Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: evidence-based recommendations from an International Association of Physicians in AIDS Care panel.

DESCRIPTION: After HIV diagnosis, timely entry into HIV medical care and retention in that care are essential to the provision of effective antiretroviral therapy (ART). Adherence to ART is among the key determinants of successful HIV treatment outcome and is essential to minimize the emergence of drug resistance. The International Association of Physicians in AIDS Care convened a panel to develop evidence-based recommendations to optimize entry into and retention in care and ART adherence for people with HIV. METHODS: A systematic literature search was conducted to produce an evidence base restricted to randomized, controlled trials and observational studies with comparators that had at least 1 measured biological or behavioral end point. A total of 325 studies met the criteria. Two reviewers independently extracted and coded data from each study using a standardized data extraction form. Panel members drafted recommendations based on the body of evidence for each method or intervention and then graded the overall quality of the body of evidence and the strength for each recommendation. RECOMMENDATIONS: Recommendations are provided for monitoring entry into and retention in care, interventions to improve entry and retention, and monitoring of and interventions to improve ART adherence. Recommendations cover ART strategies, adherence tools, education and counseling, and health system and service delivery interventions. In addition, they cover specific issues pertaining to pregnant women, incarcerated individuals, homeless and marginally housed individuals, and children and adolescents, as well as substance use and mental health disorders. Recommendations for future research in all areas are also provided.

Advancing novel HIV prevention intervention research with MSM--meeting report.

HIV continues to exact an enormous toll on society and to disproportionately affect gay and bisexual men and other men who have sex with men (MSM). Innovative prevention interventions are needed to reverse this trend. In August 2009, the U.S. National Institute of Mental Health and the Centers for Disease Control and Prevention convened a meeting of scientists, community representatives, advocates, and federal partners to discuss innovative prevention-intervention science. The meeting was structured to maximize discussion of (1) healthy sex interventions, (2) community and structural interventions, (3) integrated biomedical and behavioral interventions, and (4) interventions to improve uptake of HIV testing. Presentations and discussion focused on research gaps in designing risk-reducing and sexual health-promoting interventions for MSM, including interventions to address mental health, substance use, disclosure, and stigma. This article summarizes the meeting proceedings, highlights key points, and outlines future directions.

Mental health considerations in secondary HIV prevention.

Despite substantial attention in the past decade to the co-morbidity of mental health problems among people living with HIV/AIDS (PLWHA), these problems remain a significant barrier to maintaining health and secondary prevention. To address these issues, program staff from the Center for Mental Health Research on AIDS at the NIMH convened a meeting on 19th and 20th July 2007 to discuss the intersection of mental health and HIV. The conveners brought together leaders in the fields of mental illness and HIV to discuss current gaps in the research related to the prevention, diagnosis, and treatment of mental disorders among PLWHA, and how attention to mental health can affect a variety of health outcomes. Attendees were asked to discuss key questions that, if addressed through empirical investigation, could move the field toward the aim of reducing or alleviating the burden of mental illness for those living with HIV disease. The purpose of this brief report is to summarize this meeting's proceedings, overview key points of discussion, and outline areas that may be useful to consider for clinical researchers in the field.

Adherence to biomedical HIV prevention methods: considerations drawn from HIV treatment adherence research.

Biomedical approaches to HIV prevention (eg, microbicides, antiretroviral preexposure prophylaxis) are undergoing clinical trials to test their efficacy. One key consideration emerging from completed trials is the critical role of adherence to the investigational product. Suboptimal product adherence may compromise clinical trial results and ultimately undermine the effectiveness of biomedical prevention methods in any future real-world use. Efforts to strengthen biomedical HIV prevention product adherence can benefit from existing research methodologies, findings, and interventions developed for adherence to HIV treatment. Research on treatment adherence is most relevant to medication-based biomedical prevention strategies, such as antiretroviral preexposure prophylaxis and acyclovir for herpes simplex virus-2. Three areas where HIV treatment adherence literature can inform research on such biomedical prevention strategies are 1) specialized methods for assessing medication adherence, 2) research findings emphasizing social context as an adherence determinant, and 3) promising behavioral interventions to improve adherence.

Prevention interventions with persons living with HIV/AIDS: state of the science and future directions.

The National Institutes of Health (NIH/NIMH), the Centers for Disease Control and Prevention (CDC), and the HIV/AIDS Bureau of the Health Resources and Services Administration (HRSA) support the CDC's Serostatus Approach to Fighting the HIV Epidemic (SAFE; Janssen et al., 2001). One aim of the strategy is to help individuals living with HIV (and their partners) adopt and sustain HIV and STD risk reduction, treatment adherence, and effective strategies for coping with HIV/AIDS. Efficacious interventions are needed by community organizations and clinics that provide evidence-based services. To expedite translation from research to practice, we convened scientist-practitioners, HIV treatment and prevention providers, and community/consumer members. In this article, we include an overview of prevention trials with HIV-positive persons presented at the meeting, discuss strengths and limitations, recommendations for future research, and discuss sponsoring agencies' plans for advancing prevention tailored for persons living with HIV.

Addressing the challenges of the HIV continuum of care in high-prevalence cities in the United States.

In summary, addressing the challenges of the HIV care continuum is critical so that the goals of the NHAS can be achieved. CDC is working closely with federal partners, public health departments, and communities throughout the United States on multiple surveillance, programmatic, and research initiatives to inform and improve outcomes along the HIV care continuum. Currently, a large number of research projects are being conducted to describe the care continuum in various populations, assess and model the impact of interventions, and monitor the quality of care. To contribute to this knowledge base, NIH is working with its academic partners to support research that will inform the optimization of HIV treatment and prevention programs. As part of this focus, the CFAR/APC HIV Continuum of Care Working Group was formed to encourage communication between academic investigators and their local DOHs and to support joint research initiatives that are both timely and relevant to their own cities and environments. Finally, the results presented in this supplement may have implications for jurisdictions beyond those in which the studies were conducted.

Reducing HIV-risk behavior among adults receiving outpatient psychiatric treatment: results from a randomized controlled trial.

This study investigated the efficacy of a 10-session, HIV-risk-reduction intervention with 221 women and 187 men receiving outpatient psychiatric care for a mental illness. Patients were randomly assigned to the HIV intervention, a structurally equivalent substance use reduction (SUR) intervention, or standard care; they were assessed pre- and postintervention and at 3- and 6-month follow-ups. Patients receiving the HIV-risk-reduction intervention reported less unprotected sex, fewer casual sex partners, fewer new sexually transmitted infections, more safer sex communications, improved HIV knowledge, more positive condom attitudes, stronger condom use intentions, and improved behavioral skills relative to patients in the SUR and control conditions. Patients receiving the SUR intervention reported fewer total and casual sex partners compared with control patients. Exploratory analyses suggested that female patients and patients diagnosed with a major depressive disorder were more likely to benefit from the HIV-risk-reduction intervention.

Low-Income Women and HIV Risk Reduction: Elaborations from Qualitative Research.

Focus groups were conducted with 45 young, single, low-income women regarding the human immunodeficiency virus (HIV). Risk in this sample was substantial as 53% had multiple sexual partners, and 55% reported a recent sexually transmitted disease. Qualitative analysis of transcribed focus groups identified six themes that emerged across groups: (a) misinformation about vertical transmission and treatment of HIV-related illnesses; (b) risk perception linked to emotive factors rather than objective data; (c) uncertainty regarding the risk-reducing value of monogamy; (d) fatalism linked with ambivalence about HIV-antibody testing and treatment; (e) recognition of the importance of discussing HIV-related topics with children, but concern that such discussion with other women might be inappropriate; and (f) inconsistent communication regarding HIV-transmission and prevention with partners, partly the result of concerns about violating trust in intimate relationships. These themes warrant attention in the development of HIV risk-reduction programs.

The effects of alcohol and expectancies on risk perception and behavioral skills relevant to safer sex among heterosexual young adult women.

OBJECTIVE: This study was undertaken to test the hypotheses that acute alcohol intoxication and alcohol-rated sex expectancies are negatively related to both risk perception (a motivational factor) and ability to negotiate safer sex (a behavioral skills factor) with a partner. Motivation and behavioral skills are determinants of safer sex according to the Information-Motivation-Behavioral Skills (IMB) model. METHOD: A total of 102 heterosexual females ages 21-30 years participated in two sessions. The first session involved the administration of various measures to confirm eligibility status, and random assignment to one of three beverage conditions: "water control:" "alcohol" (0.65 g alcohol/kg body weight) or "placebo:" The second session involved administration of the beverage and then completion of a risk perception measure and an audiovisual role-play measure of behavioral skills. RESULTS: Regression analyses showed that alcohol expectancies and the perception of intoxication contributed independent variance to both risk perception and behavioral skills. Actual alcohol intoxication had little influence on these dependent variables. CONCLUSIONS: Alcohol expectancies and related factors can be related to variables that theoretically precede the occurrence of risky sex. Research is needed on the processes through which expectancies might be related to the occurrence of safer sex, as well as on person and situation variables that moderate the effects of alcohol and alcohol expectancies on safer sex.

Effects of alcohol and expectancies on HIV-related risk perception and behavioral skills in heterosexual women.

This experiment tested the effects of alcohol and expectancies on determinants of safer sex according to the information-motivation-behavioral skills model. Sixty heterosexual women attended 2 sessions. During Session 1, participants completed a set of descriptive measures; during Session 2 they were randomly assigned to 1 of 4 beverage conditions: control, alcohol-low (.35 gm alcohol/kg body weight), alcohol-moderate (.70 gm alcohol/kg body weight), or placebo. After beverage consumption, all participants completed measures of motivation to engage in risky sex and condom use negotiation skills. Results showed that the higher dose of alcohol and stronger alcohol expectancies were associated with greater motivation to engage in risky sexual behavior. However, perceived intoxication, rather than actual alcohol consumption or expectancies, was the best predictor of condom use negotiation skills. Integration of the findings with past research and their implication for the design of HIV-prevention programs are discussed.

Use of Legal Drugs by Psychiatric Outpatients: Benefits, Costs, and Change.

Caffeine, nicotine, and alcohol use by persons with a severe mental illness occurs frequently but is poorly understood. We used qualitative methods to elicit information regarding the functional relationships between legal substance use and its antecedents and consequences. This report summarizes responses provided by 37 psychiatric outpatients who participated in focus groups and key informant interviews regarding the use and functions of alcohol, caffeine, and nicotine. We describe major themes regarding positive and negative consequences, triggers for use, change efforts, and offer observations regarding substance use in this under-served population.

Toward an endgame: finding and engaging people unaware of their HIV-1 infection in treatment and prevention.

Epidemic modeling suggests that a major scale-up in HIV treatment could have a dramatic impact on HIV incidence. This has led both researchers and policymakers to set a goal of an "AIDS-Free Generation." One of the greatest obstacles to achieving this objective is the number of people with undiagnosed HIV infection. Despite recent innovations, new research strategies are needed to identify, engage, and successfully treat people who are unaware of their infection.

NIH support of Centers for AIDS Research and Department of Health Collaborative Public Health Research: advancing CDC's Enhanced Comprehensive HIV Prevention Planning project.

The contributions reported in this supplemental issue highlight the relevance of NIH-funded CEWG research to health department­supported HIV prevention and care activities in the 9 US cities with the highest numbers of AIDS cases. The project findings have the potential to enhance ongoing HIV treatment and care services and to advance the wider scientific agenda. The HIV testing to care continuum, while providing a framework to help track progress on national goals, also can reflect the heterogeneities of local epidemics. The collaborative research that is highlighted in this issue not only reflects a locally driven research agenda but also demonstrates research methods, data collection tools, and collaborative processes that could be encouraged across jurisdictions. Projects such as these, capitalizing on the integrated efforts of NIH, CDC, DOH, and academic institutions, have the potential to contribute to improvements in the HIV care continuum in these communities, bringing us closer to realizing the HIV prevention and treatment goals of the NHAS.

Raman spectroscopy using a spatial heterodyne spectrometer: proof of concept.

The use of a spatial heterodyne interferometer-based spectrometer (SHS) for Raman spectroscopy is described. The motivation for this work is to develop a small, rugged, high-resolution ultraviolet (UV) Raman spectrometer that is compatible with pulsed laser sources and that is suitable for planetary space missions. UV Raman is a particular technical challenge for space applications because dispersive (grating) approaches require large spectrographs and very narrow slits to achieve the spectral resolution required to maximize the potential of Raman spectroscopy. The heterodyne approach of the SHS has only a weak coupling of resolution and throughput, so a high-resolution UV SHS can both be small and employ a wide slit to maximize throughput. The SHS measures all optical path differences in its interferogram simultaneously with a detector array, so the technique is compatible with gated detection using pulsed lasers, important to reject ambient background and mitigate fluorescence (already low in the UV) that might be encountered on a planetary surface where samples are uncontrolled. The SHS has no moving parts, and as the spectrum is heterodyned around the laser wavelength, it is particularly suitable for Raman measurements. In this preliminary report we demonstrate the ability to measure visible wavelength Raman spectra of liquid and solid materials using an SHS Raman spectrometer and a visible laser. Spectral resolution and bandpass are also discussed. Separation of anti-Stokes and Stokes Raman bands is demonstrated using two different approaches. Finally spectral bandpass doubling is demonstrated by forming an interference pattern in both directions on the ICCD detector followed by analysis using a two-dimensional Fourier transform.

Commentary on meta-analysis of randomized controlled trials for HIV treatment adherence interventions. Research directions and implications for practice.

This meta-analysis of randomized controlled trials (RCTs) of interventions for adherence to antiretroviral therapy for HIV indicates that participants who received an adherence intervention were 1.5 times as likely to report 95% adherence and 1.25 times as likely to achieve an undetectable viral load than participants in comparison conditions. The magnitude of the aggregated intervention effect is an encouraging message for HIV treatment providers, but more work is needed. For the next generation of international adherence research, there are multiple challenges that require the collaboration of providers, patients, government funders, donor agencies, and policy-makers. This commentary examines the strengths and limitations of the evidence base, identifies critical research directions, and calls for the development of a formal process to guide the rapid implementation of efficacious adherence interventions into community and clinical practice.

The relationship between alcohol and individual differences variables on attitudes and behavioral skills relevant to sexual health among heterosexual young adult men.

The purpose of this experiment was to investigate the effects of alcohol, alcohol sex expectancies, and sexual sensation seeking on determinants of sexual health behavior according to the Information-Motivation-Behavioral Skills (IMB) model. The participants were 48 heterosexual young adult males who attended 2 laboratory sessions. During Session 1, participants completed a set of screening and individual differences measures, and during Session 2 they were randomly assigned to 1 of 3 beverage conditions: control, alcohol (0.65 g alcohol/kg body weight), or placebo. Following the experimental manipulation, all participants completed measures regarding attitudes toward condom use, intention to engage in risky sex, and condom use negotiation skills. The results showed that participants who consumed alcohol had poorer negotiation skills and greater intention to engage in risky sex compared to participants who did not drink alcohol. Although alcohol did not affect any dimension of attitude regarding condom use, attitude about condoms' effects on sex, as well as sexual sensation seeking, were correlated with both intention ratings and skills. Multiple regression models, including both attitudes and sensation seeking, showed that attitudes accounted for 20-25% of variance independent of beverage condition in predicting intention ratings and skills. The findings were consistent with past research showing that alcohol consumption can have detrimental effects on determinants of sexual health behavior and that individual differences factors can enhance the power of models like the IMB to predict such behavior.

HIV Risk Behavior among Outpatients at a State Psychiatric Hospital: Prevalence and Risk Modeling.

The purpose of this archival study was to determine the prevalence and correlates of HIV-related risk behavior among adults with a severe and persistent mental illness (SPMI). Hospital records at a public psychiatric hospital were reviewed to obtain data on demographic and psychiatric characteristics, sexual behavior, and substance use. Data were available from 889 (73%) of 1214 eligible outpatients. Of these 889 patients, 49% were sexually active, 52% used alcohol, and 18% used street drugs during the past year. Eleven percent were at high risk for HIV infection: 7% reported having 3 or more sexual partners, 3% had been infected with an STD, 3% had traded sex, and fewer than 1% had shared injection equipment. HIV-risk status was modeled with logistic regression using diagnosis, type of residence, drug and alcohol use, and demographic variables; five- and six-predictor models were derived for two HIV-risk indicators. A bootstrap simulation supported the reliability of each model. We conclude that approximately one-half of adults living with a SPMI are sexually active, and a minority engages in behaviors that increase risk of HIV infection. Routine screening for HIV risk in psychiatric settings can identify patients who may benefit from risk reduction programs.

HIV risk behavior among psychiatric outpatients: association with psychiatric disorder, substance use disorder, and gender.

People living with a mental illness are disproportionately vulnerable to human immunodeficiency virus. The current study sought to examine the influence of psychiatric disorder, substance use disorder, and gender on risky sexual behavior in this vulnerable population. Participants were 228 female and 202 male outpatients (66% mood disorder, 34% schizophrenia), each of whom took part in a Structured Clinical Interview for the DSM-IV and a comprehensive assessment of sexual risk behavior. Univariate and multivariate analyses tested a priori hypotheses. The results indicated that risk behavior was more frequent among patients diagnosed with a mood disorder (compared with those diagnosed with schizophrenia) or a substance use disorder (compared with those without a comorbid disorder) or both. We recommend routine human immunodeficiency virus risk screening and risk reduction programs for this vulnerable population.