Assessing the Information-Motivation-Behavioral Skills Model to Predict Pre-exposure Prophylaxis Adherence Among Black Men Who have Sex with Men and Transgender Women in a Community Setting in New York City.

The Information-Motivation-Behavioral Skills (IMB) Model has been used to understand adherence to medications and intentions to uptake pre-exposure prophylaxis (PrEP) to prevent HIV infection. In the current study, the IMB Model was used to understand factors that predict adherence to PrEP among a community-based cohort of 204 Black men who have sex with men (MSM) and transgender women (TGW) using structural equation modeling. PrEP motivation was directly associated with PrEP behavioral skills (ß = 0.320, p = 0.009), and PrEP behavioral skills were directly associated with PrEP adherence (ß = 0.416, p = 0.001). PrEP knowledge and PrEP motivation were not associated with PrEP adherence, directly or indirectly. The analysis identified intervenable factors that predicted PrEP adherence. Screening for motivation and behavioral skills could be used to identify where additional support to improve PrEP adherence is needed, or whether to offer alternative PrEP modalities or delivery strategies.

RESUMEN: El Modelo de Información-Motivación-Habilidades Conductuales (IMB) ha sido utilizado para comprender la adherencia a los medicamentos y la intención de tomar la profilaxis pre-exposición (PrEP) para prevenir la infección por el VIH. En el estudio actual, se usó el modelo IMB para comprender los factores que predicen la adherencia a la PrEP entre una cohorte reclutada en la comunidad de 204 hombres que tienen sexo con hombres (HSH) y mujeres transgénero (TGW) de raza negra, usando modelos de ecuaciones estructurales. La motivación de adherir a la PrEP se asoció directamente con las habilidades conductuales de la PrEP adherencia (ß = 0.320, p = 0.009), y las habilidades conductuales de la PrEP adherencia se asociaron directamente con la adherencia a la PrEP (ß = 0.416, p = 0.001). El conocimiento de PrEP y la motivación de adherir a la PrEPno se asociaron con la adherencia a la PrEP, ni directa o indirectamente. El análisis identificó factores intervenibles que predijeron la adherencia a la PrEP. La evaluación de la motivación de adherir a la PrEP y las habilidades conductuales de la PrEP adherencia podría ser usado para identificar situaciones en que se necesita apoyo adicional para mejorar la adherencia a la PrEP, o si se deben ofrecer modalidades alternativas de recibir PrEP o estrategias alternativas para entregar PrEP.

Response Rates of Medical Providers to Internet Surveys Regarding Their Adoption of Preexposure Prophylaxis for HIV: Methodological Implications.

In 2016 to 2017, we surveyed primary care providers (PCPs) in upper Manhattan and the South Bronx, New York, on their knowledge, attitudes, and practices surrounding preexposure prophylaxis (PrEP) for HIV. Despite efforts to promote survey response, we were only able to obtain a meager response rate, limiting our ability to interpret results. In this short communication, we examine our survey's methodology, as well as the methods used by other similar studies, in order to suggest how certain strategies appear to influence PCP response to PrEP surveys. Administering the survey in a variety of modes, sampling from a professional organization's listserv, promoting the survey topic's relevance to potential participants, and offering monetary incentives to each survey respondent all appear to be promising strategies for increasing response rates in PrEP provider surveys.

Multiple strategies to identify HIV-positive black men who have sex with men and transgender women in New York City: a cross-sectional analysis of recruitment results.

INTRODUCTION: Black men who have sex with men and transgender women are at high risk for HIV infection, but are more likely to be unaware of their infection or not in care for diagnosed HIV compared to other races. Respondent driven sampling has been advanced as a method to reach stigmatized and hidden populations for HIV testing. We compared strategies to recruit black, substance-using men who have sex with men and transgender women to identify newly diagnosed HIV infection, or those previously diagnosed but not in care. METHODS: The STAR (Seek, Test, and Retain) study (ClinicalTrials.gov NCT01790360) used several recruitment strategies to identify black, substance-using men who have sex with men and transgender women with undiagnosed HIV infection or with previously diagnosed HIV infection but who were not in HIV care. Respondent-driven sampling, community-based recruitment and online advertising were used to recruit participants. Incentivized peer referral was integrated into all recruitment strategies. Participants completed interviewer-administered questionnaires and HIV testing. Demographic and HIV risk-related characteristics and recruitment strategy were summarized and stratified by HIV status. Associations were tested using Pearson's chi-squared, Fisher's exact, and Wilcoxon rank sum tests. Factors associated with HIV-positive diagnosis at p < 0.1 were included in a multivariable logistic regression model. RESULTS: From July 2012 through October 2015, the study enrolled 1929 participants; 96.3% men who have sex with men and 3.7% transgender women. Behavioural risk factors included recent condomless anal sex (55.6%) and recent substance use during sex (73.1%). HIV prevalence was 8.7%. In multivariable analysis, significant associations with HIV infection included being transgender; non-Hispanic black; gay/homosexual orientation; not homeless; and less likely to have insufficient income for necessities. Among recruitment strategies, respondent driven sampling was least effective in identifying HIV-positive participants. CONCLUSIONS: Integrating multiple recruitment strategies yielded a large sample of black men who have sex with men and transgender women at substantial risk for HIV. Respondent-driven sampling was less effective than other strategies at identifying men who have sex with men and transgender women with HIV.

Tuberculosis Knowledge, Awareness, and Stigma Among African-Americans in Three Southeastern Counties in the USA: a Qualitative Study of Community Perspectives.

To inform strategies to address the tuberculosis (TB) excess among US-born African-Americans, we sought to understand the TB experience in the most highly affected southeastern communities. We conducted semi-structured interviews and focus groups in three communities with a TB excess-urban (Georgia and Tennessee) and rural (North Carolina). Participants from five groups provided diverse perspectives-African-Americans: patients with TB disease or latent TB infection (LTBI), or at high risk of contracting TB; and local community leaders and TB program staff. Few differences emerged between sites. Many participants demonstrated low levels of knowledge and awareness and held many misconceptions about TB. Patients expressed a preference for verbal communication of medical information. Patients reported fear of stigmatization and shunning, but few experienced discrimination. Patient trust for TB program staff was high, though community leaders often assumed the opposite. The findings will help guide interventions to improve knowledge and awareness regarding TB, including specific attention to the role of public and private health care providers in dispelling persistent misinformation about TB. The insight from these communities will help build the scientific foundation required to effectively eliminate health inequities.

Passing the baton: Community-based ethnography to design a randomized clinical trial on the effectiveness of oral pre-exposure prophylaxis for HIV prevention among Black men who have sex with men.

Although HIV interventions and clinical trials increasingly report the use of mixed methods, studies have not reported on the process through which ethnographic or qualitative findings are incorporated into RCT designs. We conducted a community-based ethnography on social and structural factors that may affect the acceptance of and adherence to oral pre-exposure prophylaxis (PrEP) among Black men who have sex with men (BMSM). We then devised the treatment arm of an adherence clinical trial drawing on findings from the community-based ethnography. This article describes how ethnographic findings informed the RCT and identifies distilled themes and findings that could be included as part of an RCT. The enhanced intervention includes in-person support groups, online support groups, peer navigation, and text message reminders. By describing key process-related facilitators and barriers to conducting meaningful mixed methods research, we provide important insights for the practice of designing clinical trials for 'real-world' community settings.

Knowledge and Attitudes About Tuberculosis Among U.S.-Born Blacks and Whites with Tuberculosis.

Non-Hispanic blacks represent 13% of the U.S.-born population but account for 37% of tuberculosis (TB) cases reported in U.S.-born persons. Few studies have explored whether this disparity is associated with differences in TB-related knowledge and attitudes. Interviews were conducted with U.S.-born, non-Hispanic blacks and whites diagnosed with TB from August 2009 to December 2010 in cities and states that accounted for 27% of all TB cases diagnosed in these racial groups in the U.S. during that time period. Of 477 participants, 368 (77%) were non-Hispanic black and 109 (23%) were non-Hispanic white. Blacks had significantly less knowledge and more misconceptions about TB transmission and latent TB infection than whites. Most TB patients in both groups recalled being given TB information; having received such information was strongly correlated with TB knowledge. Providing information to U.S.-born TB patients significantly increased their knowledge and understanding of TB. More focused efforts are needed to provide TB information to U.S.-born black TB patients.

Opportunities for tuberculosis diagnosis and prevention among persons living with HIV: a cross-sectional study of policies and practices at four large Ryan White Program-Funded HIV clinics.

OBJECTIVE: We describe the frequency and attributes of tuberculosis testing and treatment at four publicly-funded HIV clinics. METHODS: We abstracted medical records from a random sample of 600 HIV-infected patients having at least one clinic visit in 2009 at four clinics in New York and Los Angeles Metropolitan Statistical areas. We described testing and treatment for tuberculosis infection (TBI), 2008-2010, and estimated adjusted odds ratios (aORs). We interviewed key informants and described clinic policies and practices. RESULTS: Of 600 patients, 500 were eligible for testing, and 393 (79%) were tested 2008-2010; 107 (21%) did not receive at least one tuberculin skin test or interferon gamma release assay. Results were positive in 20 (5%) patients, negative in 357 (91%), and unknown in 16 (4%). Fourteen (70%) of 20 patients with TBI initiated treatment at the clinics; only three were documented to have completed treatment. Three hundred twenty three (54%) patients had chest radiography, 346 (58%) had tuberculosis symptom screening, and three had tuberculosis disease (117 per 100,000 person-years, 95% confidence interval (CI) = 101-165). Adjusting for site, non-Hispanic ethnicity (aOR = 4.9, 95% CI = 2.6-9.5), and employment (aOR = 1.9, 95% CI = 1.0-3.4) were associated with TBI testing; female gender (aOR = 2.0, 95% CI = 1.4-3.3), non-black race (aOR = 1.7, 95% CI = 1.3-2.5), and unemployment (aOR = 1.5, 95% CI = 1.1-2.1) were associated with chest radiography. Clinics evaluated TBI testing performance annually and identified challenges to TB prevention. CONCLUSIONS: Study clinics routinely tested patients for TBI, but did not always document treatment. In a population with a high TB rate, ensuring treatment of TBI may enhance TB prevention.

Treatment practices, outcomes, and costs of multidrug-resistant and extensively drug-resistant tuberculosis, United States, 2005-2007.

To describe factors associated with multidrug-resistant (MDR), including extensively-drug-resistant (XDR), tuberculosis (TB) in the United States, we abstracted inpatient, laboratory, and public health clinic records of a sample of MDR TB patients reported to the Centers for Disease Control and Prevention from California, New York City, and Texas during 2005-2007. At initial diagnosis, MDR TB was detected in 94% of 130 MDR TB patients and XDR TB in 80% of 5 XDR TB patients. Mutually exclusive resistance was 4% XDR, 17% pre-XDR, 24% total first-line resistance, 43% isoniazid/rifampin/rifabutin-plus-other resistance, and 13% isoniazid/rifampin/rifabutin-only resistance. Nearly three-quarters of patients were hospitalized, 78% completed treatment, and 9% died during treatment. Direct costs, mostly covered by the public sector, averaged $134,000 per MDR TB and $430,000 per XDR TB patient; in comparison, estimated cost per non-MDR TB patient is $17,000. Drug resistance was extensive, care was complex, treatment completion rates were high, and treatment was expensive.

Examining the impact of patient characteristics and symptomatology on knowledge, attitudes, and beliefs among foreign-born tuberculosis cases in the US and Canada.

Foreign-born individuals represent the majority of TB cases in the US/Canada. Little is known about their TB knowledge, attitudes, and beliefs (KAB). Cross-sectional survey was conducted in 22 sites in the US/Canada among foreign-born adults with active TB. Multiple regression was used to examine KAB factors against covariates. Of 1,475 participants interviewed, most answered the six knowledge items correctly. Significant predictors of correct knowledge included region of origin, education, income, age, visa status, place of diagnosis, BCG vaccination, and TB symptoms. Significant predictors of higher perceived risk/stigma scores included region of origin, age, place of diagnosis, English fluency, time in the US/Canada, TB symptoms, and household rooms. This study examines associations between TB KAB and patient and disease characteristics in foreign-born individuals in the US/Canada. The findings call for improved health education, along with efforts to reduce stigma and enhance realistic risk assessments.

Female sex and discontinuation of isoniazid due to adverse effects during the treatment of latent tuberculosis.

OBJECTIVES: To determine the rate of and risk factors for discontinuation of isoniazid due to adverse effects during the treatment of latent tuberculosis infection in a large, multi-site study. METHODS: The Tuberculosis Epidemiologic Studies Consortium (TBESC) conducted a prospective study from March 2007-September 2008 among adults initiating isoniazid for treatment of LTBI at 12 sites in the US and Canada. The relative risk for isoniazid discontinuation due to adverse effects was determined using negative binomial regression. Adjusted models were constructed using forward stepwise regression. RESULTS: Of 1306 persons initiating isoniazid, 617 (47.2%, 95% CI 44.5-50.0%) completed treatment and 196 (15.0%, 95% CI 13.1-17.1%) discontinued due to adverse effects. In multivariable analysis, female sex (RR 1.67, 95% CI 1.32-2.10, p < 0.001) and current alcohol use (RR 1.41, 95% CI 1.13-1.77, p = 0.003) were independently associated with isoniazid discontinuation due to adverse effects. CONCLUSIONS: The rate of discontinuation of isoniazid due to adverse effects was substantially higher than reported earlier. Women were at increased risk of discontinuing isoniazid due to adverse effects; close monitoring of women for adverse effects may be warranted. Current alcohol use was also associated with isoniazid discontinuation; counseling patients to abstain from alcohol could decrease discontinuation due to adverse effects.

Peer knowledge and roles in supporting access to care and treatment.

People living with HIV (PLWHIV) have been involved in the continuum of HIV care since the early days of the epidemic providing education and prevention services. There is a growing interest in utilizing HIV positive peers to support access to care and treatment, but little is known about the range of roles these peers perform and what they need to know to do this work. This study of 186 HIV-positive peers currently providing community health services in eight states found that peers perform a wide range of roles, including assistance with care and treatment, emotional support, and service referrals. Over 80% discussed medications with clients. On average, experienced peers provided correct responses to 73% of questions about HIV and AIDS, and 65% of questions about the appropriate role of a peer. Peers living with HIV for more than 5 years, in paid employment with more than a high school education had higher HIV knowledge scores than volunteers. Higher education, length of time living with HIV, age and speaking English as the primary language were associated with higher peer knowledge scores. This study suggests that we cannot assume that peers already working in the field are fully knowledgeable about HIV care and treatment or peer roles. It is important to address gaps in knowledge through continuing education and to create common standards for the training and skills that peers who work in community health settings need to have.

Tuberculosis knowledge, attitudes, and beliefs in foreign-born and US-born patients with latent tuberculosis infection.

UNLABELLED: Foreign-born individuals comprise the majority of patients treated for latent tuberculosis infection (LTBI) in the US. It is important to understand this population's tuberculosis-related knowledge, attitudes, and beliefs (KAB) as they may affect treatment acceptance and completion. KAB in 84 US-born and 167 foreign-born LTBI patients enrolled in a clinical trial assessing treatment completion at an urban public hospital were assessed at baseline. Demographic and substance use information was also collected. RESULTS: Of 251 participants, 66.5% were foreign-born. While misconceptions existed among both US and foreign-born regarding transmission and contagiousness of LTBI, overall knowledge scores did not differ significantly between groups. With respect to attitudinal factors, foreign-born participants were less likely to acknowledge that they had LTBI and felt more "protected" from developing TB. Improved understanding of foreign-born patients' KAB may contribute to the reduction of barriers to treatment and improved outcomes.

Latent TB infection treatment acceptance and completion in the United States and Canada.

BACKGROUND: Treatment of latent TB infection (LTBI) is essential for preventing TB in North America, but acceptance and completion of this treatment have not been systematically assessed. METHODS: We performed a retrospective, randomized two-stage cross-sectional survey of treatment and completion of LTBI at public and private clinics in 19 regions of the United States and Canada in 2002. RESULTS: At 32 clinics that both performed tuberculin skin testing and offered treatment, 123 (17.1%; 95% CI, 14.5%-20.0%) of 720 subjects tested and offered treatment declined. Employees at health-care facilities were more likely to decline (odds ratio [OR], 4.74; 95% CI, 1.75-12.9; P = .003), whereas those in contact with a patient with TB were less likely to decline (OR, 0.19; 95% CI, 0.07-0.50; P = .001). At 68 clinics starting treatment regardless of where skin testing was performed, 1,045 (52.7%; 95% CI, 48.5%-56.8%) of 1,994 people starting treatment failed to complete the recommended course. Risk factors for failure to complete included starting the 9-month isoniazid regimen (OR, 2.08; 95% CI, 1.23-3.57), residence in a congregate setting (nursing home, shelter, or jail; OR, 2.94; 95% CI, 1.58-5.56), injection drug use (OR, 2.13; 95% CI, 1.04-4.35), age >or= 15 years (OR, 1.49; 95% CI, 1.14-1.94), and employment at a health-care facility (1.37; 95% CI, 1.00-1.85). CONCLUSIONS: Fewer than half of the people starting treatment of LTBI completed therapy. Shorter regimens and interventions targeting residents of congregate settings, injection drug users, and employees of health-care facilities are needed to increase completion.

Cost-effectiveness of critical time intervention to reduce homelessness among persons with mental illness.

OBJECTIVES: Cost-effective programs are needed to assist homeless persons with severe mental illness in their transition from shelters to community living. The authors investigated the cost-effectiveness of the critical time intervention program, a time-limited adaptation of intensive case management, which has been shown to significantly reduce recurrent homelessness among men with severe mental illness. METHOD: S: Ninety-six study participants recruited from a psychiatric program in a men's public shelter from 1991 to 1993 were randomly assigned to the critical time intervention program or to usual services. Costs and housing outcomes for the two groups were examined over 18 months. RESULTS: Over the study period, the critical time intervention group and the usual services group incurred mean costs of 52,374 dollars and 51,649 dollars, respectively, for acute care services, outpatient services, housing and shelter services, criminal justice services, and transfer income. During the same period, the critical time intervention group experienced significantly fewer homeless nights than the usual care group (32 nights versus 90 nights). For each willingness-to-pay value--the additional price society is willing to spend for an additional nonhomeless night--greater than 152 dollars, the critical time intervention group exhibited a significantly greater net housing stability benefit, indicating cost-effectiveness, compared with usual care. CONCLUSION: S: Although difficult to conduct, studies of the cost-effectiveness of community mental health programs can yield rich information for policy makers and program planners. The critical time intervention program is not only an effective method to reduce recurrent homelessness among persons with severe mental illness but also represents a cost-effective alternative to the status quo.

Beneficence vs. obligation: challenges of the Americans with Disabilities Act for consumer employment in mental health services.

Involvement of mental health service consumers in the provision of mental health services is a growing model in community mental health. It is, however, a complicated issue, made ever more so by the passage of the Americans with Disabilities Act. In this ethnographic case study, we seek to explore the changes one social services agency has made to adjust to the requirements of the ADA and the impact of these changes on their consumer employees. Our results indicate potential for positive progress as a result of the ADA, but also unexpected pitfalls as organizational cultures change as well.