study through an ASO staff member (36% v. 20%, p < 0.001), ASO listserv/newsletter (12% v. 5%, p = 0.007), or physician/staff at a clinic (20% v. 11%, p = 0.006). HIV-negative participants involved in current relationships were more likely than HIV-positive participants to learn of the study through their partner (46% v. 8%, p < 0.001). Seventy-eight percent of index participants invited their primary HIV-serodiscordant partner to participate, and 40% were successful. Successful recruitment of primary partners was associated with longer relationship duration, higher relationship satisfaction, and a virally suppressed HIV-positive partner. CONCLUSIONS: Our findings provide important new information on and support the use of a multi-pronged approach to recruit HIV-positive and HIV-negative individuals involved in HIV-serodiscordant relationships in Canada. More creative strategies are needed to help index partners recruit their partner in relationships with lower satisfaction and shorter duration and further minimize the risk of "happy couple" bias.

Examining HIV-related stigma among African, Caribbean, and Black church congregants from the Black PRAISE study in Ontario, Canada.

HIV-related stigma impedes adoption and implementation of effective HIV prevention and treatment strategies. It may also exacerbate racial/ethnic HIV disparities. Given high levels of religious observance within African, Caribbean, and Black (ACB) communities and the social capital that faith-based organizations hold, these entities may be promising venues for stigma-remediation and effective partners in community-based, HIV-focused programing. However, more research is needed to understand HIV-related stigma in these institutions. This study examines HIV-related stigma among six ACB churches in Ontario, Canada. Surveys were distributed to ACB attendees (N = 316) and linear regressions determined relationships between HIV-related stigma and stigma subdomains with demographics, greater disagreement with same-sex relationships, HIV knowledge, and religiosity. Greater disagreement with same-sex relationships was the only variable associated with the HIV-related stigma scale and all of its subscales. Age, gender, HIV knowledge, religiosity, contact with persons living with HIV, and length of time in Canada were associated with varying aspects of HIV-related stigma. Findings can inform the development of HIV-related stigma interventions and the characteristics of individuals these efforts should target to achieve maximum impact.

Black PRAISE: engaging Black congregations to strengthen critical awareness of HIV affecting Black Canadian communities.

In Canada, HIV disproportionately affects Black communities. Though Black faith leaders play an influential role engaging Black communities around social care and social justice, their response to HIV has been somewhat muted. Black PRAISE is a novel intervention for Black churches to strengthen congregants' critical awareness of HIV affecting Black communities. A multi-stakeholder team developed and tested the intervention in 2016 - 17 among six churches in the province of Ontario, where more than half of Black Canadians reside, using a community-based participatory approach. Specifically, the intervention aimed to strengthen how congregants understand HIV among Black communities and reduce their level of stigma toward people living with HIV. We addressed critical awareness among the participating congregations through (i) disseminating a booklet with validated information that promoted critical health literacy related to HIV; (ii) enabling pastors to deliver a sermon on love, compassion and social justice; and (iii) developing and screening a short film that featured Black Canadians discussing their experiences of HIV-related stigma. We assessed changes in knowledge and stigma by surveying congregants (N = 173) at baseline and two follow-ups using validated instruments and other measures. Through Black PRAISE, congregants significantly increased their HIV-related knowledge; moreover, exposure to all the intervention components was associated with a significantly reduced level of stigma. A likely strategic outcome of Black PRAISE is that churches are empowered to help strengthen Black people's community-based response to HIV and join efforts to eliminate the structural conditions that increase Black people's vulnerability to HIV.

Interventions to improve retention-in-care and treatment adherence among patients with drug-resistant tuberculosis: a systematic review.

The global loss to follow-up (LTFU) rate among drug-resistant tuberculosis (DR-TB) patients remains high at 15%. We conducted a systematic review to explore interventions to reduce LTFU during DR-TB treatment.We searched for studies published between January 2000 and December 2017 that provided any form of psychosocial or material support for patients with DR-TB. We estimated point estimates and 95% confidence intervals of the proportion LTFU. We performed subgroup analyses and pooled estimates using an exact binomial likelihood approach.We included 35 DR-TB cohorts from 25 studies, with a pooled proportion LTFU of 17 (12-23)%. Cohorts that received any form of psychosocial or material support had lower LTFU rates than those that received standard care. Psychosocial support throughout treatment, via counselling sessions or home visits, was associated with lower LTFU rates compared to when support was provided through a limited number of visits or not at all.Our review suggests that psychosocial support should be provided throughout DR-TB treatment in order to reduce treatment LTFU. Future studies should explore the potential of providing self-administered therapy complemented with psychosocial support during the continuation phase.

Design and implementation of a sexual health intervention for migrant construction workers situated in Shanghai, China.

BACKGROUND: China's growing population of internal migrants has exceeded 236 million. Driven by rapid development and urbanization, this extreme population mobility creates opportunities for transmission of HIV and sexually-transmitted infections (STI). Large numbers of rural migrants flock to megacities such as Shanghai in search of employment. Although migrants constitute a key population at heightened risk of acquiring HIV or an STI, there is a lack of easily accessible sexual health services available for them. In response, we designed a short, inexpensive sexual health intervention that sought to improve HIV and STI knowledge, while reducing stigma, risky sexual behaviour, and sexual transmission of HIV and STI among migrant construction workers (MCW) situated in Shanghai, China. RESULTS: We implemented a three-armed, community-randomized trial spread across three administrative districts of Shanghai. The low-intensity intervention included educational pamphlets. The medium-intensity intervention included pamphlets, posters, and videos. The high-intensity intervention added group and individual counselling sessions. Across 18 construction sites, 1871 MCW were allocated at baseline to receive one intervention condition. Among baseline participants, 1304 workers were retained at 3-months, and 1013 workers were retained at 6-months, representing a total of 579 person-years of follow-up. All workers, regardless of participation, had access to informational materials even if they did not participate in the evaluation. Overall outputs included: 2284 pamphlets distributed, 720 posters displayed, 672 h of video shown, 376 participants accessed group counselling, and 61 participants attended individual counselling sessions. A multivariable analysis of participation found that men (aOR = 2.2; 95 % CI 1.1, 4.1; p = 0.036), workers situated in Huangpu district (aOR = 5.0; 95 % CI 2.6, 9.5; p < 0.001), and those with a middle school education (aOR = 1.9; 95 % CI 1.2, 3.0; p = 0.01) were more likely to have participated in intervention activities. CONCLUSION: A brief educational intervention that prioritized ease of delivery to a highly mobile workforce was feasible and easily accessed by participants. Routine implementation of sexual health interventions in workplaces that employ migrant labour have the potential to make important contributions toward improving HIV and STI outcomes among migrant workers in China's largest cities.

Retrospective reports of developmental stressors, syndemics, and their association with sexual risk outcomes among gay men.

Gay and bisexual men (GBM) continue to have a disproportionately higher HIV incidence than any other group in Canada and the United States. This study examined how multiple co-occurring psychosocial problems, also known as a syndemic, contribute to high-risk sexual behavior among GBM. It also examined the impact of early life adversity on high-risk sexual behavior as mediated by syndemic severity. A sample of 239 GBM completed self-report questionnaires at baseline and 6-month follow-up. Syndemic variables included depression, polysubstance use, and intimate partner violence. Early life adversity variables measured retrospectively included physical and verbal bullying by peers and physical and sexual abuse by adults. A Cochran-Armitage trend test revealed a proportionate increase between number of syndemic problems and engagement in high-risk sex (p < .0001), thereby supporting syndemic theory. All early life adversity variables were positively correlated with number of syndemic problems. A bootstrap mediation analysis revealed indirect effects of two types of early life adversity on high-risk sex via syndemic severity: verbal bullying by peers and physical abuse by adults. There was also an overall effect of physical bullying by peers on high-risk sexual behavior, but no specific direct or indirect effects were observed. Consistent with syndemic theory, results provide evidence that certain types of early life adversity impact high-risk sex later in life via syndemic problems. Behavioral interventions to reduce sexual risk among GBM should address anti-gay discrimination experienced before adulthood as well as adult psychological problems.

A scoping review and thematic analysis of social and behavioural research among HIV-serodiscordant couples in high-income settings.

BACKGROUND: While HIV incidence has stabilized in many settings, increases in health and wellbeing among many people living with HIV/AIDS suggest that the number of HIV-serodiscordant relationships is growing. Given the deficit of reviews addressing social and behavioural characteristics of HIV-serodiscordant couples within high-income settings, our objective was to understand the scope of the published literature, identify evidence gaps, and suggest future research needs. METHODS: Ten electronic databases were searched. Studies were included if they were reported in English, used primary data, were from the combination antiretroviral (cART) era (>1996), reported on social or behavioural aspects, included any fraction of primary (i.e., stable) relationships, and were conducted in high-income settings. Studies that identified their unit of analysis as either the dyad or individual member of the couple were included. Studies were coded according to a thematic framework. RESULTS: Included studies (n = 154) clustered into eight themes: risk behaviours (29%), risk management (26%), reproductive issues (12%), relationship quality (9%), serostatus disclosure (7%), adherence to antiretroviral therapy (7%), vulnerability (5%), and social support (3%). The proportion of studies conducted among heterosexual couples, same-sex male couples, and mixed cohorts were 42%, 34%, and 24%, respectively. Most studies (70%) were conducted in the United States, 70% of all studies were quantitative (including interventions), but only one-third were focused on couples (dyads) where both partners are recruited to a study. Over 25% of studies focused on sexual risk among same-sex male couples. CONCLUSIONS: Future research efforts should focus on the interrelationship of risk management strategies and relationship quality, social determinants of health and wellbeing, HIV testing, vulnerable populations, reproductive issues among same-sex couples, disclosure of serodiscordant status to social networks, dyadic studies, population-based studies, and interventions to support risk management within couples. Additional population-based studies and studies among marginalized groups would be helpful for targeting research and interventions to couples that are most in need. As HIV-positive partners are typically the link to services and research, innovative ways are needed for reaching out to HIV-negative partners. Our review suggests that significantly more research is needed to understand the social and behavioural contexts of HIV-serodiscordant relationships.

Impact evaluation of a community-based intervention to reduce risky sexual behaviour among female sex workers in Shanghai, China.

BACKGROUND: Female sex workers (FSWs) are at risk for sexually transmitted infections (STIs), including HIV. We implemented an HIV/STI preventive intervention among FSWs in Shanghai that aimed to increase condom use, improve HIV knowledge, and reduce STI and HIV incidence. METHODS: From six districts in Shanghai, 750 randomly selected venue-based FSWs were allocated to either a behavioural intervention or control group. In the intervention and control groups, 221 and 278 participants, respectively, had at least one follow-up at three or six months. In analysis, we randomly selected 57 lost to follow-up cases in the intervention group and imputed baseline values to equalize the arms at n = 278 (74.1% follow-up rate in each group). The impacts of the intervention on condom use, HIV/STI risk perception and knowledge, and STI incidence were assessed using either a logistic or linear model, adjusting for the baseline measure of the outcome and venue type. RESULTS: The intervention improved consistent condom use with any partner type in the previous month (AOR = 2.09, 95% CI, 1.43-3.04, p = 0.0001). Consistent condom use with clients in the three most recent sex acts increased in both arms, and with primary partners in the intervention arm, but there was no difference between groups after adjusting for baseline condom use and venue type. There were no differences in cumulative incidence of any STI (i.e., chlamydia, gonorrhoea, syphilis) between groups. HIV transmission knowledge (p = 0.0001), condom use skill (p = 0.0421), and self-efficacy for using condoms (p = 0.0071) were improved by the intervention. HIV-related stigma declined (p = 0.0119) and HIV and STI risk perception were improved (4.6 to 13.9%, and 9.4 to 20.0%, respectively). The intervention was associated with these improvements after adjusting for the baseline measure and venue type. CONCLUSION: Following a preventive intervention among Shanghai FSWs, our findings demonstrate that a simple, community-based educational intervention improved overall condom use, HIV and STI knowledge, and attitudes in relation to HIV/AIDS. The intervention should be implemented widely after tailoring educational materials regarding condom negotiation with different partner types (i.e., commercial sex clients and primary partners).

Risk factors for intimate partner violence in women in the Rakai Community Cohort Study, Uganda, from 2000 to 2009.

BACKGROUND: Intimate partner violence (IPV) is a significant public health problem. There is a lack of data on IPV risk factors from longitudinal studies and from low and middle income countries. Identifying risk factors is needed to inform the design of appropriate IPV interventions. METHODS: Data were from the Rakai Community Cohort Study annual surveys between 2000 and 2009. Female participants who had at least one sexual partner during this period and had data on IPV over the study period were included in analyses (N = 15081). Factors from childhood and early adulthood as well as contemporary factors were considered in separate models. Logistic regression was used to assess early risk factors for IPV during the study period. Longitudinal data analysis was used to assess contemporary risk factors in the past year for IPV in the current year, using a population-averaged multivariable logistic regression model. RESULTS: Risk factors for IPV from childhood and early adulthood included sexual abuse in childhood or adolescence, earlier age at first sex, lower levels of education, and forced first sex. Contemporary risk factors included younger age, being married, relationships of shorter duration, having a partner who is the same age or younger, alcohol use before sex by women and by their partners, and thinking that violence is acceptable. HIV infection and pregnancy were not associated with an increased odds of IPV. CONCLUSIONS: Using longitudinal data, this study identified a number of risk factors for IPV. These findings are useful for the development of prevention strategies to prevent and mitigate IPV in women.

"Live a normal life": Constructions of resilience among people in mixed HIV status relationships in Canada.

Positive Plus One is a mixed-methods study of long-term mixed HIV-serostatus relationships in Canada (2016-19). Qualitative interviews with 51 participants (10 women, 41 men, including 27 HIV-positive and 24 HIV-negative partners) were analyzed using inductive thematic analysis to examine notions of relationship resilience in the context of emerging HIV social campaigns. Relationship resilience meant finding ways to build and enact life as a normal couple, that is, a couple not noticeably affected by HIV, linked to the partner with HIV maintaining viral suppression and achieving "undetectable = untransmittable" (U = U). Regardless of serostatus, participants with material resources, social networks, and specialized care were better able to construct resilience for HIV-related challenges within their relationships. Compared to heterosexual couples and those facing socioeconomic adversity, gay and bisexual couples were easier able to disclose, and access capital, networks and resources supporting resilience. We conclude that important pathways of constructing, shaping, and maintaining resilience were influenced by the timing of HIV diagnosis in the relationship, access to HIV-related information and services, disclosure, stigma and social acceptance.

Effect of early versus deferred antiretroviral therapy for HIV on survival.

BACKGROUND: The optimal time for the initiation of antiretroviral therapy for asymptomatic patients with human immunodeficiency virus (HIV) infection is uncertain. METHODS: We conducted two parallel analyses involving a total of 17,517 asymptomatic patients with HIV infection in the United States and Canada who received medical care during the period from 1996 through 2005. None of the patients had undergone previous antiretroviral therapy. In each group, we stratified the patients according to the CD4+ count (351 to 500 cells per cubic millimeter or >500 cells per cubic millimeter) at the initiation of antiretroviral therapy. In each group, we compared the relative risk of death for patients who initiated therapy when the CD4+ count was above each of the two thresholds of interest (early-therapy group) with that of patients who deferred therapy until the CD4+ count fell below these thresholds (deferred-therapy group). RESULTS: In the first analysis, which involved 8362 patients, 2084 (25%) initiated therapy at a CD4+ count of 351 to 500 cells per cubic millimeter, and 6278 (75%) deferred therapy. After adjustment for calendar year, cohort of patients, and demographic and clinical characteristics, among patients in the deferred-therapy group there was an increase in the risk of death of 69%, as compared with that in the early-therapy group (relative risk in the deferred-therapy group, 1.69; 95% confidence interval [CI], 1.26 to 2.26; P<0.001). In the second analysis involving 9155 patients, 2220 (24%) initiated therapy at a CD4+ count of more than 500 cells per cubic millimeter and 6935 (76%) deferred therapy. Among patients in the deferred-therapy group, there was an increase in the risk of death of 94% (relative risk, 1.94; 95% CI, 1.37 to 2.79; P<0.001). CONCLUSIONS: The early initiation of antiretroviral therapy before the CD4+ count fell below two prespecified thresholds significantly improved survival, as compared with deferred therapy.

The impact of stressful life events on unprotected anal intercourse among gay and bisexual men.

We investigated the hypothesis that gay and bisexual men experiencing stressful life events are more likely to engage in risky sexual behavior. Data were from a cohort study of 155 HIV-positive and 207 HIV-negative men in Ontario, Canada (1998-2007). We quantified the relation between stressful life events and unprotected anal intercourse with a non-regular partner. In the past 6 months, 19% reported unprotected intercourse (HIV+: 28%; HIV-: 13%) and 58% reported one or more stressful life events (HIV+: 64%; HIV-: 55%). Among HIV-negative men, the odds of unprotected intercourse increased by 1.15 for each additional event (95%CI 1.06, 1.24). Among HIV-positive men, those who reported the event "problems due to alcohol or drugs" were 1.80 (95%CI 1.27, 2.56) times more likely to report unprotected intercourse. Interventions to assist men to cope with stress may help to prevent population spread of HIV and improve overall health.

Dual pharmaceutical citizenship: Exploring biomedicalization in the daily lives of mixed HIV-serostatus couples in Canada.

Positive Plus One is the first large-scale mixed methods study of mixed HIV serostatus couples in Canada. We aimed to understand how biomedicalization i.e., a social process of commodification and expansion of the jurisdiction of medicine over health, influenced the everyday relationships of these couples. We completed 51 semi-structured interviews among a purposive sample of HIV-positive (n = 27) and HIV-negative (n = 24) partners in current or past mixed-serostatus relationships. Participants were recruited after completing an online survey where they consented to be re-contacted for qualitative interviews. Participants represented a diversity of sexual orientations, gender identities, and other sociodemographic characteristics. Drawing on inductive thematic analysis to identify patterns within couples, across serostatus and sexual orientations, we argue that everyday lives of mixed-serostatus couples were shaped by biomedical knowledge and enacted through routine adherence to obtain and maintain viral load undetectability. Our findings illustrated the importance of learning biomedical knowledge for mixed-serostatus couples in this study, the empowering influence of undetectable = untransmittable (UU) discourse, and its role in rendering HIV mundane through routine ART adherence. We introduce the concept of 'dual pharmaceutical citizenship' to underscore a process by which particular biopolitical and biomedical expectations are fulfilled in mixed-serostatus relationships. These findings have implications for people who do not readily accept or have access to biomedical knowledge, particularly when treatment-as-prevention frames a "right" and "wrong" approach to HIV management. Future studies should focus on couples where at least one partner does not readily accept or have access to biomedical knowledge.

Social capital and HIV-serodiscordance: Disparities in access to personal and professional resources for HIV-positive and HIV-negative partners.

As people living with HIV are living longer lives, they have a correspondingly greater opportunity to enjoy long-term romantic and sexual partnerships, including with persons who do not live with HIV ("serodiscordant" relationships). In these dyads, asymmetries may emerge in access to social resources between partners. In this paper we examined how serodiscordant couples access informal (interpersonal, such as family and friends) and formal (practitioner, such as doctor or social worker) social resources for health. We recruited 540 participants in current serodiscordant relationships, working with 150 AIDS service organizations and HIV clinics across Canada from 2016 to 2018. Our findings demonstrate that partners with HIV have greater access to formal resources than their partners (through health care professionals, therapists/counselors/support workers), while both persons have similar access to resources through informal social relationships (family and friends). Furthermore, the findings indicated that HIV positive partners accessed more varied forms of support through formal ties, compared to HIV negative persons. We offer recommendations for changes to how HIV-negative partners in a serodiscordant relationship are served and cared for, and particularly, the importance of moving toward dyad-focused policies and practices.

Prevalence and predictors of urethral chlamydia and gonorrhea infection in male inmates in an Ontario correctional facility.

OBJECTIVES: To determine the prevalence of urethral chlamydia and gonorrhea in males in a correctional facility in Ontario, Canada, and to explore risk factors for infection. METHODS: Between June and December, 2009, 500 adult males who had been newly admitted at a correctional facility in southern Ontario completed a survey of risk factors and provided a urine sample for testing. Those who tested positive were treated and their names were provided to the local public health unit for follow-up including contact tracing. Prevalence and 95% confidence intervals were calculated for infection with chlamydia and gonorrhea, respectively, and a multivariable model was used to look at risk factors for infection. RESULTS: The study population reported high levels of sexual risk behaviours and drug use. The overall chlamydia prevalence was 2.9% (95% CI 1.6-4.8) and the overall gonorrhea prevalence was 0.6% (95% CI 0.1-1.8). Rates were particularly high for chlamydia in younger males, at 16% (95% CI 4.5-36) in 18-19 year olds and 3.7% (95% CI 1.0-9.3) in 20-24 year olds, and for gonorrhea in males aged 20-24 at 1.9% (95% CI 0.2-6.6). A multivariable logistic regression model revealed that though not statistically significant, younger age was associated with infection. CONCLUSION: The relatively high prevalence of chlamydia and gonorrhea found in this study suggests that primary and secondary prevention programs should be instituted for males in correctional facilities, in particular among younger inmates. Further research is required to ensure internal and external generalizability of these results, as well as to determine the cost-effectiveness of potential interventions.

Love, Judgement and HIV: Congregants' Perspectives on an Intervention for Black Churches to Promote Critical Awareness of HIV Affecting Black Canadians.

We assess participants' experience of Black Pastors Raising Awareness and Insight of Stigma through Engagement (Black PRAISE), an intervention for Black churches to promote critical awareness of HIV affecting Black Canadian communities. We used a community-based participatory approach to implement Black PRAISE among six churches in the Greater Toronto Area and Ottawa, in October-November 2016. For the intervention, congregants received a booklet with validated HIV-related information, attended a sermon on compassion and justice, viewed a short film on HIV-related stigma, and completed baseline and follow-up surveys to evaluate the effectiveness of the intervention. We then conducted in-depth interviews with 18 pastors and congregants from the six churches to explore how they experienced the intervention. Three major themes emerged from an iterative exploration of the thematic content of the interviews: the beneficial impact of the intervention; reconciling the moral and theological issues of their faith with the social reality of HIV and stigma; and perspectives on future stigma reduction efforts. Participants spoke approvingly about Black PRAISE and supported stigma reduction but acknowledged uncertainties about their capacity to actualise their commitment. The main overarching lessons from Black PRAISE are as follows: first, our results support a community-based participatory approach to productively engaging Black congregations in stigma reduction and health promotion; second, promising or successful interventions incorporate multiple components to promote critical awareness about the specific health issue for Black life and wellbeing; and third, interventions are more likely to succeed if they support critical reflection on the underlying conceptual issues, implicit assumptions and belief systems among the professional and lay stakeholders.

Late presentation for human immunodeficiency virus care in the United States and Canada.

BACKGROUND. Initiatives to improve early detection and access to human immunodeficiency virus (HIV) services have increased over time. We assessed the immune status of patients at initial presentation for HIV care from 1997 to 2007 in 13 US and Canadian clinical cohorts. METHODS. We analyzed data from 44,491 HIV-infected patients enrolled in the North American-AIDS Cohort Collaboration on Research and Design. We identified first presentation for HIV care as the time of first CD4(+) T lymphocyte (CD4) count and excluded patients who prior to this date had HIV RNA measurements, evidence of antiretroviral exposure, or a history of AIDS-defining illness. Trends in mean CD4 count (measured as cells/mm(3)) and 95% confidence intervals were determined using linear regression adjusted for age, sex, race/ethnicity, HIV transmission risk, and cohort. RESULTS. Median age at first presentation for HIV care increased over time (range, 40-43 years; P < .01), whereas the percentage of patients with injection drug use HIV transmission risk decreased (from 26% to 14%; P < .01) and heterosexual transmission risk increased (from 16% to 23%; P < .01). Median CD4 count at presentation increased from 256 cells/mm(3) (interquartile range, 96-455 cells/mm(3)) to 317 cells/mm(3) (interquartile range, 135-517 cells/mm(3)) from 1997 to 2007 (P < .01). The percentage of patients with a CD4 count > or = 350 cells/mm(3) at first presentation also increased from 1997 to 2007 (from 38% to 46%; P < .01). The estimated adjusted mean CD4 count increased at a rate of 6 cells/mm(3) per year (95% confidence interval, 5-7 cells/mm(3) per year). CONCLUSION. CD4 count at first presentation for HIV care has increased annually over the past 11 years but has remained <350 cells/mm(3), which suggests the urgent need for earlier HIV diagnosis and treatment.

Trends in multidrug treatment failure and subsequent mortality among antiretroviral therapy-experienced patients with HIV infection in North America.

BACKGROUND: Although combination antiretroviral therapy continues to evolve, with potentially more effective options emerging each year, the ability of therapy to prevent multiple regimen failure and mortality in clinical practice remains poorly defined. METHODS: Sixteen cohorts representing over 60 sites contributed data on all individuals who initiated combination antiretroviral therapy. We identified those individuals who experienced virologic failure (defined as a human immunodeficiency virus [HIV] RNA level >1000 copies/mL), received modified therapy, and subsequently had a second episode of virologic failure. Multivariate Cox regression was used to assess factors associated with time to second regimen failure and the time to death after the onset of second regimen failure. RESULTS: Of the 42,790 individuals who received therapy, 7159 experienced a second virologic failure. The risk of second virologic failure decreased from 1996 (56 cases per 100 person-years) through 2005 (16 cases per 100 person-years; P < .001). The cumulative mortality after onset of second virologic failure was 26% at 5 years and decreased over time. A history of AIDS, a lower CD4(+) T cell count, and a higher plasma HIV RNA level were each independently associated with mortality. Similar trends were observed when analysis was limited to the subset of previously treatment-naive patients CONCLUSIONS: Although the rates of multiple regimen failure have decreased dramatically over the past decade, mortality rates for those who have experienced failure of at least 2 regimens have remained high. Plasma HIV RNA levels, CD4(+) T cell counts at time of treatment failure, and a history of AIDS remain independent risk factors for death, which emphasizes that these factors remain important targets for those in need of more-aggressive therapeutic interventions.

Delayed application of condoms with safer and unsafe sex: factors associated with HIV risk in a community sample of gay and bisexual men.

While condom use remains one of the most effective measures to prevent the sexual transmission of HIV, decreasing attention appears to be given to its importance and techniques of effective use relative to potential biomedical technologies. This paper focuses on delayed condom application (DCA), one practice which has been implicated in HIV transmission among gay and bisexual men. It examines the prevalence of the practice within a gay community and explores factors associated with condom use among those who practice only safer sex and those who report at least some unprotected anal sex. Data were taken from an anonymous, cross-sectional study of a self-identified sample of gay and bisexual men (N=5080). Among 2614 men who responded to relevant questions, multivariate polytomous logistic regressions were used to identify variables associated with DCA. Nearly, half of the men reported delayed condom application for insertive anal intercourse in the previous 12 months. While the majority of this group also reported episodes of unprotected anal sex, more than 25% of those who reported delayed application only reported safer sexual practices. Most socio-demographic variables found to be associated with unsafe sex in other studies were not associated with DCA. Negative condom use experiences such as tearing, splitting and slippage were associated with delayed application among the two groups. DCA, which may be considered by men as an effective harm reduction strategy requires attention. Interventions to address this behavior need to consider the physical issues of condom use along with the complex array of social, structural, psychological, and interpersonal issues.