Efficacy of assisted partner services for people who inject drugs in Kenya to identify partners living with HIV and hepatitis C virus infection: a prospective cohort study.

BACKGROUND: People who inject drugs are at increased risk of both HIV and hepatitis C virus (HCV) infections but face barriers to testing and engagement in care. Assisted partner services are effective in locating people with HIV but are understudied among people who inject drugs. We assessed whether assisted partner services could be used to find, test for HIV and HCV infections, and link to care the partners of people who inject drugs in Kenya. METHODS: In this prospective study at eight sites offering harm-reduction services in Kenya, we enrolled people aged 18 years or older who inject drugs and were living with HIV (index participants) between Feb 27, 2018, and Nov 1, 2021. Index participants provided information about their sexual and injecting partners (ie, anyone with whom they had had sexual intercourse or injected drugs in the previous 3 years), and then community-embedded peer educators located partners and referred them for enrolment in the study (partner participants). All participants underwent testing for HCV infection, and partner participants also underwent HIV testing. Index and partner participants with HIV but who were not on antiretroviral therapy (ART) were linked with treatment services, and those positive for HCV were linked to treatment with direct-acting antivirals. We calculated the number of index participants whom we needed to interview to identify partner participants with HIV and HCV infection. FINDINGS: We enrolled 989 people living with HIV who inject drugs, who mentioned 4705 sexual or injecting partners. Of these 4705 partners, we enrolled 4597 participants, corresponding to 3323 unique individuals. 597 (18%) partner participants had HIV, of whom 506 (85%) already knew their status. 358 (71%) of those who knew they were HIV positive were virally suppressed. 393 (12%) partner participants were HCV antibody positive, 213 (54%) of whom had viraemia and 104 (26%) of whom knew their antibody status. 1·66 (95% CI 1·53-1·80) index participants had to be interviewed to identify a partner with HIV, and 4·24 (3·75-4·85) had to be interviewed to find a partner living with HIV who was unaware of their HIV status, not on ART, or not virally suppressed. To find a partner seropositive for HCV who did not know their antibody status, 3·47 (3·11-3·91) index participants needed to be interviewed. Among the 331 index and partner participants living with HIV who were not on ART at enrolment, 238 (72%) were taking ART at 6-month follow-up. No adverse events were attributed to study procedures. INTERPRETATION: Use of assisted partner services among people with HIV who inject drugs was safe and identified partners with HIV and HCV infections. Assisted partner services was associated with increased uptake of ART for both index participants and partners. FUNDING: US National Institutes of Health.

Virologic non-suppression and HIV drug resistance among people who inject drugs and their sexual and injecting partners in Kenya.

We evaluated the prevalence and correlates of HIV viral non-suppression and HIV drug resistance (HIV-DR) in a cohort of people who inject drugs living with HIV (PWID-LH) and their sexual and injecting partners living with HIV in Kenya. HIV-DR testing was performed on participants with viral non-suppression. Of 859 PWID-LH and their partners, 623 (72.5%) were on antiretroviral therapy (ART) ≥4 months and 148/623 (23.8%) were not virally suppressed. Viral non-suppression was more common among younger participants and those on ART for a shorter duration. Among 122 (82.4%) successfully sequenced samples, 55 (45.1%) had detectable major HIV-DR mutations, mainly to non-nucleoside and nucleotide reverse transcriptase inhibitors (NNRTI, NRTI). High levels of HIV-DR among those with viral non-suppression suggests need for viral load monitoring, adherence counselling, and timely switching to alternate ART regimens in this key population.

Prevalence and correlates of violence among sexual and injecting partners of people who inject drugs living with HIV in Kenya: a cross-sectional study.

BACKGROUND: In Kenya, violence is common among people who inject drugs (PWID) living with HIV and their sexual and injecting partners and may lead to decreased uptake of HIV services, increased HIV risk behaviors, and increased HIV transmission. Violence is defined as any physical harm, threatened harm, or forced sexual acts inflicted on a person in the past year. Understanding the nature of violence and its correlates among PWID and their partners will inform population-specific public health interventions and policy recommendations. METHODS: This is a cross-sectional study nested in a prospective cohort study conducted in eight public health centers, methadone clinics, and needle syringe programs in Nairobi, Kilifi, and Mombasa counties in Kenya. 3,302 sexual and/or injecting partners of PWID living with HIV were recruited through assisted partner services and participated in the study. Prevalence and correlates of violence were identified using the Wald test and negative binomial regression. RESULTS: Out of 3302 study participants, 1439 (44%) had experienced violence within the past year. Physical violence was the most common form of violence experienced (35%), followed by being threatened (23%) or subjected to sexual violence (7%). In an adjusted analysis, female participants reported higher experiences of sexual violence (prevalence ratio [PR] = 2.46; 95% confidence interval [CI] 1.62, 3.74; p < 0.001) compared to male participants. In adjusted analysis, coastal residents had a higher experience of overall violence (PR = 1.48; 95% CI 1.27, 1.72; p < 0.001) than those living in Nairobi. This regional effect was relatively stronger among the female respondents (pinteraction = 0.025). Participants' sex modified the association between region and experiencing violence after adjusting potential confounding factors. CONCLUSIONS: The study reveals the prevalence of violence among PWID and identifies high-risk sub-groups, including women, specifically for sexual violence, and coastal residents. Tailored interventions addressing their unique needs are essential. A holistic approach that combines violence prevention and response, comprehensive harm reduction, healthcare access, and community support is crucial to address the complex issue of drug use and HIV burden among PWID in Kenya for improved health outcomes.

Social and environmental determinants influencing injection drug use and HIV risk among two sister cities on the US-Mexico border: a comparative cross-sectional study, 2016-2018.

The economic, social, cultural and political milieus that influence injection drug-related HIV risk behaviors along the US-Mexico border in the previous decade have been studied comparing cities on an East-West axis. In an effort to inform interventions targeting factors beyond the individual level, we used a cross-sectional study design comparing people who inject drugs during 2016-2018, living on a North-South axis, in two cities-Ciudad Juárez, Chihuahua, Mexico and El Paso, Texas, USA-situated at the midpoint of the 2000 US-Mexico borderland stretch. We conceptualize injection drug use and its antecedents and consequences as influenced by factors operating at various levels of influence. Results of analysis comparing samples recruited from each border city indicated significant differences in demographic, socioeconomic, micro- and macro-level factors that affect risk. Similarities emerged in individual-level risk behaviors and some dynamics of risk at the drug use site most frequented to use drugs. In addition, analyses testing associations across samples indicated that different contextual factors such as characteristics of the drug use sites influenced syringe sharing. In this article, we reflect on the potential tailored interventions needed to target the context of HIV transmission risk among people who use drugs and reside in binational environment.

The Brief Human Immunodeficiency Virus (HIV) Index: A Rapid 3-Item Scale to Measure Engagement in HIV Care.

We created a brief version of The Index, a validated patient-reported measure that has potential to quickly identify patients at risk for poor retention. We analyzed Index scores from 2406 patients from 2016 to 2017 in a national cohort of patients in human immunodeficiency virus (HIV) care. Index scores predicted poor retention 12 months after administered.

A factorial experiment grounded in the multiphase optimization strategy to promote viral suppression among people who inject drugs on the Texas-Mexico border: a study protocol.

BACKGROUND: People who inject drugs living with HIV (PWIDLH) suffer the lowest rates of HIV viral suppression due to episodic injection drug use and poor mental health coupled with poor retention in HIV care. Approximately 44% of PWIDLH along the US-Mexico border are retained in care and only 24% are virally suppressed. This underserved region faces a potential explosion of transmission of HIV due to highly prevalent injection drug use. This protocol describes an optimization trial to promote sustained viral suppression among Spanish-speaking Latinx PWIDLH. METHODS: The multiphase optimization strategy (MOST) is an engineering-inspired framework for designing and building optimized interventions and guides this intervention. The primary aim is to conduct a 24 factorial experiment in which participants are randomized to one of 16 intervention conditions, with each condition comprising a different combination of four behavioral intervention components. The components are peer support for methadone uptake and persistence; behavioral activation therapy for depression; Life-Steps medication adherence counseling; and patient navigation for HIV care. Participants will complete a baseline survey, undergo intervention, and then return for 3-,6-,9-, and 12-month follow-up assessments. The primary outcome is sustained viral suppression, defined as viral loads of < 40 copies per mL at 6-,9-, and 12-month follow-up assessments. Results will yield effect sizes for each component and each additive and interactive combination of components. The research team and partners will make decisions about what constitutes the optimized multi-component intervention by judging the observed effect sizes, interactions, and statistical significance against real-world implementation constraints. The secondary aims are to test mediators and moderators of the component-to-outcome relationship at the 6-month follow-up assessment. DISCUSSION: We are testing well-studied and available intervention components to support PWIDLH to reduce drug use and improve their mental health and engagement in HIV care. The intervention design will allow for a better understanding of how these components work in combination and can be optimized for the setting. TRIAL REGISTRATION: This project was registered at clinicaltrials.gov (NCT05377463) on May 17th, 2022.

Occupational roles and risks of community-embedded peer educators providing HIV, hepatitis C and harm reduction services to persons who inject drugs in Nairobi, Kenya.

BACKGROUND: In Kenya, harm reduction organizations have adopted evidence-based peer educator (PE) programs, where former people who inject drugs (PWID) serve as community health liaisons to engage PWID in HIV, HCV and harm reduction services. While PEs play an integral role in healthcare delivery, little data exists on their roles, risks and experiences working with PWID, which may be used to inform local harm reduction policy. METHODS: PE's from two harm reduction sites in Nairobi were randomly and purposively selected to participate in semi-structured in-depth interviews. Thematic analysis was conducted to characterize the expected versus actual roles that PEs employ while serving PWID, personal motivation and/or challenges and occupational health risks. Data was analyzed using Atlas.ti software. RESULTS: Twenty PEs participated in the study. On average, PEs were 37 years of age, with 3 years of service. Female representation was 30%. Expected responsibilities included locating clients, establishing rapport, educating and escorting clients to addiction care facilities. Additional roles included attending to clients outside of work hours, escorting clients to medical appointments and facilitating patient-provider discussions. Occupational health risks included harassment by police and drug dealers, needle sticks, and close proximity to drug use environments that could prompt drug relapse. Despite these challenges and risks, PEs are motivated by their personal experiences of overcoming addiction with help from harm reduction programs. CONCLUSIONS/RECOMMENDATIONS: PEs play a vital role in HIV, HCV and harm reduction service delivery in Kenya, often exceeding their job descriptions by offering additional support to PWID. Recommendations include (1) advocating for PEs to provide patient navigation services, (2) promoting the use of post-exposure prophylaxis (PEP), (3) providing occupational mental health services to prevent drug relapse, and (4) collaborating with law enforcement to address harassment, with the ultimate goal of reducing HIV and HCV incidence among PWID.

Assisted Partner Services for People Who Inject Drugs: Index Characteristics Associated With Untreated HIV in Partners.

BACKGROUND: Assisted partner services (APSs) is a feasible, acceptable, and effective strategy that increases uptake of HIV testing; however, it has not been used widely among people who inject drugs (PWID) in Africa to notify sexual and injecting partners of potential exposures to HIV and provide testing services. SETTING: Nairobi, Kilifi, and Mombasa counties in Kenya. METHODS: PWID living with HIV (indexes) were enrolled and asked to provide contact information for sexual and injecting partners who were traced and offered HIV testing. APS efficiency was assessed by the number of indexes needed to interview (NNTI) to find 1 additional partner who was unaware of their HIV status or not on antiretroviral therapy (ART). We defined index participant characteristics associated with greater efficiency, defined as lower NNTIs. RESULTS: Among 783 indexes, the NNTI to identify one partner unaware of their HIV status was 7.1 and to identify one HIV-positive partner not on ART (regardless of status awareness) was 4.1. APS was provided to 977 partners and was more efficient in identifying partners who were not on ART (n = 201) among indexes who were female (NNTI = 2.9 vs. 5.7, P < 0.001), unaware of their HIV status (NNTI = 2.2 vs. 4.2, P = 0.009), not on ART (NNTI = 2.1 vs. 4.9; P < 0.001), not enrolled in a methadone program (NNTI = 3.3 vs. 10.4, P < 0.001), reported injecting <5 years (NNTI = 3.3 vs. 5.0; P = 0.005), or from Nairobi (NNTI = 3.2 vs. 5.6, P < 0.001). CONCLUSION: Scaling up APS among PWID living with HIV with certain characteristics could result in more efficient APS and greater partner engagement in HIV care.

Characteristics associated with HIV and hepatitis C seroprevalence among sexual and injecting partners of HIV positive persons who inject drugs in Nairobi and coastal Kenya.

BACKGROUND: Persons who inject drugs (PWID) have higher HIV and hepatitis C virus (HCV) seroprevalence than the general population in many parts of sub-Saharan Africa (SSA). The seroprevalences of HIV and HCV are also higher in coastal Kenya than in Nairobi. Understanding drivers of regional HIV and HCV variation among PWID in Kenya may inform population-specific prevention interventions. METHODS: Using a cross-sectional study, we defined HIV and HCV seroprevalence among persons identified as sexual or injecting partners of HIV positive PWID in two regions of Kenya and used logistic regression to identify demographic and behavioral characteristics associated with higher seroprevalence. RESULTS: Among 2386 partners, 469 (19.7%) tested HIV positive and 297(12.4%) tested HCV antibody positive. Partners on the Coast were more likely to live with HIV (seroprevalences: Coast = 23.8%, Nairobi = 17.1%; p < 0.001) and be HCV antibody positive (seroprevalences: Coast = 17.0%, Nairobi = 8.6%; p < 0.001). After adjusting for sex, age, and years injecting and accounting for clustering by site, the higher prevalence of both diseases in the Coast remained significant for HIV (OR 1.68, 95% CI 1.13-2.51) but not for HCV (OR 1.72, 95% CI 0.84-3.74). Compared to those recruited in Nairobi, partners on the Coast were older (Coast = 35 years, Nairobi = 31 years; p < 0.001), more likely to be male (Coast = 77.6%, Nairobi = 61.7%; p < 0.001), to have paid (Coast = 59.2%, Nairobi = 32.8%; p < 0.001) or received (Coast = 44.2%, Nairobi 35.4%; p < 0.001) money for sex, or to have had sex with someone they knew to be HIV positive (Coast 22.0%, Nairobi 10.8%; p < 0.001). Partners who had injected for five or more years had 1.48 times greater odds (95% CI 1.20-1.82) of living with HIV compared to partners who injected less than 5 years and more than twice the odds of HCV (95% CI 1.84-4.11). CONCLUSION: HIV and HCV seroprevalence among sexual and injecting partners of PWID was, respectively, 5 times and > 12 times greater than is reported among the general population in Kenya (4% and < 1%, respectively). Providing resources and education will be crucial to reduce exposure and to maintain the lower needle and equipment sharing that we observed compared to other studies.

Participation in methadone programs improves antiretroviral uptake and HIV viral suppression among people who inject drugs in Kenya.

BACKGROUND: HIV prevalence among people who inject drugs (PWID) in Kenya is estimated to be 18% compared to 4.5% in the general population. Studies from high-income countries have demonstrated that methadone use is associated with increased uptake of antiretroviral therapy (ART) and higher rates of viral suppression among PWID with HIV. However, it is unclear whether methadone use has the same effect among African PWID living with HIV. METHODS: We performed a cross-sectional study to evaluate associations between methadone program participation and ART uptake and viral suppression (HIV RNA viral load <1000 copies/ml) among PWID with HIV in Kenya. Participants were recruited from needle and syringe programs and methadone clinics, interviewed on site, and samples were obtained and assayed for HIV viral loads. Univariate and multiple logistic regression were used to determine associations. RESULTS: Among 679 participants, median age was 37 years, 48% were female, and 24% were in a methadone program. We observed higher proportions of ART use (96% vs. 87%, p = 0.001) and HIV viral suppression (78% vs. 65%, p = 0.012) among PWID on methadone compared to those not on methadone treatment. PWID who were not participating in a methadone program were 3-fold more likely to be off ART and approximately twice as likely to be viremic compared to those in methadone programs (adjusted odds ratio [aOR] = 3.35, 95% confidence interval [CI]: 1.35-8.35 and aOR = 1.90, 95% CI: 1.03-3.52, respectively). CONCLUSIONS: In this study, Kenyan PWID living with HIV participating in a methadone treatment program were more likely to be on ART and to have achieved viral suppression. Scale-up of methadone programs may have a positive impact on HIV epidemic control for this key population.

Barriers and facilitators of HIV and hepatitis C care among people who inject drugs in Nairobi, Kenya: a qualitative study with peer educators.

BACKGROUND: In Kenya, people who inject drugs (PWID) are disproportionately affected by HIV and hepatitis C (HCV) epidemics, including HIV-HCV coinfections; however, few have assessed factors affecting their access to and engagement in care through the lens of community-embedded, peer educators. This qualitative study leverages the personal and professional experiences of peer educators to help identify HIV and HCV barriers and facilitators to care among PWID in Nairobi, including resource recommendations to improve service uptake. METHODS: We recruited peer educators from two harm reduction facilities in Nairobi, Kenya, using random and purposive sampling techniques. Semi-structured interviews explored circumstances surrounding HIV and HCV service access, prevention education and resource recommendations. A thematic analysis was conducted using the Modified Social Ecological Model (MSEM) as an underlying framework, with illustrative quotes highlighting emergent themes. RESULTS: Twenty peer educators participated, including six women, with 2-months to 6-years of harm reduction service. Barriers to HIV and HCV care were organized by (a) individual-level themes including the competing needs of addiction and misinterpreted symptoms; (b) social network-level themes including social isolation and drug dealer interactions; (c) community-level themes including transportation, mental and rural healthcare services, and limited HCV resources; and (d) policy-level themes including nonintegrated health services, clinical administration, and law enforcement. Stigma, an overarching barrier, was highlighted throughout the MSEM. Facilitators to HIV and HCV care were comprised of (a) individual-level themes including concurrent care, personal reflections, and religious beliefs; (b) social network-level themes including community recommendations, navigation services, family commitment, and employer support; (c) community-level themes including quality services, peer support, and outreach; and (d) policy-level themes including integrated health services and medicalized approaches within law enforcement. Participant resource recommendations include (i) additional medical, social and ancillary support services, (ii) national strategies to address stigma and violence and (iii) HCV prevention education. CONCLUSIONS: Peer educators provided intimate knowledge of PWID barriers and facilitators to HIV and HCV care, described at each level of the MSEM, and should be given careful consideration when developing future initiatives. Recommendations emphasized policy and community-level interventions including educational campaigns and program suggestions to supplement existing HIV and HCV services.

Peer-mediated HIV assisted partner services to identify and link to care HIV-positive and HCV-positive people who inject drugs: a cohort study protocol.

INTRODUCTION: Targeted, tailored interventions to test high-risk individuals for HIV and hepatitis C virus (HCV) are vital to achieving HIV control and HCV microelimination in Africa. Compared with the general population, people who inject drugs (PWID) are at increased risk of HIV and HCV and are less likely to be tested or successfully treated. Assisted partner services (APS) increases HIV testing among partners of people living with HIV and improves case finding and linkage to care. We describe a study in Kenya examining whether APS can be adapted to find, test and link to HIV care the partners of HIV-positive PWID using a network of community-embedded peer educators (PEs). Our study also identifies HCV-positive partners and uses phylogenetic analysis to determine risk factors for onward transmission of both viruses. METHODS: This prospective cohort study leverages a network of PEs to identify 1000 HIV-positive PWID for enrolment as index participants. Each index completes a questionnaire and provides names and contact information of all sexual and injecting partners during the previous 3 years. PEs then use a stepwise locator protocol to engage partners in the community and bring them to study sites for enrolment, questionnaire completion and rapid HIV and HCV testing. Outcomes include number and type of partners per index who are mentioned, enrolled, tested, diagnosed with HIV and HCV and linked to care. ETHICS AND DISSEMINATION: Potential index participants are screened for intimate partner violence (IPV) and those at high risk are not eligible to enrol. Those at medium risk are monitored for IPV following enrolment. A community advisory board engages in feedback and discussion between the community and the research team. A safety monitoring board discusses study progress and reviews data, including IPV monitoring data. Dissemination plans include presentations at quarterly Ministry of Health meetings, local and international conferences and publications. TRIAL REGISTRATION NUMBER: NCT03447210, Pre-results stage.

"Violence and love and drugs it all goes hand in hand": A mixed methods analysis of the substance abuse, violence, and HIV/AIDS syndemic among women who use methamphetamine.

Background: The synergistic epidemics of substance use, violence, and HIV/AIDS, also known as the SAVA syndemic, disproportionately affects vulnerable women in the United States. Methamphetamine use is closely linked with physical and sexual violence, including intimate partner violence (IPV), which heightens women's vulnerability to HIV. This mixed methods study examined the prevalence and correlates of violence among women who use methamphetamine, (n = 209) enrolled in an HIV intervention study in San Diego, California. Methods: At baseline, 209 women completed an interviewer-administered computer-assisted survey. A sub set of women who reported lifetime IPV (n = 18) also participated in qualitative interviews to contextualize our understanding of patterns of violence over time. Results: In the overall cohort, reports of lifetime (66.0%) and past 2-month (19.6%) IPV were prevalent. Moreover, women reported lifetime physical only (27.3%), sexual only (6.2%), or both forms of violence (50.7%) by multiple perpetrators. Factors independently associated with lifetime IPV were having unprotected sex with a steady partner (odds ratio [OR]: 2.50, 95% confidence interval [CI]: 1.04, 6.00) and being high on methamphetamine during unprotected sex with a steady partner (OR: 2.56, 95% CI: 1.30, 5.09) within the past 2 months. Our qualitative narratives illuminated how IPV in women's steady relationships often reflects a culmination of violent victimization throughout their lifetime which is further exacerbated by methamphetamine use and sexual risk through gendered power dynamics. Conclusions: HIV prevention interventions should address the SAVA syndemic in a holistic manner, including the role of methamphetamine use in the context of women's abusive steady relationships.

Successful engagement in buprenorphine treatment among hospitalized patients with opioid use disorder and trauma.

BACKGROUND: The opioid epidemic continues to cause significant morbidity and mortality. Although there are effective medications for opioid use disorder (OUD), a minority of patients receive these treatments. OUD is common among patients hospitalized for traumatic injury and hospitalization could be an opportunity to initiate medications and link to ongoing buprenorphine care. METHODS: This retrospective cohort study based on electronic health record review included patients who were: (1) hospitalized between January 1, 2018 and June 30, 2019, (2) age ≥18 years, (3) seen by an Addiction Medicine Consult Service, and (4) initiated on buprenorphine with plans for continuation post-discharge. Descriptive statistics identified differences between trauma and non-trauma groups and regression analysis identified predictors of 30 day buprenorphine follow up. RESULTS: Of 197 eligible patients, 60 (30.5 %) were hospitalized for traumatic injuries. Compared to non-trauma patients, trauma patients were younger, more likely to be employed, more likely to report using cannabis and tobacco, less likely to have recently injected drugs, and hospitalized longer. Among patients with follow-up data available (n = 147), 63.2 % of trauma patients were seen within 30 days, compared to 48.2 % of non-trauma patients (p = 0.16). There were no significant differences between the two groups with regards to urine drug test results or acute care utilization in the follow-up period. CONCLUSIONS: Among hospitalized patients with OUD who initiate buprenorphine, those who were hospitalized for trauma were at least as likely to link to out-patient treatment. Trauma admissions represent an important opportunity for diagnosing and linking patients with OUD to buprenorphine treatment.

Project Engage: Snowball Sampling and Direct Recruitment to Identify and Link Hard-to-Reach HIV-Infected Persons Who Are Out of Care.

INTRODUCTION: Innovative strategies are needed to identify and link hard-to-find persons living with HIV (PLWH) who are out of care (OOC). Project Engage, a health department-based project in Los Angeles County, used a mixed-methods approach to locate and provide linkage for PLWH who have limited contact with HIV medical and nonmedical services. METHODS: Incentivized social network recruitment (SNR) and direct recruitment (DR) was used to identify eligible OOC alters for a linkage intervention that included HIV clinic selection, appointment and transportation support, reminder calls/texts, and clinic navigation. RESULTS: Between 2012 and 2015, 112 alters were identified using SNR (n = 74) and DR (n = 38). Most alters were male (80%), African American (38%), and gay (60%). Sizable percentages were homeless (78%), had engaged in sex work (32%) in the previous 6 months, had injected drugs (47%), were incarcerated in the previous 12 months (50%), and had only received HIV care during the previous 5 years while incarcerated (24%). SNR alters were more likely than DR alters to be African American, uninsured, unemployed, homeless, sex workers, injection drug users, recently incarcerated, and have unmet service needs. Alters linked to care within 3 (69%), 4-6 (5%), and 7-12 months (8%), and 72% were retained at 6-12 months. The percent virally suppressed increased (27% vs. 41%) and the median viral load decreased (P = 0.003) between linkage and follow-up at 6-12 months. DISCUSSION: The alternative approaches presented were effective at locating marginalized HIV-positive persons who are OOC for linkage and retention. The SNR approach was most successful at identifying alters with serious social challenges and gaps in needed medical/ancillary services.

"Come on Baby. You Know I Love You": African American Women's Experiences of Communication with Male Partners and Disclosure in the Context of Unwanted Sex.

We examined African American women's experiences of communication with their male intimate partners a couple of hours before and after an incident of unwanted sex. We also examined women's experiences of disclosure following an incident of unwanted sex. Semi-structured qualitative interviews were conducted with a community-based sample of sexually active African American women (n = 19) reporting at least one incident of sexual coercion (i.e., being pressured into unwanted sex without consent) by an intimate male partner since the age of 18. Our analysis was guided by "the sexual division of power" from Connell's (1987) theory of gender and power. Data were analyzed inductively by examining the interviews for common themes in the following domains: communication before the unwanted sex, communication after the unwanted sex, and disclosure to others. Men pressured partners for unwanted sex through verbal and non-verbal tactics, ranging from pestering and blunt requests for sex to verbal bullying and violence. Many women responded by clearly saying no. However, many women also described eventually ceasing to resist their partners and engaging in unwanted sex. After the unwanted sex, men actively and passively avoided discussing the incident. Although many women discussed the unwanted sex with family and friends, less women disclosed to trained professionals. In some cases, women did not discuss the incident with anyone at all. These findings indicate that, when addressing sexual violence against women, there is a need to target men as well as the norms of masculinity that underpin physical and sexual violence against women.

Live to tell: Narratives of methamphetamine-using women taken hostage by their intimate partners in San Diego, CA.

BACKGROUND: Hostage-taking, an overlooked phenomenon in public health, constitutes a severe form of intimate partner violence and may be a precursor to female homicide within relationships characterized by substance use. Criminal justice studies indicate that most hostage incidents are male-driven events with more than half of all cases associated with a prior history of violence and substance use. Methamphetamine use increases a woman's risk of partner violence, with methamphetamine-using individuals being up to nine times more likely to commit homicide. As homicide is the most lethal outcome of partner violence and methamphetamine use, this study aims to characterize the potential role of hostage-taking within these intersecting epidemics. METHODS: Methamphetamine-using women enrolled in an HIV behavioural intervention trial (FASTLANE-II) who reported experiences of partner violence were purposively selected to participate in qualitative sub-studies (Women's Study I & II). Twenty-nine women, ages 26-57, participated in semi-structured interviews that discussed relationship dynamics, partner violence, drug use and sexual practices. RESULTS: Findings indicated four cases of women being held hostage by a partner, with two women describing two separate hostage experiences. Women discussed partner jealousy, drug withdrawal symptoms, heightened emotional states from methamphetamine use, and escalating violent incidents as factors leading up to hostage-taking. Factors influencing lack of reporting incidents to law enforcement included having a criminal record, fear of partner retaliation, and intentions to terminate the relationship when the partner is incarcerated. CONCLUSION: Educating women on the warning signs of hostage-taking within the context of methamphetamine use and promoting behaviour change among male perpetrators can contribute to reducing the risk of homicide. Furthermore, bridging the gap between health services and law enforcement agencies and providing comprehensive services that address the needs of methamphetamine-using women in violent relationships can prevent or minimize potential harm to vulnerable women.

"When you get old like this you don't run those risks anymore": influence of age on sexual risk behaviors and condom use attitudes among methamphetamine-using heterosexual women with a history of partner violence.

BACKGROUND: Drug use and partner violence affect older women, yet few studies highlight age-specific HIV risks and prevention strategies. This study compares sexual risk behaviors, condom use attitudes, and HIV knowledge between midlife/older women (ages 45+) and younger women (ages 18-44) reporting methamphetamine use and partner violence in San Diego, California. METHODS: Our mixed methods study used themes from a qualitative substudy (n = 18) to inform logistic regression analysis of baseline data from an HIV behavioral intervention trial (n = 154). FINDINGS: Age-related qualitative themes included physiologic determinants, HIV knowledge, and "dodging the bullet," referring to a lifetime of uncertainty surrounding HIV serostatus after engaging in unsafe drug and sex practices. Midlife/older age was associated with never being married (24.2% vs. 51.2; p = .03), having less than a high school education/GED (12.1% vs. 34.7%; p = .04), lower condom use self-efficacy (2.87 vs. 3.19; p = .03), lower positive outcome expectancies (1.9 vs. 2.1; p = .04), and lower HIV knowledge (85.3% vs. 89.7%; p = .04); however, sexual risk behaviors were not associated with age group. In the multivariate analysis, midlife/older age remained independently associated with lower condom use self-efficacy (adjusted odds ratio, 0.49; 95% CI, 0.27-0.87) and lower HIV knowledge (adjusted odds ratio, 0.96; 95% CI, 0.93-0.99). CONCLUSIONS: Midlife/older methamphetamine-using women with experiences of partner violence present similar sexual risk profiles, but possess different HIV-related knowledge and attitudes toward prevention methods compared with their younger counterparts. Clinicians and public health practitioners can have a positive impact on this overlooked population by assessing HIV risks during routine screenings, encouraging HIV testing, and providing age-appropriate HIV prevention education.

Women's perspectives on female-initiated barrier methods for the prevention of HIV in the context of methamphetamine use and partner violence.

BACKGROUND: Female-initiated barrier methods for the prevention of HIV may be an effective alternative for drug-using women who are unable to negotiate safe sex, often as a result of physical and/or sexual partner violence. METHODS: Utilizing a SAVA (substance abuse, violence, and AIDS) syndemic framework, we qualitatively examined perspectives on female condoms and vaginal microbicides among 18 women with histories of methamphetamine abuse and partner violence in San Diego, California. FINDINGS: Most women were not interested in female condoms owing to perceived discomfort, difficulty of insertion, time-intensive effort, and unappealing appearance. Alternatively, most women viewed vaginal microbicides as a useful method. Positive aspects included convenience, ability to disguise as a lubricant, and a sense of control and empowerment. Concerns included possible side effects, timing of application, and unfavorable characteristics of the gel. Acceptability of female-initiated barrier methods was context dependent (i.e., partner type, level of drug use and violence that characterized the sexual relationship). CONCLUSIONS: Findings indicate that efforts are needed to address barriers identified for vaginal microbicides to increase its uptake in future HIV prevention trials and marketing of future Food and Drug Administration-approved products. Strategies should address gender-based inequalities (e.g., partner violence) experienced by drug-using women and promote female empowerment. Education on female-initiated barrier methods is also needed for women who use drugs, as well as health care providers and other professionals providing sexual health care and contraception to women with histories of drug use and partner violence.

Prevention interventions for human immunodeficiency virus in drug-using women with a history of partner violence.

The intersecting epidemics of human immunodeficiency virus (HIV) and partner violence disproportionately affect women who use drugs. Despite accumulating evidence throughout the world linking these epidemics, HIV prevention efforts focused on these synergistic issues as well as underlying determinants that contribute to the HIV risk environment (eg, housing instability, incarceration, policing practices, survival sex) are lacking. This article highlights selected behavior change theories and biomedical approaches that have been used or could be applied in HIV prevention interventions for drug-using women with histories of partner violence and in existing HIV prevention interventions for drug-using women that have been gender-focused while integrating histories of partner violence and/or relationship power dynamics. To date, there is a paucity of HIV prevention interventions designed for drug-using women (both in and outside of drug treatment programs) with histories of partner violence. Of the few that exist, they have been theory-driven, culture-specific, and address certain aspects of gender-based inequalities (eg, gender-specific norms, relationship power and control, partner violence through assessment of personal risk and safety planning). However, no single intervention has addressed all of these issues. Moreover, HIV prevention interventions for drug-using women with histories of partner violence are not widespread and do not address multiple components of the risk environment. Efficacious interventions should target individuals, men, couples, and social networks. There is also a critical need for the development of culturally tailored combination HIV prevention interventions that not only incorporate evidence-based behavioral and biomedical approaches (eg, microbicides, pre-exposure prophylaxis, female-initiated barrier methods) but also take into account the risk environment at the physical, social, economic and political levels. Ultimately, this approach will have a significant impact on reducing HIV infections among drug-using women with histories of partner violence.