An Innovative Adaptation of an HIV Status-Neutral, Community-Informed, Socioemotional Asset-Building Intervention With the House Ball Community.

Black men who have sex with men (MSM) have the highest incidence of new HIV diagnoses compared to other populations and face multiple stigmas. Some have found refuge in the House Ball Community (HBC)-a national network of Black lesbian, gay, bisexual, and transgender (LGBT) kinship commitments (families) that affirm gender expression(s) and sexualities and provide skills-building for its members. Internal and external socioemotional assets influence the health of young Black sexual and gender minorities; building these assets in the HBC is critical to facilitating engagement in health-promoting behaviors. To address this critical gap in HIV prevention, we describe an adaptation of 3MV, a best-evidence, group-level retreat-based risk reduction intervention developed for HIV-negative Black MSM. Clinicians, researchers, HBC members/leaders, and community experts collaborated to adapt 3MV for the HBC. Our Family, Our Voices (OFOV) is an HIV status-neutral, risk-reduction intervention that focuses on asset-building for young, gender-diverse Black HBC members, with the HBC family unit as the focus of the intervention. We describe the collaborative adaptation process and the development of HBC-relevant intervention topics. This novel adaptation and collaborative community model provides a framework for researchers and clinicians to follow when adapting evidence-based interventions for priority populations.

Young Transgender Women of Color: Homelessness, Poverty, Childhood Sexual Abuse and Implications for HIV Care.

This study describes a sample of HIV+ young transgender women of color aged 18-24 and their experience with homelessness as part of a demonstration project of engagement and retention in HIV medical care funded by Health Resources and Services Administration. The study engaged transgender women of color in HIV care in nine sites across the US between 2012 and 2017. This analysis describes and compares transwomen who had been homeless in the last 6 months to those not homeless. We hypothesized that homelessness would compete with HIV care, food, shelter, and be associated with poverty. Variable domains included sociodemographic, mental health and substance use, HIV care, sexual risk behavior, social support from transgender and other friends, and childhood sexual abuse. There were 102 youth enrolled, 77 (75.5%) who had been homeless, and 25 (24.5%) who had not been homeless. Bivariate analyses showed that low income, sex work as source of income, inability to afford food, lack of viral load (VL) suppression, childhood sexual abuse, lower levels of social support, and higher levels of depression were associated with homelessness. A logistic regression model showed that being unable to afford food (AOR = 9.24, 95% CI 2.13-40.16), lack of VL suppression in last 6 months (AOR = 0.10, 95% CI .02-.57), and lack of transgender friend support (AOR = 0.09, 95% CI .02-.53) was associated with homelessness. Programs that place basic needs first-food and shelter-may be able to engage and assist young transgender women of color with HIV to survive and live healthier lives.

ED chest radiography for children with asthma exacerbation is infrequently associated with change of management.

BACKGROUND: Acute asthma exacerbations (AAE) account for many Pediatric Emergency Department (PED) visits. Chest radiography (CXR) is often performed in these patients to identify practice-changing findings such as pneumonia (PNA). Limited knowledge exists to balance the cost and radiation dose of CXR with expected yield of clinically meaningful information. OBJECTIVE: To determine in children with AAE with CXR, whether patient characteristics are associated with radiographic PNA; and significant practice change by initiation of antibiotic. DESIGN/METHODS: Retrospective chart review of AAE patients with CXR performed in a PED in 2014. We examined univariate associations between patient characteristics and PNA on CXR and administration of antibiotic. Multiple logistic regression models then subsequently examined adjusted associations between patient characteristics and both outcomes. RESULTS: Of 288 patients, 43 (15%) had PNA on CXR and 51 (17.8%) received antibiotics. There were no statistically significant univariate associations between either outcome and age, race, gender, insurance status, mode of PED arrival, fever or hypoxia (all p>0.11). Crackles were associated with antibiotic administration (p=0.03), but not PNA on CXR (p=0.07). Only previous antibiotic use within 7days had both significant univariate associations (p=0.002) and adjusted associations with both PNA on CXR (aOR 3.6) and antibiotic administration (aOR 3.3). CONCLUSION: CXR infrequently adds valuable information in children with AAE. Patients treated with antibiotic within 7days are more likely to have PNA identified on CXR and receive antibiotics. A larger study is needed to examine potential significance of hypoxia and crackles.

The Transgender Women of Color Initiative: Implementing and Evaluating Innovative Interventions to Enhance Engagement and Retention in HIV Care.

To improve health outcomes among transgender women of color living with HIV, the Health Resources and Services Administration's Special Programs of National Significance program funded the Enhancing Engagement and Retention in Quality HIV Care for Transgender Women of Color Initiative in 2012. Nine demonstration projects in four US urban areas implemented innovative, theory-based interventions specifically targeting transgender women of color in their jurisdictions. An evaluation and technical assistance center was funded to evaluate the outcomes of the access to care interventions, and these findings will yield best practices and lessons learned to improve the care and treatment of transgender women of color living with HIV infection.

A multicenter study of initiation of antiretroviral therapy and transmitted drug resistance in antiretroviral-naive adolescents and young adults with HIV in New York City.

BACKGROUND: In December 2009, the Department of Health and Human Services guidelines for initiation of antiretroviral therapy (ART) changed to include patients with CD4 counts between 350 and 500 cells/µL. The aims of this study were to assess uptake of this recommendation in ART-naive youth with human immunodeficiency virus (HIV) and to describe the epidemiology of transmitted genotypic drug resistance mutations (DRMs) in this population. METHODS: A multicenter, retrospective cohort study of ART initiation in ART-naive youth was performed. Eligible subjects were 13-25 years of age, were diagnosed with HIV within 1 year of presentation to care at the study sites, and presented to care from January 2007 to June 2011. RESULTS: Of 685 potential subjects identified, 331 (49%) fulfilled inclusion criteria. Mean CD4 count at presentation to care was 452 cells/µL. Overall, 191 (58%) subjects started ART. The mean CD4 count at ART initiation was 261 cells/µL before and 363 cells/µL after the 2009 guideline change (P < .0001). Of 212 (64%) subjects with resistance testing available prior to ART initiation, 38 (18%) subjects had a major DRM and an increased proportion of resistance was seen in later study years. CONCLUSIONS: Our study demonstrated an uptake in recently changed guideline recommendations to treat HIV-infected individuals at higher CD4 counts and reinforces the importance of performing resistance testing at entry into care, as 18% of our population had major DRMs prior to initiation of ART.

Leveraging family-based assets for Black men who have sex with men in House Ball Communities: Protocol for a cluster randomized controlled trial.

Black men who have sex with men (MSM) continue to have the highest incidence of new human immunodeficiency virus (HIV) diagnoses in the United States but are least likely to be engaged in care or to be virally suppressed. Many Black MSM face multiple stigmas, but some have found refuge in the House Ball Community (HBC)-a national network of Black lesbian, gay, bisexual, and transgender kinship commitments that provide care-giving, affirmation, and survival skills-building for its members. We propose to modify a skills-building and HIV prevention best-evidence, group-level intervention for HIV- negative Black MSM (Many Men Many Voices) into a family-based intervention to focus on asset-building for both HIV-negative and HIV-positive Black MSM within HBC families. The adapted intervention will be re-branded as Our Family Our Voices (OFOV). We proposed a mixed-methods study to test the feasibility and preliminary efficacy of OFOV adapted for HIV status-neutral use with HBC families. First, we will develop the intervention protocol using the ADAPT-ITT model for modifying behavioral interventions. Then, we will conduct a cluster randomized controlled trial with six HBC families in New York City. Families will be randomized to the OFOV intervention or waitlist control arm. Primary outcomes will be HIV testing, HIV pre-exposure prophylaxis use, currently in HIV care and on HIV treatment. Secondary outcomes will be the number of family-based assets, resilience, number of sexual partners, and relative frequency of condomless anal intercourse. The results of the formative research, including the pilot trial, will contribute to the evidence-base regarding the development of HIV status-neutral interventions that respond to the diversity and complexities of HBC families and that recognize the importance of asset-building for facilitating HBC resilience to stigma as a part of the United States' domestic policy objective of ending the HIV epidemic by 2030.

Prevention of perinatal transmission of zidovudine- and nevirapine-resistant HIV.

PURPOSE: The use of a three-drug regimen for the prevention of perinatal transmission of zidovudine- and nevirapine-resistant HIV is described. SUMMARY: A 17-year-old Hispanic woman infected with HIV arrived at our clinic for the management of her first pregnancy. The patient was in her second trimester of her pregnancy, had not previously been treated with antiretroviral therapy, and was only taking daily prenatal vitamins at the time of her first clinic visit. Her HIV RNA viral load was 240 copies/mL, and the virus was resistant to both zidovudine and nevirapine. Nelfinavir (compounded suspension), lamivudine, and zidovudine were prescribed for the mother, though she was generally nonadherent to therapy. Nelfinavir, lamivudine, and zidovudine were initiated for the newborn within eight hours of delivery. Six months later, the patient returned to the clinic in the first trimester of her second pregnancy. At this visit, her HIV RNA viral load was 120 copies/mL. After the birth of her second child, the infant received the same regimen received by her firstborn: zidovudine 4 mg/kg orally twice daily for six weeks, lamivudine 2 mg/kg orally twice daily for two weeks, and nelfinavir 55 mg/kg orally twice daily for two weeks. At four months of age, each infant was found to be HIV-negative. CONCLUSION: A prophylactic regimen that included nelfinavir, lamivudine, and zidovudine was used to prevent perinatal transmission of HIV in two neonates. The regimen was well tolerated, and both infants were determined to be HIV-negative at four months of age.

Baseline social characteristics and barriers to care from a special projects of national significance women of color with HIV study: a comparison of urban and rural women and barriers to HIV care.

We describe the baseline sociodemographic characteristics of the Health Resources and Services Administration's Special Programs of National Significance Women of Color (WOC) Initiative. Between November 2010 and July 2013, 921 WOC were prospectively enrolled in HIV medical care at nine sites, six urban (N = 641) and three rural sites (N = 280) across the US. We describe the study sample, drawing comparisons between urban and rural sites on sociodemographics, barriers to HIV care, HIV care status at study entry, substance use and sexual risk factors, and the relationship among these variables. Urban sites' participants differed from rural sites on all sociodemographic variables except age (median = 42.3). Women at urban sites were more likely to be Hispanic, less educated, single, living alone, unstably housed, unemployed, and to have reported lower income. More urban women were transferring care to HIV care or had been lost to care. Urban women reported more barriers to care, many relating to stigma or fatalism about HIV care. Urban women reported more substance use and sexual risk behaviors. A better understanding of how HIV care is embedded in communities or fragmented across many sites in urban areas may help understand barriers to long-term engagement in HIV care encountered by WOC.

Gender Power Inequality and Continued Sexual Risk Behavior among Racial/Ethnic Minority Adolescent and Young Adult Women Living with HIV.

Adolescent and young adult minority women account for approximately 20% of new cases of HIV in this age group each year in the United States. It is vital to understand factors that influence sexual risk behavior in this population in order to prevent secondary transmission of HIV. As part of a larger qualitative study of youths living with HIV, in- depth interviews were conducted with 26 Black and Latina young women aged 16 to 24 years, infected with HIV through heterosexual transmission. The study explored factors related to continued unprotected sex with male partners. Since learning of their HIV infection, 23% reported multiple episodes of unprotected vaginal and/or anal sex, 27% reported condom use for some but not all of the time, 42% reported condom use all of the time and 7% were not sexually active. Among the highest risk participants partner refusal to use a condom, having the same HIV sero-status as partner, negative attitudes toward condoms, beliefs about HIV transmission, and fear of disclosure to new partners were associated with risky sex. The data suggests that more research is needed to develop more intensive interventions that address the role of gender power inequity for this sub-set of young women living with HIV.

Continued Sexual Risk Behaviour in African American and Latino Male-to-Female Transgender Adolescents Living with Hiv/Aids: A Case Study.

PURPOSE: This study examined the social and contextual factors associated with continued high risk sexual behaviors among male-to-female transgender (MTFTG) adolescents living with HIV/AIDS. The study is part of a larger qualitative study of 59 racial/ethnic minority adolescents living with HIV/AIDS. METHODS: In-depth focused interviews were conducted with five MTFTG adolescents (16-24 years) living with HIV. Content analysis was conducted to identify themes related to continued sexual risk behaviors. RESULTS: Four out of five of MTFTG adolescents reported inconsistent condom use since their HIV diagnosis. Transgender stigma contributed to financial vulnerability leading to the adoption of sex work to support themselves. Sex and drugs were used to manage transgender stigma and sexual risk-taking with sex work partners was influenced by financial vulnerability. CONCLUSIONS: MTFTG adolescents with HIV have unique psychosocial needs related to transgender stigma and structural needs to decrease financial vulnerability that contribute to risky sexual behavior.

The influence of substance use, social sexual environment, psychosocial factors, and partner characteristics on high-risk sexual behavior among young Black and Latino men who have sex with men living with HIV: A qualitative study.

Understanding the sexual risk behaviors of youths living with HIV/AIDS is critical to secondary prevention of HIV. As part of a larger qualitative study of youths living with HIV, in-depth interviews were conducted with 27 African American and Latino, HIV-infected young men who have sex with men, aged 16-24 years, living in New York City. The study explored the role of substance use, the social-sexual-environmental, and psychological contexts in which sexual risk behaviors occurred. Since learning of their HIV infection, the majority of participants had reduced their risky sexual behaviors; however, a subset (26%) of participants continued to have unprotected sex, in most cases with multiple partners. Substance use, the social environmental context of the sexual encounter, the psychological impact of HIV on sexual behavior, and partner characteristics were associated with high-risk sexual behaviors in this group. Among high-risk participants, factors associated with risky sexual behaviors clustered, with 57% reporting two or more factors. More intensive interventions are needed for this subset of youths living with HIV, including assessment and treatment for substance use and mental health issues, strategies for stress reduction, and partner interventions.

Physical and sexual abuse and unstable housing among adolescents with HIV.

Stable housing is a necessary component of treatment of adolescents with HIV. This study examines the housing status at two points in time of a sample of 224 adolescents with HIV seen at an adolescent medicine clinic in New York City. It addresses whether unstable housing is associated with several forms of abuse, and what factors predict continued instability. 38.6% (n = 86) had a prior history of unstable housing, reduced to 12.9% at the time of program entry. Multivariate logistic regression models predicting current and prior unstable housing revealed two variables related to both outcomes: physical abuse and referral from youth/social services entities. Continued unstable housing was associated with all abuse variables and adolescent history of arrest. When adolescents in abusive situations come to the attention of programs for youth, they have a positive impact on transitioning most adolescents to safer households, potentially improving adolescents' accessing of health care services.