The Relative Influence of Perceived Immigration Laws and Consequences on HIV Testing Among US Latino Immigrants.

The CDC recommends that persons aged 13-64 receive an HIV test at least once in their lifetime and that some groups test annually or more frequently. Nearly one-half of US Latino immigrants have never been tested for HIV. To the extent that immigration-related laws deter documented and undocumented immigrants from engaging in communicable disease control measures, these laws undermine public health efforts. 1750 noncitizen adult, sexually active, Spanish-speaking Latino immigrants across four cities in the US completed a cross-sectional survey assessing perceptions of immigration-related laws and immigration consequences related to HIV testing and diagnosis. Participants were recruited in-person by staff in community settings, through flyers posted in places frequented by Latino immigrants, and by word-of-mouth through snowball sampling. Outcomes were whether participants had ever received an HIV test and whether they tested in the previous 12 months. Multivariable analyses examined the relative contribution of perceived immigration laws and consequences on HIV testing behaviors when considering established predictors of HIV testing. Perceptions of HIV-related immigration laws and immigration consequences was a significant predictor of never having had an HIV test even when considered relative to common predictors of HIV testing. The influence of perceived immigration laws and consequences on testing in the previous 12 months was not significant in multivariable analysis. Perceived HIV-related immigration laws and consequences appear to be a substantial contributor to reluctance to be tested for HIV among Latino immigrants who have never been tested. Effective interventions should be developed to address these.

RESUMEN: El CDC recomienda que las personas de 13 a 64 años se hagan una prueba del VIH al menos una vez en la vida y que algunos grupos se hagan la prueba anualmente o con mayor frecuencia. Casi la mitad de los inmigrantes latinos de los Estados Unidos nunca se han hecho la prueba del VIH. En la medida en que las leyes relacionadas con la inmigración disuadan a los inmigrantes documentados e indocumentados de participar en medidas de control de enfermedades transmisibles, estas leyes socavan los esfuerzos de salud pública. 1750 inmigrantes latinos adultos no ciudadanos, sexualmente activos y de habla hispana en cuatro ciudades de EE. UU. completaron una encuesta transversal que evaluó las percepciones de las leyes relacionadas con la inmigración y de las consecuencias de la inmigración relacionadas con las pruebas y el diagnóstico del VIH. Los participantes fueron reclutados en persona en contextos comunitarios, a través de volantes publicados en lugares frecuentados por inmigrantes latinos y de boca en boca a través de muestras de bola de nieve. Las variables dependientes fueron si los participantes se habían hecho una prueba del VIH alguna vez y si se habían hecho la prueba en los últimos 12 meses. Los análisis multivariados examinaron la contribución relativa de la percepción de las leyes de inmigración y de las consecuencias de inmigración sobre los comportamientos relativo a las pruebas del VIH, controlando por predictores conocidos de las pruebas del VIH. Las percepciones de las leyes de inmigración relacionadas con el VIH y las consecuencias de la inmigración fueron un predictor significativo de nunca haberse realizado una prueba del VIH, aun considerando los predictores comunes de la prueba del VIH. La influencia de la percepción de las leyes de inmigración y de las consecuencias de la inmigración sobre la prueba en los últimos 12 meses no fue significativa en el análisis multivariado. Las leyes de inmigración y las consecuencias percibidas relacionadas con el VIH parecen contribuir sustancialmente a la renuencia a hacerse la prueba del VIH entre los inmigrantes latinos que nunca se han hecho la prueba. Deben desarrollarse intervenciones efectivas para abordar esta renuencia.

Latino migrants' healthcare use in the US and perceived immigration laws and consequences: A multivariable analysis.

BACKGROUND: Using healthcare, whether for routine preventative examinations, chronic condition management, or emergent conditions, is an essential element of achieving and maintaining health. Over 44 million migrants live in the US today and nearly half (44.6 %) are Latino. To the extent that immigration law-related concerns deter US Latino migrants from using healthcare, they jeopardize the health of a substantial though marginalized US subpopulation. METHODS: A multistate sample (N = 1750) of noncitizen adult, Spanish speaking Latino migrants (both undocumented and documented) living in the US completed a cross-sectional survey comprising a scale assessing perceptions of immigration laws and consequences related to healthcare use and whether they had received and/or needed but did not receive healthcare in the previous 12-months. Participants were recruited in community settings and by word-of-mouth. Univariate analyses examined associations among study outcomes and common predictors of healthcare use. Multivariable analyses examined the relative contribution of perceived immigration laws and consequences on healthcare use and unmet need. RESULTS: Perceptions of immigration laws and immigration consequences were a significant predictor of not having received healthcare in the previous 12-months and having needed and not received healthcare in the same period, even when considered relative to common predictors of healthcare use. Immigration documentation status and preferred language predicted healthcare use in univariate analyses but not in the multivariable model. CONCLUSIONS: Perceived immigration laws and consequences related to healthcare use may influence migrants' healthcare use. Effective interventions should be developed to address immigration-related concerns.

US public charge policy and Latinx immigrants' thoughts about health and healthcare utilization.

OBJECTIVES: We examined Latinx immigrants' perceptions of US policy related to restrictions on immigrants' use of public resources and their thoughts about the influence of these on immigrants' healthcare utilization. DESIGN: A series of 16 focus group discussions with Latinx immigrant men and women (documented and undocumented) (N = 130) were conducted between May and July 2017 across four US cities. RESULTS: Four central themes emerged: participants attributed the limited resources available for affordable healthcare for many uninsured US immigrants (both documented and undocumented) to the US government's view of immigrants as burdens on public resources and its subsequent unwillingness to dedicate funds for their care; participants expressed concerns, some unfounded, about negative immigration ramifications arising from diagnosis with health conditions perceived to be serious and/or expensive to treat; participants noted that some immigrants avoided using health programs and services to which they were entitled because of immigration concerns; finally, participants described how access to information on immigration laws and healthcare resources, and conversely, misinformation about these, influenced healthcare utilization. CONCLUSIONS: Participants were acutely aware of the image of immigrants as public charges or potential burdens on government resources that underlies US immigration policy. In some cases, participants came to inaccurate and potentially harmful conclusions about the substance of laws and regulations based on their beliefs about the government's rejection of immigrants who may burden public resources. This underscores the importance of ensuring that immigrants have access to information on immigration-related laws and regulations and on healthcare resources available to them. Participants noted that access to information also fostered resilience to widespread misinformation. Importantly, however, participants' beliefs had some basis in US immigration policy discourse. Law and policy makers should reconsider legislation and political commentary that frame self-reliance, the guiding principle of US immigration policy, in terms of immigrants' use of publicly funded healthcare resources.

1000 Hometown Heroes: Mobilising community social influencers for COVID-19 prevention, care and coping.

Coronavirus disease 2019 (COVID-19) created life-disrupting stressors that disproportionately burden disadvantaged communities with devastating impacts that extend far beyond the burden of the disease itself, including joblessness, housing and food insecurity, educational system upheavals, isolation due to disrupted relationships, worsened mental health and substance use and violence. Socially interconnected community members are resources whose efforts can be mobilised to improve COVID-19 coping within their social networks. This research examined the feasibility, acceptability, and reach of a social media-based peer influencer intervention for COVID-19 coping. Over a 9-month period in 2020, the project enrolled 1253 social influencers in Milwaukee-primarily ethnic and racial minorities-who regularly received and passed along messages to members of their social networks that provided advice about COVID-19 pandemic coping, economic survival, health protection, mental health, family needs, social justice and other impacts. Messages were shared by influencers with others over social media and also text messages, phone calls and conversations. Facebook social media tracking metrics objectively measured the community reach of social influencers' messages. Quantitative surveys and qualitative follow-up interviews with a subset of influencers also measured the feasibility and acceptability of the intervention. Social media monitoring metrics showed that, by the end of the project, influencers' messages reached an average of 7978 unique individuals per week and had an average of 13,894 total views per week, with more than 140,000 total cumulative organic impressions. More than half of social influencers indicated that-beyond Facebook message sharing-they shared COVID-19 prevention, care, and coping messages with social network members in conversations, phone calls and text messages. Social influencers reported that they valued having the opportunity to help community members to cope with pandemic stressors by conveying practical COVID-19 coping advice.

The Role of Context in Integrating Buprenorphine into a Drop-In Center in Kampala, Uganda, Using the Consolidated Framework for Implementation Research.

BACKGROUND: Although Africa has long borne the brunt of the human immunodeficiency virus (HIV) epidemic, until recently, the continent has been considered largely free of illicit drug use and injection drug use in particular. In Uganda, the number of people who use or inject drugs (PWUD and PWID, respectively) has increased, and PWID are a key population at high risk for human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection. However, harm reduction practices, including providing clean injection equipment and medication-assisted treatment (MAT), have only recently been piloted in the country. This project aims to integrate buprenorphine into a harm reduction drop-in center (DIC). METHODS: The Consolidated Framework for Implementation Research was used to guide our preparations to integrate buprenorphine into existing practices at a harm reduction DIC. We conducted key informant interviews with members of a community advisory board and DIC staff to document this process, its successes, and its failures. RESULTS: Results indicate that criminalization of drug use and stigmatization of PWUD challenged efforts to provide buprenorphine treatment in less regulated community settings. CONCLUSIONS: DIC staff and their commitment to harm reduction and advocacy facilitated the process of obtaining necessary approvals.

Latinx Immigrants' Legal Concerns About SARS-CoV-2 Testing and COVID-19 Diagnosis and Treatment.

Immigration concerns can deter immigrants from utilizing healthcare services. We examined Latinx immigrants' immigration concerns related to COVID-19 testing and treatment. A multi-state sample of 336 US Latinx immigrants (documented and undocumented) completed a cross-sectional online survey in Spanish. Factor analysis informed the construction of a COVID-19 Immigration Concerns Scale. Multiple logistic regression was used to examine associations between the scale and indices of perceived immigration risk and healthcare access and utilization. Concerns clustered around two factors: (1) providers' release of information to immigration authorities and drawing government attention; and (2) eligibility for COVID-19 services and the immigration ramifications of using these. The regression equation highlighted strong associations between these and perceived instability of immigration laws and enforcement concerns after controlling for healthcare access and utilization. COVID-19-related immigration concerns were substantial and multifaceted. Perceived instability of laws was strongly related to concerns but remains understudied.

The Influence of Perceived Immigration Context and Healthcare Utilization Immigration Law Concerns Latinx Immigrants' HIV Testing.

Although new HIV infections have remained stable or decreased for most U.S. groups at risk for HIV, incidence among Latinx increased by 6% and among Latinx individuals, immigrants are disproportionately infected. One driver of these infections is low rates of HIV testing. While research shows the chilling effect that restrictive immigration laws can have on immigrants' health care utilization, few studies have examined the influence of perceived immigration context and healthcare utilization immigration law concerns on following a public health recommendation such as HIV testing. The purpose of the study is to test an exploratory model of immigration-related variables and their impact on U.S. Latinx immigrants' yearly HIV testing. U.S.-Latinx immigrants (N=169) completed a cross-sectional survey assessing perceived enforcement of immigration laws, perceptions of law enforcement attitudes towards Latinx and immigrants, fear of deportation, concerns with the consequences of immigration laws for health care utilization, and yearly HIV testing. Path analysis findings indicated that perceived enforcement of immigration laws was related to perceived negative attitudes from law enforcement towards Latinx and immigrants which was associated with fear of deportation. Fear of deportation was associated with concerns with the implications of immigration laws for accessing publicly funded healthcare services and these concerns were negatively related to yearly HIV testing and mediated the association between fear of deportation and yearly HIV testing. Findings point to the need of developing and implementing individual- and policy-level interventions to increase HIV testing among Latinx immigrants in a restrictive immigration law environment. Resumen: Aunque nuevas infecciones de VIH se han mantenido estable o han disminuido para la mayoría de los grupos en los Estados Unidos (E.U.) en alto riesgo de contraer VIH, la incidencia de VIH entre Latinx ha aumentado 6% y entre individuos Latinx, los inmigrantes están desproporcionalmente afectados por la epidemia. Uno de los factores que contribuye a la alta tasa de VIH es la baja tasa de pruebas de VIH entre inmigrantes. Aunque la investigación confirma los efectos escalofriantes que las leyes restrictivas de inmigración pueden tener en la utilización de servicios de salud entre los inmigrantes, pocos estudios han examinado la influencia de la percepción del contexto de inmigración y las preocupaciones sobre las implicaciones de las leyes de inmigración si se utilizan servicios de salud públicos en seguir la recomendación de salud pública de hacerse la prueba de VIH regularmente. El propósito del estudio es someter a la prueba un modelo exploratorio de la influencia de variables relacionadas a la inmigración y su impacto en las pruebas anuales de HIV en los inmigrantes Latinx que viven en los E.U. (N=169). Los participantes contestaron un cuestionario transversal que midió la percepción del enforzamiento de las leyes de inmigración, la percepción de las actitudes de los agentes que enforzan las leyes de inmigración hacia Latinx y inmigrantes, el miedo a la deportación, las preocupaciones especificas sobre las consecuencias de las leyes de inmigración para la utilización de servicios de salud, la percepción de la sociedad sobre el estigma de VIH, y si los inmigrantes se hacen la prueba de VIH anualmente. Los resultados de los análisis de trayectoria indicaron que el enforzamiento de las leyes de inmigración esta relacionada con la percepción de que los agentes policiacos que enforzan las leyes tienen actitudes negativas hacia Latinx y inmigrantes lo cual esta asociado con el miedo a la deportación. El miedo a la deportación esta asociado a las preocupaciones sobre las implicaciones de las leyes de inmigración para la utilización de los servicios de salud patrocinados por el gobierno federal y estas preocupaciones fueron negativamente relacionadas con las pruebas anuales de VIH y mediaron la asociación entre el miedo a la deportación y las pruebas anuales de VIH. Los resultados señalan la importancia de desarrollar e implementar intervenciones al nivel individual y al nivel de política para aumentar las pruebas de VIH entre los inmigrantes Latinx en un ambiente de leyes restrictivas de inmigración.

Complex solutions for a complex problem: A meta-analysis of the efficacy of multiple-behavior interventions on change in outcomes related to HIV.

OBJECTIVE: The purpose of this meta-analysis was to examine the success of multiple-behavior interventions and to identify whether the efficacy of such programs depends on the number of recommendations prescribed and the type of outcomes measured. METHOD: We conducted a synthesis of 136 research reports (N = 59,330) using a robust variance estimate model (Tanner-Smith et al., 2016) to study change between baseline and the first follow-up across multiple-behavior interventions, single-behavior interventions, and passive controls. RESULTS: Multiple-behavior interventions were more efficacious than their single-behavior counterparts (multiple-behaviors: d = .44 [95% confidence interval, CI [.27, .60]); single-behavior: d = .21 [95% CI [.00, .43]), with efficacy varying based on the type of outcomes measured. Publication bias analysis revealed a small asymmetry but controlling for it did not eliminate these effects. There was a strong linear relation between the number of recommendations prescribed by an intervention and intervention efficacy (B = .07, SE = .01, p < .001), with strongest improvements observed for interventions making five or more recommendations. These patterns remained when controlling for other intervention and population characteristics. CONCLUSIONS: Multiple-behavior interventions are successful in the HIV domain and increasing the number of recommendations made in the intervention generally maximizes improvements. These findings provide insights that may guide the design and implementation of integrated interventions. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Assessment of COVID-19-Related Immigration Concerns Among Latinx Immigrants in the US.

Importance: Despite the contentious immigration environment and disproportionate rates of COVID-19 infection among Latinx individuals in the US, immigrants' concerns about engaging in COVID-19-related testing, treatment, and contact tracing have been largely unexplored. Objective: To examine the proportions of Latinx immigrants who endorse statements about the potential negative immigration ramifications of seeking and using COVID-19-related testing and treatment services and engaging in contact tracing. Design, Setting, and Participants: In this cross-sectional survey study, 25 COVID-19-related items were incorporated into the online Spanish-language survey of an ongoing study. Data were collected between July 15 and October 9, 2020, in Chicago, Illinois; Los Angeles, California; and Phoenix, Arizona. A nonrandom sample of 379 adult, Spanish-speaking, noncitizen Latinx immigrants (with either documented or undocumented immigration status) were sent surveys. Of those, 336 individuals (88.7% participation rate) returned surveys, and 43 individuals did not. An additional 213 individuals were screened but ineligible. Descriptive statistics were computed, and mean comparisons and bivariate correlations between sociodemographic variables, indices of immigration risk, and COVID-19-related survey items were conducted. Main Outcomes and Measures: Items elicited agreement or disagreement with statements about immigrants' access to COVID-19-related testing and treatment services and the potential immigration ramifications of using these services. Willingness to identify an undocumented person during contact tracing was also assessed. Results: A total of 336 Latinx immigrants completed surveys. The mean (SD) age of participants was 39.7 (8.9) years; 210 participants (62.5%) identified as female, and 216 participants (64.3%) had undocumented immigration status. In total, 89 participants (26.5%) agreed that hospital emergency departments were the only source of COVID-19 testing or treatment for uninsured immigrants, and 106 participants (31.6%) agreed that using public testing and health care services for COVID-19 could jeopardize one's immigration prospects. A total of 96 participants (28.6%) and 114 participants (33.9%), respectively, would not identify an undocumented household member or coworker during contact tracing. Reluctance to identify an undocumented household member or coworker was associated with having had deportation experiences (r = -0.17; 95% CI, -0.06 to 0.27; P = .003) but not with the number of years lived in the US (r = 0.07; 95% CI, -0.16 to 0.17; P = .15) or immigration status (r = 0.03; 95% CI, -0.07 to 0.13; P = .56). Conclusions and Relevance: In this cross-sectional survey study, a substantial number of immigrants endorsed statements about immigrants' restricted access to COVID-19-related testing and treatment services and the potential negative immigration ramifications of using these services. These results suggest that programs for COVID-19-related testing, contact tracing, and vaccine administration that are designed to allay immigration concerns are needed.

Cumulative Effects of Adding a Small Group Intervention to Social Network Testing on HIV Testing Rates Among Crack Users in San Salvador, El Salvador.

The present study evaluates a combination prevention intervention for crack users in San Salvador, El Salvador that included social network HIV testing, community events and small group interventions. We examined the cumulative effects of the social network HIV testing and small group interventions on rates of HIV testing, beyond the increase that we saw with the introduction of the social network HIV testing intervention alone. HIV test data was converted into the number of daily tests and analyzed the immediate and overtime impact of small group interventions during and in the twelve weeks after the small group intervention. The addition of the small group interventions to the baseline of monthly HIV tests resulted in increased rates of testing lasting 7 days after the small group interventions suggesting a reinforcing effect of small group interventions on testing rates.

Contextual influences on Latino men's sexual and substance use behaviors following immigration to the Midwestern United States.

Objectives: Latinos in the United States experience a disproportionate number of HIV and other sexually transmitted infections (STIs) and higher use of alcohol and illegal drugs, which has been attributed to increases in risk behaviors following immigration. Whereas substantial research documents these behavioral changes, little is known about how immigrants increase their risk or why some immigrants increase their risk and other immigrants do not. This study explored how the social and normative context affects sexual and substance use behaviors among Latino immigrant men in a midsized Midwestern city of the United States.Methods: We interviewed 64 Latino immigrant men recruited from community sites in Milwaukee, Wisconsin (mean age = 32.6 years). Participants reported the social and normative contexts preceding and following immigration, including social networks and support, perceptions of the law, and familiar and peer normative influences.Results: Immigrants attributed changes in their sexual and substance use behaviors to their immigration goals, social support, peer and familial normative influences, and restrictions related to their immigrant status. Immigration for economic and personal advancement was generally protective from behaviors that would interfere with those goals as were extended familial networks that could provide support, resources, and normative control. The need to stay under the radar of authorities, the proportion of Latinos in the community, the social and normative changes associated with immigrants' age, and the higher perceptions of risk for HIV in the United States compared with their home countries also influenced immigrants' sexual and substance use behaviors.Conclusions: Changes in risk behavior after immigration to the United States reflect a combination of social and normative factors and personal goals. Interventions and policies aiming to prevent HIV and substance use among Latino immigrants should understand the contextual conditions that decrease or increase their risk behaviors in the United States.

Informal workplaces and their comparative effects on the health of street vendors and home-based garment workers in Yangon, Myanmar: a qualitative study.

BACKGROUND: Globally, two billion workers are employed informally but there is limited research on the relationship between informal work and health. Existing studies have focused on informality as an employment condition, with little emphasis on the diversity of physical and social contexts in which informal work takes place. The study considers the diversity of informal workplaces and explores the ways in which this diversity might influence health and well-being of two informal occupational groups in Yangon, the former capital of Myanmar. METHODS: We conducted 21 field observations and 47 semi-structured interviews with street vendors and home-based garment workers based in Yangon, Myanmar. A constant comparative method was used to identify and compare how the physical characteristics of their informal workplaces affect their health for these two informal subgroups. RESULTS: Although both street vendors and home-based garment workers work informally, their exposure to occupational health and income risks are specific to the physical features of their informal workplaces. Street vendors, who work in public spaces with minimal coverage, are more likely to experience the direct effects of outdoor pollution, inclement weather and ergonomic risks from lifting, carrying and transporting heavy merchandise while home-based garment workers, many of whom live and work in unsanitary housing and deprived neighborhoods, are more likely to experience pollution in or near their homes, and ergonomic risks from poor posture. Similarly, although both groups face safety challenges, street vendors face urban violence and abuse during their commute and at vending points whereas home-based garment workers felt unsafe in their home-based workplaces due to the presence of crime and violence in their neighborhoods. CONCLUSION: While informal employment is universally characterized by lack of social protection, exposure to occupational health and income risks for subpopulations of informal workers is determined by the specific physical and social environments of their workplaces. Efforts to improve the health of informal workers should consider the contexts in which informal work takes place to develop tailored interventions for subpopulations of informal workers.

More behavioral recommendations produce more change: A meta-analysis of efficacy of multibehavior recommendations to reduce nonmedical substance use.

Death and morbidity associated with substance use have risen continuously over the last few decades, increasing the need for rigorous examination of promising programs. Interventions attempting to change multiple behaviors have been designed to address interconnected problems such as use of both alcohol and drugs. This meta-analysis aimed to examine the efficacy of multibehavior interventions to curb nonmedical substance use in relation to the theoretical relation among different substance use behaviors. Specifically, our synthesis aimed to estimate the optimal number of recommendations for intervention efficacy and evaluate the impact of different combinations of recommendations on intervention efficacy. A synthesis of multibehavior interventions addressing nonmedical substance use was conducted to measure behavioral changes between the pretest and the follow-up. These changes were then compared across different numbers of recommendations. Sixty-nine reports and 233 effect sizes (k of conditions = 155, n = 28,295) were included. A positive linear relation was found between the number of targeted behaviors and intervention efficacy, which was stronger for drug use than alcohol use. Furthermore, recommendations on drug use worked better when paired with recommendations targeting other behaviors, whereas recommendations on alcohol use worked more independently. Lastly, multibehavior interventions were especially efficacious when delivered by experts. Overall, our synthesis indicated that targeting multiple substances is beneficial for changing drug use outcomes, but less so for alcohol use outcomes. Therefore, in the current substance use epidemic, innovative multibehavior programs appear to hold promise, especially to combat nonmedical drug use. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

HIV Testing and Mistaken Beliefs about Immigration Laws.

Evidence suggests that migrants may underutilize USA health care because of misconceptions about immigration-related consequences of health care use. This study aimed to explore whether common misconceptions about the immigration consequences of seeking health care, receiving an HIV test, and being diagnosed with HIV were associated with participant self-report of never having received an HIV test. The study sample comprised 297 adult, sexually active, documented and undocumented Spanish-speaking Latino migrants. Participants completed a cross-sectional survey via ACASI. In multiple logistic regression analyses controlling for sociodemographic variables and HIV stigma, misconceptions about laws emerged as a strong predictor of never having received an HIV test (p < .001). Associations between participants' endorsement of misconceptions and their HIV testing history suggest that incorrect perceptions of laws do deter some subgroups of USA Latino migrants from HIV testing. Identifying misconceptions about negative immigration consequences of engaging in important health behaviors should be a community health research priority.

Intervention Reach and Sexual Risk Reduction of a Multi-level, Community-Based HIV Prevention Intervention for Crack Users in San Salvador, El Salvador.

This article examines the effects of a multi-level, community-based HIV prevention intervention for crack users residing in low-income neighborhoods in San Salvador, El Salvador conducted between August 2011 and June 2016. The intervention consisted of three components introduced sequentially: (1) rapid HIV testing in community settings; (2) a social network HIV testing intervention; and (3) small group interventions with crack users who were members of the same social network. The intervention was evaluated with an interrupted time series design in which we used respondent-driven sampling to conduct 7 cross-sectional surveys with crack users along a 3-4 month period for each assessment (total n = 1597). Results revealed a significant increase in exposure to the intervention over time with 50% of the participants reporting exposure to one or more of the three components. Getting an HIV test at the community site was associated with reductions in total times each individual had sex without a condom (p < 0.05) compared to those who had been exposed to no intervention components. Being referred by another crack user through the Social Network HIV intervention was also associated with reductions in total numbers of condomless sex (p < 0.05) The cumulative effect of being exposed to more than one intervention component was associated with reductions in total number of times individuals had condomless sex (p < 0.05). In spite of the high level of intervention reach and that self-reported exposure to intervention components was associated with lower sexual risk, reductions in sexual risk over time were not observed in the full sample, indicating that the penetration of HIV prevention components was not sufficient to produce population level change.

A social systems analysis of implementation of El Salvador's national HIV combination prevention: a research agenda for evaluating Global Health Initiatives.

BACKGROUND: Global Health Initiatives (GHIs) have been instrumental in the rapid acceleration of HIV prevention, treatment access, and availability of care and support services for people living with HIV (PLH) in low and middle income countries (LMIC). These efforts have increasingly used combination prevention approaches that include biomedical, behavioral, social and structural interventions to reduce HIV incidence. However, little research has evaluated their implementation. We report results of qualitative research to examine the implementation of a national HIV combination prevention strategy in El Salvador funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria. METHODS: We conducted in-depth interviews with principal recipients of the funding, members of the Country Coordinating Mechanism (CCM) and front line peer outreach workers and their clients. We analyzed the data using a dynamic systems framework. RESULTS: El Salvador's national HIV combination prevention strategy had three main goals: 1) to decrease the sexual risk behaviors of men who have sex with men (MSM), commercial sex workers (CSW) and transgender women (TW); 2) to increase HIV testing rates among members of these populations and the proportion of PLH who know their status; and 3) to improve linkage to HIV treatment and adherence to antiretroviral therapy (ART). Intervention components to achieve these goals included peer outreach, community prevention centers and specialized STI/HIV clinics, and new adherence and retention protocols for PLH. In each intervention component, we identified several factors which reinforced or diminished intervention efforts. Factors that negatively affected all intervention activities were an increase in violence in El Salvador during implementation of the strategy, resistance to decentralization, and budget constraints. Factors that affected peer outreach and sexual risk reduction were the human resource capacity of grassroots organizations and conflicts of the national HIV strategy with other organizational missions. CONCLUSIONS: Overall, the national strategy improved access to HIV prevention and care through efforts to improve capacity building of grass roots organizations, reduced stigma, and improved coordination among organizations. However, failure to respond to environmental and organizational factors limited the intervention's potential impact.

The Development and Psychometric Properties of the Immigration Law Concerns Scale (ILCS) for HIV Testing.

To develop, pilot test, and conduct psychometric analyses of an innovative scale measuring the influence of perceived immigration laws on Latino migrants' HIV-testing behavior. The Immigration Law Concerns Scale (ILCS) was developed in three phases: Phase 1 involved a review of law and literature, generation of scale items, consultation with project advisors, and subsequent revision of the scale. Phase 2 involved systematic translation- back translation and consensus-based editorial processes conducted by members of a bilingual and multi-national study team. In Phase 3, 339 sexually active, HIV-negative Spanish-speaking, non-citizen Latino migrant adults (both documented and undocumented) completed the scale via audio computer-assisted self-interview. The psychometric properties of the scale were tested with exploratory factor analysis and estimates of reliability coefficients were generated. Bivariate correlations were conducted to test the discriminant and predictive validity of identified factors. Exploratory factor analysis revealed a three-factor, 17-item scale. subscale reliability ranged from 0.72 to 0.79. There were significant associations between the ILCS and the HIV-testing behaviors of participants. Results of the pilot test and psychometric analysis of the ILCS are promising. The scale is reliable and significantly associated with the HIV-testing behaviors of participants. Subscales related to unwanted government attention and concerns about meeting moral character requirements should be refined.

Latino Acculturation and Periodontitis Status Among Mexican-Origin Adults in the United States: NHANES 2009-2012.

This study examined the association between Latino acculturation indicators (language and citizenship/nativity status) and periodontitis using data from the National Health and Nutrition Examination Survey (NHANES) 2009-2012. Descriptive statistics and logistic regression analyses were performed and all analyses were adjusted for the complex survey design. Results showed that 63.2% of participants had periodontitis: 9.4% mild, 37.9% moderate, and 16% severe. Language was significantly associated with periodontitis after adjusting for age, educational level, gender, usual source of care, flossing, smoking, and glycohemoglobin level (P = .02). Dental public and private health efforts should implement culturally tailored oral health promotion education efforts for this population.

Using Peer-Referral Chains with Incentives to Promote HIV Testing and Identify Undiagnosed HIV Infections Among Crack Users in San Salvador.

In El Salvador, crack users are at high risk for HIV but they are not targeted by efforts to promote early HIV diagnosis. We evaluated the promise of peer-referral chains with incentives to increase HIV testing and identify undiagnosed HIV infections among networks of crack users in San Salvador. For 14 months, we offered HIV testing in communities with a high prevalence of crack use. For the following 14 months, we promoted chains in which crack users from these communities referred their peers to HIV testing and received a small monetary incentive. We recorded the monthly numbers of HIV testers, and their crack use, sexual risk behaviors and test results. After launching the referral chains, the monthly numbers of HIV testers increased significantly (Z = 6.90, p < .001) and decayed more slowly (Z = 5.93, p < .001), and the total number of crack-using testers increased nearly fourfold. Testers in the peer-referral period reported fewer HIV risk behaviors, but a similar percentage (~5 %) tested HIV positive in both periods. More women than men received an HIV-positive diagnosis throughout the study (χ(2)(1, N = 799) = 4.23, p = .040). Peer-referral chains with incentives can potentially increase HIV testing among networks of crack users while retaining a focus on high-risk individuals.