Measuring ART Adherence Among Young Adults with Perinatally Acquired HIV: Comparison Between Self-report, Telephone-Based Pill Count, and Objective Pharmacologic Measures.

Tenofovir diphosphate (TVF-DP) can be quantified in red blood cells (RBCs) and dried blood spots (DBS) and can objectively measure ART adherence and predict viral suppression. Data on the association of TFV-DP with viral load are very limited in adolescents and young adults (AYA) living with perinatally-acquired HIV (PHIV), as are data comparing TFV-DP to other measures of ART adherence, such as self-report and unannounced telephone pill count. Viral load and ART adherence (self-report, TFV-DP and unannounced telephone pill count) were assessed and compared among 61 AYAPHIV recruited from an ongoing longitudinal study (CASAH) in New York City.

Women's Perceptions of HIV- and Sexuality-Related Stigma in Relation to PrEP: Qualitative Findings from the Masibambane Study, Durban, South Africa.

Daily oral pre-exposure prophylaxis (PrEP) offers effective HIV prevention. In South Africa, PrEP is publicly available, but use among young women remains low. We explored young women's perceptions of PrEP to inform a gender-focused intervention to promote PrEP uptake. Six focus group discussions and eight in-depth interviews exploring perceptions of PrEP were conducted with forty-six women not using PrEP, ages 18-25, from central Durban. Data were thematically analyzed using a team-based consensus approach. The study was conducted among likely PrEP users: women were highly-educated, with 84.8% enrolled in post-secondary education. Qualitative data revealed intersecting social stigmas related to HIV and women's sexuality. Women feared that daily PrEP pills would be confused with anti-retroviral treatment, creating vulnerability to misplaced HIV stigma. Women also anticipated that taking PrEP could expose them to assumptions of promiscuity from the community. To address these anticipated community-level reactions, women suggested community-facing interventions to reduce the burden on young women considering PrEP. Concerns around PrEP use in this group of urban, educated women reflects layered stigmas that may inhibit future PrEP use. Stigma-reducing strategies, such as media campaigns and educational interventions directed at communities who could benefit from PrEP, should re-frame PrEP as an empowering and responsible choice for young women.

Construct Validity Supports Use of a Novel, Tablet-Based Neurocognitive Assessment for Adolescents and Young Adults Affected by Perinatal HIV from Vulnerable Communities in the United States.

Construct validity of novel tablet-based neurocognitive tests (in the NeuroScreen app) measuring processing speed, working memory, and executive functioning in adolescents and young adults (AYA) living with perinatally-acquired HIV (PHIV) and perinatal HIV-exposure without infection (PHEU) was examined. Sixty-two AYA (33 PHIV, 29 PHEU) were recruited from an ongoing longitudinal study (CASAH) in New York City. Medium to large and statistically significant correlations were found between NeuroScreen and gold standard, paper-and-pencil tests of processing speed, working memory, and executive functioning. Results provide partial support for NeuroScreen as an alternative to cumbersome paper-and-pencil tests for assessing neurocognition among HIV-affected AYA.

Longitudinal trajectories of neurocognitive test performance among individuals with perinatal HIV-infection and -exposure: adolescence through young adulthood.

There are an estimated 2.1 million youth less than 15 years of age living with HIV globally (the majority perinatally HIV-infected [PHIV]) and millions more perinatally HIV-exposed uninfected (PHEU) youth who are expected to survive through adolescence and into adulthood. Transitioning from adolescence to young adulthood requires adaptation to more demanding social interactions, academic pressures, and individual responsibilities which place distinct demands on neurocognitive functions. This study examined longitudinal trajectories of neurocognitive test performance in the domains of processing speed (PS), working memory (WM), and executive functioning (EF) among PHIV and demographically similar PHEU from adolescence through young adulthood. Data for this paper come from four time points, spanning approximately 10 years, within the Child and Adolescent Self-Awareness and Health Study (CASAH). Youth age ranged from 15 to 29 years. Longitudinal linear mixed effect models were computed for each test. Few differences in performance were found on tests of EF and WM between PHIV and PHEU youth as they aged, though PHEU youth showed significantly better PS as they aged than PHIV youth. Future research is needed to understand these vulnerable youth's neurocognitive trajectories as a function of HIV infection and -exposure, biological functions and psychosocial stressors.

Patterns of a Rectal Microbicide Placebo Gel Use in a Preparatory Stage for a Phase I Trial Among Young Men Who Have Sex with Men.

We examined young gay, bisexual, and other men who have sex with men's (YGBMSM) usage patterns of a pre-coital, applicator-administered rectal placebo gel. An ethnically diverse sample of 94 YGBMSM (aged 18-30 years) were asked to insert hydroxyethylcellulose placebo gel rectally before receptive anal intercourse (RAI) and report their gel use through an interactive voice response system (IVRS) across 12 weeks. We used trajectory analyses to characterize participants' use of the rectal gel over the 12 weeks, and examine whether these trajectories varied based on participants' sociodemographic characteristics, sexual behaviors, application and insertion behaviors, and experiences using the placebo gel. A cubic model was the best fit for these longitudinal data, with two distinct trajectories of gel use observed. The first trajectory ('High with Varying Gel Use per Week') represented YGBMSM (N = 38; 40.3%) who reported using the rectal gel on several occasions per week. The second trajectory ('Low and Consistent Gel Use per Week') represented participants (N = 56; 59.7%) who reported a consistent average use of one gel per week. Participants in the High with Varying Gel Use Trajectory reported trying out a greater number of positions when inserting the gel across the 12-weeks than peers in the Low and Consistent Gel Use Trajectory. YGBMSM reporting more RAI occasions during the trial were more likely be present in the High with Varying Gel Use Trajectory than peers in the Low and Consistent Gel Use Trajectory. Future research examining how to facilitate gel application and adherence among YGBMSM is merited.

Correlates of Sexual Risk among Recent Gay and Bisexual Immigrants from Western and Eastern Africa to the USA.

We examined correlates of sexual risk among gay and bisexual men, who recently migrated from western and eastern African countries to the USA and lived in New York City and who are HIV negative or of unknown status. These men migrate from countries where same-sex sexuality is socially rejected and mostly illegal contributing to the motivation to migrate. Their background might predispose these men to engagement in sexual risk practices, while they are not specifically addressed in HIV prevention programming. Participants (N = 62) reported in face-to-face interviews on pre- and postmigration experiences, psychosocial determinants of sexual risk, and current sexual practices. Operationalization of sexual risk was based on the number of men with whom they had condomless receptive and/or insertive anal sex. Over a third of the men reported always having used condoms in the past year; among the other men, sexual risk varied. Multivariate analyses showed that sexual risk was lower among men with a stronger motivation to avoid HIV infection and higher among men who currently engaged in transactional sex. Further analyses indicated that housing instability was independently associated with reduced motivation to avoid HIV infection and with engagement in transactional sex in the USA. In recent western and eastern African gay and bisexual immigrants to the USA, structural factors, including housing instability, are strongly associated with sexual risk.

Changes in Substance Use Symptoms Across Adolescence in Youth Perinatally Infected with HIV.

The paper utilizes data collected at three time points in a longitudinal study of perinatally HIV-infected (PHIV+) and a comparison group of perinatally exposed but HIV-uninfected (PHEU) youths in the United States (N = 325). Using growth curve modeling, the paper examines changes in substance use symptoms among PHIV+ and PHEU youths as they transition through adolescence, and assesses the individual and contextual factors associated with the rate of change in substance use symptoms. Findings indicate that substance use symptoms increased over time among PHIV+ youths, but not among PHEU youths. The rate of change in these symptoms was positively associated with an increasing number of negative life events. Study findings underscore the need for early, targeted interventions for PHIV+ youths, and interventions to reduce adversities and their deleterious effects in vulnerable populations.

To Use a Rectal Microbicide, First Insert the Applicator: Gel and Applicator Satisfaction Among Young Men Who Have Sex With Men.

We examined how experiences with a rectal placebo gel and applicator used with receptive anal intercourse (RAI) related to young men who have sex with men's (YMSM) likelihood of using a rectal microbicide gel and applicator in the future. An ethnically diverse sample of 95 YMSM (aged 18 to 30 years) were asked to insert hydroxyethylcellulose (HEC) placebo gel rectally before RAI during 12 weeks and report the product's acceptability (i.e., satisfaction with applicator and gel, respectively; perceived gel side effects; and sexual satisfaction when gel was used) and likelihood of future microbicide use. Main and interaction effects predicting future use intentions were tested using linear regression. We found a positive association between future use intentions and applicator satisfaction (b = .33, p < .001). In a subsequent interaction effects model, we found that greater gel satisfaction was associated with increased future use intentions; however, the strength of this relationship was magnified when YMSM reported greatest satisfaction with the rectal applicator. Applicator satisfaction may be a salient factor in YMSM's decision-making to use a rectal microbicide in the future. Although the importance of developing a satisfactory rectal microbicide gel for YMSM is undeniable for its future use, our results also emphasize the importance of developing strategies that increase YMSM's comfort and skill when using a rectal applicator. Future research examining how to optimize the design, properties, and characteristics of a rectal applicator as a strategy to promote greater satisfaction and use among YMSM is merited.

Depressive symptoms among MSM who engage in bareback sex: does mood matter?

Much research has examined the relationship between depressive symptoms and unprotected sex among men who have sex with men (MSM), but little is known about how depression is related to the sexual behavior of men who intentionally engage in unprotected anal intercourse, or bareback sex. In this study, we explored the extent to which depressive symptoms were associated with rates of unprotected sex among barebackers, and whether this relationship was dependent upon HIV serostatus. Using a sample of 120 MSM who engage in intentional condomless sex, we found that for HIV-negative participants, depressive symptoms were associated with the overall frequency of unprotected anal intercourse as well as unprotected anal intercourse with a serodiscordant partner. For HIV-positive participants, depressive symptoms were not associated unprotected intercourse. Additional research is needed to better understand depression among men who bareback and how interventions could be designed to address depression and reduce sexual risk behaviors.

Is 'bareback' a useful construct in primary HIV-prevention? Definitions, identity and research.

The terms bareback and bareback identity are increasingly being used in academic discourse on HIV/AIDS without clear operationalization. Using in-depth, face-to-face interviews with an ethnically diverse sample of 120 HIV-infected and -uninfected men, mainly gay-identifying and recruited online in New York City, this study explored respondents' definitions of bareback sex, the role that intentionality and risk played in those definitions, and whether respondents identified as 'barebackers'. Results showed overall agreement with a basic definition of bareback sex as condomless anal intercourse, but considerable variation on other elements. Any identification as barebacker appeared too loose to be of use from a public health prevention perspective. To help focus HIV-prevention efforts, we propose a re-conceptualization that contextualises risky condomless anal intercourse and distinguishes between behaviours that are intentional and may result in HIV-primary transmission from those that are not.

Preference for gel over suppository as delivery vehicle for a rectal microbicide: results of a randomised, crossover acceptability trial among men who have sex with men.

OBJECTIVE: To assess whether men who have sex with men (MSM) prefer a gel or a suppository as a delivery vehicle for a rectal microbicide. METHODS: 77 HIV-negative MSM with a recent history of inconsistent condom use during receptive anal intercourse (RAI) who acknowledged being at risk of contracting HIV were enrolled in a randomised, crossover acceptability trial. They compared 35 ml placebo gel with 8 g placebo rectal suppositories used on up to three RAI occasions each. RESULTS: Participants preferred the gel over the suppository (75% versus 25%, p<0.001) and so did their partners (71% versus 29%, p<0.001). The gel received more favourable ratings overall and on attributes such as colour, smell, consistency, feeling in rectum immediately after insertion and/or 30 minutes after insertion and application process. The gel resulted in less negative ratings in terms of participants being bothered by leakage, soiling, bloating, gassiness, stomach cramps, urge to have bowel movement, diarrhoea, pain or trauma. Participants liked the gel more in terms of feelings during anal sex, sexual satisfaction, partners' sexual satisfaction and liking the product when condoms were used and when condoms were not used. CONCLUSIONS: In this sample taken from one of the populations most likely to benefit from rectal microbicide availability, gel had greater acceptability than a suppository as a potential microbicide vehicle.

[Assessment of generic and disease-specific health-related quality of life instruments in peripheral arterial disease]. / Die Erfassung der allgemeinen und gesundheitsbezogenen Lebensqualität bei Patienten mit peripherer arterieller Verschlusskrankheit--eine Ubersicht.

As chronic diseases are continuously increasing in our aging society, the description and improvement of quality of medical care needs critical examination of the multidimensional subject of "quality of life". Health-related quality of life is currently used as an outcome-criterion in modern medicine. As there is no generally accepted definition of quality of life, various components of the state of health and the patient's behaviour are recorded by questionnaires. The level of subjective well- being is determined by several dimensions such as physical constitution of the patient, state of mind, functional competency in everyday life and the form of interpersonal relationships. Based on these principles various instruments for measuring quality of life are developed. The assessment of the subjective quality of life reflects the increased acceptance of the patient's view. In addition to the common generic instruments such as SF-36, FLZ(M), MLDL, EQ-5D, WHOQOL-100, NHP, SIP, also disease-specific instruments e.g. for peripheral arterial disease are currently used (PAVK-86, CLAU-S, VASCUQOL, SIP(IC), and WIQ). At the moment SF-36 is the best established questionnaire as generic QOL instrument. FLZ(M) takes the individual weighting of items into account, by correlating the importance and the contentment for life. For evaluating the effectivity of medical outcome and the success of therapeutic treatment for patients with vascular disease, the VASCUQOL instrument seems to be the best choice. Simultaneous application of a generic instrument and disease-specific questionnaires displays as well the subjective quality of health as the individual impairment of the patient in a good way. As a consequence using both instruments is superior to the exclusive use of a generic questionnaire.

Women's anal sex practices: implications for formulation and promotion of a rectal microbicide.

To gain insight into practices that may inform formulation and use of rectal microbicides, in-depth interviews were conducted with an ethnically diverse sample of 28 women who engage in anal intercourse. Microbicides are compounds under development to decrease sexually transmitted infections. Most women practiced anal sex in conjunction with vaginal intercourse. Anal sex typically was not preplanned, and few women reported preparation. Condom use was rare. Most women relied on saliva, vaginal fluids, prelubricated condoms, or used no lubrication at last intercourse. Women were uncertain about the amount of lubricant used during sex, with typical estimates of 1 to 2 teaspoons. This may prove challenging to the formulation and promotion of rectal microbicides, as substantially higher amounts may be required. Additional challenges include infrequent use of packaged lubricants, and typical male lubricant application, which may make women's control of rectal microbicides more difficult. Women overwhelmingly expressed interest in rectal microbicides.

HIV risk behaviors and the context of sexual coercion in young adults' sexual interactions: results from a diary study in rural South Africa.

BACKGROUND: Gender inequalities in relationship power may promote unprotected sexual intercourse. GOALS: The goal of this study was to gain insight into the specific gender dynamics in the intimate relationships of rural South African young adults that contribute to risk for HIV infection. STUDY: Using diary methods, 25 female and 25 male secondary school students in rural South Africa provided daily reports (N = 1000) over a 3-week timeframe, including details regarding 466 sexual interactions. RESULTS: Inconsistent condom use was more likely in relationships in which the male partner had ever used threat or force to engage in sex during this period (unadjusted odds ratio, 13.4; 95% confidence interval, 1.57-114.26). Male sexual coercion was more likely in relationships in which alcohol was ever used in conjunction with sex and when a man's desire to engage in sex was perceived as greater than the woman's. CONCLUSION: This study adds to the growing evidence that sexual relationships characterized by gender inequality and sexual coercion are contexts of sexual risk.

A randomized controlled trial to test an HIV-prevention intervention for Latino gay and bisexual men: lessons learned.

At the time of this writing, no randomized controlled trial (RCT) of an intervention to reduce unsafe sex among Latino gay and bisexual men (LGBM) had been published. We report the results of an RCT conducted in New York City in which 180 LGBM were assigned either to an intervention developed specifically for this population or to a wait-list control group. The intervention was based on empowerment theory and used factors identified in prior research as determinants of unsafe sex. By eligibility criteria, all men had engaged in unprotected anal intercourse (UAI) within two months of the baseline assessment. At first (two months) and second (six months later) follow-up assessments, approximately half of the men in the experimental group reported no UAI. Yet, a similar proportion of the control group also reported no UAI. Baseline data indicate that although the men had been the subject of social oppression and sexual prejudice (homophobia), they did not feel disempowered, externally controlled or fatalistic, and they reported self-efficacy and intentionality to enact safer sex. Lessons learned are discussed, as well as notes of caution for future research employing a similar conceptual framework.

Attitudes of adult 46, XY intersex persons to clinical management policies.

PURPOSE: We surveyed a clinic sample of adult 46,XY intersex patients regarding attitudes to clinical management policies. MATERIALS AND METHODS: All adult former patients of 1 pediatric endocrine clinic in the eastern United States whose addresses could be obtained and who consented to participation were surveyed by a comprehensive written followup questionnaire. Three questions on attitudes concerning the desirability of a third gender category and the age at which genital surgery should be done were presented in the context of ratings of satisfaction with gender, genital status and sexual functioning. RESULTS: A total of 72 English speaking patients with 46,XY, including 32 men and 40 women 18 to 60 years old, completed the questionnaire. The majority of respondents stated that they were mainly satisfied with being the assigned gender, did not have a time in life when they felt unsure about gender, did not agree to a third gender policy, did not think that the genitals looked unusual (although the majority of men rated their penis as too small), were somewhat or mainly satisfied with sexual functioning, did not agree that corrective genital surgery should be postponed to adulthood and stated that their genital surgeries should have been performed before adulthood, although there were some significant and important differences among subgroups. CONCLUSIONS: The majority of adult patients with intersexuality appeared to be satisfied with gender and genital status, and did not support major changes in the prevailing policy. However, a significant minority was dissatisfied and endorsed policy changes.

Levels and correlates of psychological distress in male couples of mixed HIV status.

Few studies have analyzed the impact of HIV infection on dyadic functioning and on the distress levels of each partner, independently, in HIV-serodiscordant relationships, particularly in same-sex dyads. The main purpose of this study was to assess levels of psychological distress in the HIV-positive and HIV-negative members of HIV-discordant male couples and to explore possible couple-related factors associated with distress. This was done within a systems theory framework. Levels of distress among the men were in the mild to moderate range, according to general population norms. Factors associated with distress in the men included dyadic satisfaction, sexual satisfaction, avoidance and self-blame coping style, and support from one's partner. Results suggest the need for 'couple-focused' clinical interventions for HIV-discordant couples.

Correlates of adherence to combination antiretroviral therapy among members of HIV-positive mixed status couples.

This exploratory study assessed medication adherence and its correlates in HIV-positive members of HIV mixed status couples. Forty couples were interviewed; the HIV-positive participants consisted of 19 gay men, 14 heterosexual men and seven heterosexual women. Mean self-reported adherence (over the past three days) for the whole sample was 95%; the mean adherence rate for gay men (99%) was significantly higher (p < 0.05) than that of heterosexual men (94%) and heterosexual women (87%) based on a ranked transformation of the adherence score. In analyses involving measures rated by the HIV-positive partner, higher adherence was associated with more years of education, greater perceived treatment efficacy, stronger belief that combination therapy is a significant advancement in treatment, and greater knowledge of HIV treatments and consequences of poor adherence. Higher adherence was associated with the HIV-negative partner attributing less risk to unprotected anal/vaginal sex within the couple, while lower adherence was associated with a greater likelihood that the couple engaged in unprotected anal/vaginal sex in the last two months. A larger sample is needed to substantiate these findings.

Frequent use of lubricants for anal sex among men who have sex with men: the HIV prevention potential of a microbicidal gel.

OBJECTIVES: This study assessed frequency of rectal lubricant use, opinions about rectal microbicidal gels, and willingness to participate in acceptability trials of rectal microbicides among Latino men who have sex with men (MSM). METHODS: Latino MSM (N = 307) living in New York City were surveyed from October 1995 through November 1996. Eleven Latino MSM participated in a focus group. RESULTS: Among those having anal sex during the prior year, 93% used lubricants (59% always and 74% in at least 80% of sexual encounters) regardless of condom use. Of the 29 men who practiced anal sed but did not use condoms, 90% used lubricants with similar frequency. Of those using lubricants, 94% used at least 1 teaspoon per occasion. A transparent product, free of smell and taste, was favored. Of the MSM in the sample, 92% said that they would use a lubricant with an anti-HIV microbicidal agent, and 87% expressed interest in participating in an acceptability trial. Product and dispenser preferences also were discussed. CONCLUSIONS: A rectal lubricant with microbicidal properties appears acceptable and desirable to Latino men who have anal sex with other men.

Substance use and sexual risk behavior: understanding their association among four ethnic groups of Latino men who have sex with men.

PURPOSE: To explore the association between substance use in conjunction with sex and unprotected anal sex among Colombian, Dominican, Mexican, and Puerto Rican men who have sex with men (MSM), considering ethnicity, acculturation, and mediating variables. METHODS: A New York City convenience sample of 307 men provided information on past year's sexual behavior, substance use, acculturation, attendance at bars, discos, and parties, self-worth, machismo, and sensation seeking. RESULTS: Alcohol use and drug use were positively associated with unprotected anal sex, particularly with casual partners. Different rates of substance use among the four ethnic groups were found, but were not significant when adjusting for acculturation. Among men who engaged in both unprotected and protected anal sex, substance use was not more common on unprotected occasions than on protected occasions. Attendance at bars, clubs, etc. was not associated with unprotected anal sex. Sensation seeking, self-worth, and machismo were related to substance use and unprotected anal sex. In multivariate analyses, the substance use/unprotected sex association remained when adjusting for ethnicity, acculturation, partner type, attendance at bars, and personality variables. IMPLICATIONS: Substance use and unprotected sex are associated among these Latino MSM. However, there does not appear to be a simple causal relationship between the variables. Several other variables co-vary with these factors but did not statistically explain their association.