Bridging barriers to clinic-based HIV testing with new technology: translating self-implemented testing for African American youth.

Numerous barriers to clinic-based HIV testing exist (e.g., stigmatization) for African American youth. These barriers may be addressed by new technology, specifically HIV self-implemented testing (SIT). We conducted a series of formative phase 3 translation studies (49 face-to-face interviews, 9 focus groups, 1 advisory panel review) among low-income African American youth (15-19 years) and providers of adolescent services in two US cities to identify potential translation difficulties of the OraQuick SIT. Based on content analysis, we found that providers and African American youth viewed SITs positively compared to clinic-based testing. Data suggest that SITs may reduce social stigma and privacy concerns and increase convenience and normalization of HIV testing. Challenges with SIT implementation include difficulties accessing confirmatory testing, coping with adverse outcomes, and instructional materials that may be inappropriate for low socioeconomic status (SES) persons. Study results underscore the need for translation studies to identify specific comprehension and implementation problems African American youth may have with oral SITs.

Differential HIV risk in bathhouses and public cruising areas.

OBJECTIVES: This report investigates differences in risk behaviors among men who have sex with men (MSM) who went to gay bathhouses, public cruising areas, or both. METHODS: We used a probability sample of MSM residing in 4 US cities (n = 2,881). RESULTS: Men who used party drugs and had unprotected anal intercourse with nonprimary partners were more likely to go to sex venues than men who did not. Among attendees, MSM who went to public cruising areas only were least likely, and those who went to both public cruising areas and bathhouses were most likely to report risky sex in public settings. CONCLUSIONS: Distinguishing between sex venues previously treated as a single construct revealed a significant association between pattern of venue use and sexual risk. Targeting HIV prevention in the bathhouses would reach the segment of men at greatest risk for HIV transmission.

The continuing HIV epidemic among men who have sex with men.

OBJECTIVES: This study characterized the AIDS epidemic among urban men who have sex with men (MSM). METHODS: A probability sample of MSM was obtained in 1997 (n = 2881; 18 years and older) from New York, Los Angeles, Chicago, and San Francisco, and HIV status was determined through self-report and biological measures. RESULTS: HIV prevalence was 17% (95% confidence interval = 15%, 19%) overall, with extremely high levels in African Americans (29%), MSM who used injection drugs (40%), "ultraheavy" noninjection drug users (32%), and less educated men (< high school, 37%). City-level HIV differences were non-significant once these other factors were controlled for. In comparing the present findings with historical data based on public records and modeling, HIV prevalence appears to have declined as a result of high mortality (69%) and stable, but high, incidence rates (1%-2%). CONCLUSIONS: Although the findings suggest that HIV prevalence has declined significantly from the mid-1980s, current levels among urban MSM in the United States approximate those of sub-Saharan countries (e.g., 14%-25%) and are extremely high in many population subsegments. Despite years of progress, the AIDS epidemic continues unabated among subsegments of the MSM community.

Health-related characteristics of men who have sex with men: a comparison of those living in "gay ghettos" with those living elsewhere.

OBJECTIVES: This study investigated the limitations of probability samples of men who have sex with men (MSM), limited to single cities and to the areas of highest concentrations of MSM ("gay ghettos"). METHODS: A probability sample of 2881 MSM in 4 American cities completed interviews by telephone. RESULTS: MSM who resided in ghettos differed from other MSM, although in different ways in each city. Non-ghetto-dwelling MSM were less involved in the gay and lesbian community. They were also less likely to have only male sexual partners, to identify as gay, and to have been tested for HIV. CONCLUSIONS: These differences between MSM who live in gay ghettos and those who live elsewhere have clear implications for HIV prevention efforts and health care planning.

National trends in condom use among at-risk heterosexuals in the united states.

Based on national level surveys, we examined data relevant to the United States' overall effort to prevent the spread of HIV among heterosexual adults. We examined changes in condom use among at-risk heterosexuals over the past decade. The observed increases over time in condom use across all heterosexual at-risk population segments are consistent with the observed (declines) trends in HIV and syphilis in the 1990s. These results and findings from prior studies suggest that U.S. efforts to facilitate condom use and contain HIV and related sexually transmitted disease (STD)-cofactors among adult at risk heterosexuals was succeeding over most of the 1990s. The absence of national level behavioral trend data after 1996, and the ambiguities of HIV spread suggest some caution in projecting trends into this century. National and local efforts need to be directed at sustaining behavioral change and conducting more rigorous studies on population trends in HIV/STD-related behaviors/pathogens.

Use of antiretroviral therapies among HIV-infected men who have sex with men: a household-based sample of 4 major American cities.

OBJECTIVES: This study sought to determine the prevalence and determinants of use of recommended antiretroviral regimens among urban seropositive men who have sex with men (MSM). METHODS: A probability telephone sample of MSM was taken within regions of Chicago, Los Angeles, New York, and San Francisco. Analysis focused on use of antiretroviral therapies. RESULTS: Although the majority of seropositive MSM with CD4 counts below 500 per microliter were using recommended antiretroviral regimens, 26% of seropositive MSM were not receiving such care. Men who were younger, who reported a sexual orientation other than homosexual, who had a more recent interview date, who were at middle levels of affiliation with the gay community, and who reported higher levels of perceived exclusivity on the part of the gay community were less likely to be using recommended antiretroviral regimens. CONCLUSIONS: Although current efforts to make antiretroviral therapies available to HIV-seropositive MSM are reasonably effective, additional efforts are needed for MSM characterized by relative youth and lower social support.

Alcohol use, drug use and alcohol-related problems among men who have sex with men: the Urban Men's Health Study.

AIMS: To measure the prevalence and independent associations of heavy and problematic use of alcohol and recreational drugs among a household-based sample of urban MSM (men who have sex with men). DESIGN: Cross-sectional survey. PARTICIPANTS: Men who identified as being gay or bisexual or who reported sex with another man in the prior 5 years were included in this analysis (n = 2172). SETTING: A probability telephone sample of MSM was taken within Zip Codes of four large American cities (Chicago, Los Angeles, New York and San Francisco) estimated to have total concentrations of at least 4% of all households with one resident MSM. MEASUREMENTS: Standard measures of alcohol use, problems associated with alcohol use, and recreational drug use were administered by trained telephone interviewers. FINDINGS: Both recreational drug (52%) and alcohol use (85%) were highly prevalent among urban MSM, while current levels of multiple drug use (18%), three or more alcohol-related problems (12%), frequent drug use (19%) and heavy-frequent alcohol use (8%) were not uncommon. The associations of heavy and/or problematic substance use are complex, with independent multivariate associations found at the levels of demographics, adverse early life circumstances, current mental health status, social and sexual practices and connection to gay male culture. CONCLUSIONS: The complex pattern of associations with heavy and/or problematic substance use among urban MSM suggests that heavy and/or problematic substance use is grounded in multiple levels: the individual, the interpersonal and the socio-cultural.

The impact of T-ACASI interviewing on reported drug use among men who have sex with men.

Measurements of drug use and other illicit or stigmatized behaviors are subject to nontrivial underreporting biases. During in-person surveys, respondents are more likely to report such behaviors when interviewed using techniques that maximize interviewee privacy, e.g., use of paper SAQs and audio-CASI rather than questioning by human interviewers. Until recently, respondents in telephone surveys could not be offered similar privacy. A new technology, telephone audio computer-assisted self-interviewing (T-ACASI) overcomes this limitation of telephone surveys by allowing respondents to respond to a computer. A randomized experimental test of T-ACASI was embedded in the Urban Men's Health Study (UMHS). UMHS surveyed a probability sample of 2,881 men from four United States cities and who reported having sex with men. Respondents interviewed using T-ACASI reported a higher prevalence of drug use and drug-related behaviors than respondents interviewed by human interviewers. However, survey respondents were more likely to break off an interview when the interview was conducted by a T-ACASI computer rather than by a human interviewer.

Health care policy. U.S. priorities-HIV prevention.

One of the scientific anomalies of the AIDS epidemic is the large difference in infection rates across populations. Given limited resources and segregated epidemics, prevention funding should be directed to population segments with high HIV prevalence and incidence. However, recent surveys of U.S. populations indicate that the allocation of prevention dollars is not consistent with the distribution of HIV in the population.

How many HIV infections cross the bisexual bridge? An estimate from the United States.

OBJECTIVE: Most heterosexual women with AIDS have been infected by male sex partners who acquired HIV via injecting drug use or sex with men. The contribution of bisexuality to heterosexual HIV however, has been poorly quantified. In this paper, we estimate the number of HIV infections that spread from the homosexual community to women who have sex with bisexual men. METHODS: We developed an HIV transmission model and assigned values to the model's parameters using data from a probability survey of US cities with a high risk of HIV. RESULTS: We estimated that these are about 400 HIV infections transmitted annually from HIV-infected bisexual men in high-risk cities to their female sex partners; two-thirds of these infections are transmitted to main female partners and one-third to casual partners. Uncertainties in the value of model parameters lead to variation in expected HIV infections mostly within the range 200 to 600, and for one parameter up to nearly 800. CONCLUSION: We conclude that transmission via bisexuality is a relatively minor component of the estimated 40,000 annual HIV infections in the USA.

AIDS-related risk behaviors and safer sex practices of women in midlife and older in the United States: 1990 to 1992.

Women in midlife and older represent over 25% of all women with AIDS and 4% of all reported AIDS cases in the United States. We present prevalence estimates and demographic correlates of AIDS-related risk behavior and safer sex practices among women in midlife and older from the National AIDS Behavioral Surveys (NABS). Data are of women aged 40 to 75 in the (a) NABS 1 national sample (n = 887), (b) NABS 1 urban sample (n = 2,111), and (c) NABS 2 national sample (n = 624). Data from the baseline survey (NABS 1) revealed that approximately 8% or 4.5 million women aged 40 to 75 engaged in behaviors that might expose them to HIV. Data from the follow-up survey (NABS 2) indicated that the proportion of women who reported a risk factor remained at about 8%. Overall safer sex practices among older women who reported sexual risk behaviors were minimal. Between 90% and 100% had not used condoms in the previous 6 months. Moreover, almost 90% of the women who reported a risk behavior did not perceive themselves to be at risk.

Predictors of follow-through on plans to be tested for HIV.

INTRODUCTION: Fewer than 40% of people in the United States with HIV risk factors have been tested. However, almost 40% of untested individuals with HIV risk factors in high AIDS prevalence cities stated in the 1991 National AIDS Behavioral Surveys (NABS) that they (1) "planned to be tested" or (2) "would get tested if no one could find out." METHODS: We used longitudinal data from the 1991 and 1992 NABS (n = 5,543), which are nationally representative telephone surveys. We assessed whether untested individuals were tested one year later, and we used logistic regressions to address two research questions: What are the predictors of testing among untested individuals? What are the predictors of testing among untested individuals who "planned to be tested" or "would get tested if no one could find out?" RESULTS: We found that 30% of individuals who "planned to be tested," 16% of individuals who "would get tested if no one could find out," and 11% of persons with no intentions to be tested had been tested one year later (P < .001). In regression analyses, risk factors and higher education were key predictors of testing. CONCLUSIONS: It is encouraging that 30% of individuals who plan to be tested did get tested within one year. Further research, however, needs to examine testing barriers for the 70% of individuals who do not follow through on testing plans. The results provide important information for targeting testing programs, developing effective public policies, and addressing the debate over issues such as name reporting and the availability of home HIV tests.

Antibody testing and condom use among heterosexual African Americans at risk for HIV infection: the National AIDS Behavioral Surveys.

OBJECTIVES: This study describes predictions of condom use and human immunodeficiency virus (HIV) antibody testing in a population-based sample of African-American heterosexuals who reported HIV risk behavior. METHODS: Data were taken from the National AIDS Behavioral Surveys. RESULTS: Of the African-American respondents, 22% reported some risk for HIV infection; of those, 24% had been tested for HIV. CONCLUSIONS: Prevention messages encouraging HIV testing and condom use have not resulted in high rates of self-protective behavior among African Americans. Future prevention interventions must focus on specific motivations and barriers with regard to engaging in preventive behavior among specific age, gender, and educational-level groups within the population of African Americans at risk for HIV infection.

Informal caregiving to persons with AIDS in the United States: caregiver burden among central cities residents eighteen to forty-nine years old.

Characteristics and caregiving experiences of friends and family members caring for people with AIDS (PWAs) were examined. Based on a probability sample of informal AIDS caregivers ages 18-49 living in central cities of the United States (n = 260), analyses were conducted to (a) identify the sociodemographic characteristics of young central city caregivers; and (b) examine the effects of caregiver characteristics (relationship to PWA, gender, race/ethnicity, income, sexual orientation, HIV status, perceived susceptibility), and level of objective caregiving demands, on subjective caregiver burden. Results indicate that the largest group of caregivers in this age category are male friends of the PWA--a group not typically found among caregivers to persons with other types of illnesses. In general, gay or bisexual caregivers, caregivers who have traditional family ties to the PWA, men relative to women, and lower income caregivers, report the greatest burden. While level of caregiving demands represents the most influential predictor of caregiver burden, white and male caregivers experience greater burden, independent of level of involvement and other caregiver characteristics. Receiving instrumental support with caregiving buffers the impact of high objective demands on subjective burden.

Relationship of sexual mixing across age and ethnic groups to herpes simplex virus-2 among unmarried heterosexual adults with multiple sexual partners.

Sexual mixing is important to understanding how sexually transmitted diseases (STDs) spread in the general population, and, identifying people who mix across social groups aids HIV-STD prevention. The authors examined (a) the extent to which people have sexual partners from other sexual networks (disassortative mixing) in a probability sample of unmarried heterosexual adults reporting multiple sexual partners (N = 545) and (b) the relationship between mixing and Herpes Simplex Virus-2 (HSV-2). After demographic variables and number of lifetime sexual partners were controlled for, heavy mixers were significantly more likely to be HSV-2 positive. Degree of mixing down produced the most powerful relationship to HSV-2. Age, education, ethnicity, and a history of incarceration or IV drug use were found to distinguish between light and heavy mixers, although differences between ethnic and age mixing were observed. The results have implications for understanding HIV-STD transmission and for directing interventions toward population segments at high risk for transmitting HIV-STDs.

HIV risk factors, condom use, and HIV antibody testing among heterosexual Hispanics: the National AIDS Behavioral Surveys (NABS).

PIP: Although Hispanics comprise only 9% of the US population, they account for 16% of AIDS cases. This study used data from the 4390 heterosexual Hispanics interviewed as part of the 1990-91 National AIDS Behavioral Survey to determine the prevalence and demographic correlates of HIV antibody testing and condom use among Hispanics at risk for HIV. Overall, 16.4% of respondents reported an HIV risk factor, primarily two or more sexual partners in the last 12 months (64%) or a high-risk main sex partner (26%). Those at risk tended to be highly acculturated unmarried males aged 18-29 years of European Spanish, South American, or Caribbean origin, with more than 12 years of education, an annual income under US$10,000, and infrequent church attendance. 35.3% of these high-risk persons had been tested for HIV; male gender and middle-income status were the strongest predictors of testing. Condoms were used at least half the time with a primary partner by 22.4% and with secondary partners by 44.7%, with higher use rates among acculturated Hispanics. The low prevalence of condom use and HIV testing among high-risk Hispanics underscores the need for campaigns that reinforce the acceptability of condom use as a social norm. Because US Hispanics are a heterogeneous group, such campaigns should target specific subgroups, including different national origins and levels of acculturation.^ieng

Cognitive and emotional assessments of perceived risk for HIV among unmarried heterosexuals.

We examined perceived risk of contracting HIV using assessments of likelihood and worry in a probability sample of unmarried heterosexuals. Perceptions of the likelihood of contracting HIV and worry about HIV were only modestly correlated (r = .23), suggesting that they are different constructs. Far more respondents expressed worry (43%) than expressed the belief that they were at risk for HIV (9%). A significant proportion of the sample reported experiences that may have placed them at risk for HIV transmission. Demographic and psychosocial correlates of perceived likelihood and worry were examined in separate multivariate logistic analyses. Misconceptions about HIV transmission, a history of injection-drug-using sexual partners, and less education were associated with higher perceived likelihood of contracting HIV. Misconceptions, having multiple sexual partners in the past year, and a history of sexually transmitted diseases (STDs) were associated with high worry about HIV. Implications of the findings for correcting HIV-related misconceptions are discussed.

Changes in multiple sexual partnerships, HIV testing, and condom use among US heterosexuals 18 to 49 years of age, 1990 and 1992.

We compared data from two independent, representative samples of the US population to determine whether heterosexual adults 18 to 49 years of age modified their human immunodeficiency virus (HIV) risk behaviors between 1990/91 and 1992. We found little change in multiple sexual partnerships, having a risky partner, and HIV test seeking in the heterosexual population. Overall, consistent condom use significantly increased from 11% in 1990/91 to 20% in 1992, but this increase was limited to selected demographic groups. These results suggest a continuing need for HIV education among heterosexual adults.