Estimating The Impact Of Out-Of-Pocket Cost Changes On Abandonment Of HIV Pre-Exposure Prophylaxis.

Oral HIV pre-exposure prophylaxis (PrEP) is highly effective for preventing HIV. Several different developments in the US either threaten to increase or promise to decrease PrEP out-of-pocket costs and access in the coming years. In a sample of 58,529 people with a new insurer-approved PrEP prescription, we estimated risk-adjusted percentages of patients who abandoned (did not fill) their initial prescription across six out-of-pocket cost categories. We then simulated the percentage of patients who would abandon PrEP under hypothetical changes to out-of-pocket costs, ranging from $0 to more than $500. PrEP abandonment rates of 5.5 percent at $0 rose to 42.6 percent at more than $500; even a small increase from $0 to $10 doubled the rate of abandonment. Conversely, abandonment rates that were 48.0 percent with out-of-pocket costs of more than $500 dropped to 7.3 percent when those costs were cut to $0. HIV diagnoses were two to three times higher among patients who abandoned PrEP prescriptions than among those who filled them. These results imply that recent legal challenges to the provision of PrEP with no cost sharing could substantially increase PrEP abandonment and HIV rates, upending progress on the HIV/AIDS epidemic.

Identifying HIV PrEP Attributes to Increase PrEP Use Among Different Groups of Gay, Bisexual, and Other Men Who Have Sex with Men: A Latent Class Analysis of a Discrete Choice Experiment.

Daily pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV among gay, bisexual, and other men who have sex with men (GBMSM), although uptake remains suboptimal. By identifying the features of PrEP that appeal to various subgroups of GBMSM, this study aimed to improve PrEP uptake by examining preferences for PrEP use. Adults ≥ 18 years old in six New England states completed an online discrete choice experiment survey. A latent class analysis (LCA) was conducted to identify groups of GBMSM based on four attributes of choices for PrEP (cost, time, side effects, and mode of administration). Multinominal logistic regression was conducted to compare the association between sociodemographic and behavioral characteristics and class memberships. Data from 675 GBMSM were analyzed. A 3-Class model was selected as the best fit model. Class 1 (47.7% of individuals) was identified as having "no specific preferences". Class 2 (18.5% of individuals) were "Cost- and time-conscious" and were significantly more likely to be older, have prior sexually transmitted infection (STI) testing, have low household income, private insurance, and have extreme concerns about HIV risk than those with no specific preference (Class 1). Finally, Class 3 (34.1% of individuals) were "Side effects-conscious" and were more likely to have low income, private insurance, and have moderate and extreme concerns about HIV risk than those with no specific preference (Class 1). Findings indicate that outreach to GBMSM who have never used PrEP should emphasize low cost and short travel times to increase potential PrEP use.

Geographic variations of pre-exposure prophylaxis reversal and abandonment among United States counties.

OBJECTIVE: In the United States, one in five newly insurer-approved pre-exposure prophylaxis (PrEP) prescriptions are reversed with over 70% of those reversed, being abandoned. Given the Ending the HIV Epidemic (EHE) initiative's goals, we assessed geographic variations of PrEP reversal and abandonment across EHE and non-EHE counties in the United States. DESIGN: This was a cross-sectional analysis of secondary data. METHODS: Data were collected from Symphony Analytics for adults 18 years and older, with a newly prescribed PrEP claim. Using the proportion of PrEP prescriptions by county, hotspot analysis was conducted utilizing Getis Ord Gi∗ statistics stratified by EHE and non EHE counties. Multivariable logistic regression was used to identify factors associated with residing in hotspots of PrEP reversal or PrEP abandonments. RESULTS: Across 516 counties representing 36,204 patients, the overall PrEP reversal rate was 19.4%, whereas the PrEP abandonment rate was 13.7%. Reversals and abandonments were higher for non-EHE (22.7 and 17.1%) than EHE (15.6 and 10.5%) counties. In both EHE and non-EHE counties, younger age, less education, females, and an out-of-pocket cost of greater than $100, were significantly associated with greater likelihood of residing in hotspots of PrEP reversal or abandonment, while Hispanics, Medicaid recipients, and an out-of-pocket cost of $10 or less had lower likelihood of residing in hotspots of reversal and abandonment. CONCLUSION: Findings indicate the need for implementation of focused interventions to address disparities observed in PrEP reversal and abandonment. Moreover, to improve primary PrEP adherence, national PrEP access programs should streamline and improve PrEP accessibility across different geographic jurisdictions.

Health Care Expenditures for Black and White US Adults Living Under Similar Conditions.

Importance: Evidence suggests that racial disparities in health outcomes disappear or diminish when Black and White adults in the US live under comparable living conditions; however, whether racial disparities in health care expenditures concomitantly disappear or diminish is unknown. Objective: To examine whether disparities in health care expenditures are minimized when Black and White US adults live in similar areas of racial composition and economic condition. Design, Setting, and Participants: This cross-sectional study used a nationally representative sample of 7062 non-Hispanic Black or White adults who live in 2238 of 2275 US census tracts with a 5% or greater Black population and who participated in the Medical Expenditure Panel Study (MEPS) in 2016. Differences in total health care expenditures and 6 specific categories of health care expenditures were assessed. Two-part regression models compared expenditures between Black and White adults living in the same Index of Concentration at the Extremes (ICE) quintile, a measure of racialized economic segregation. Estimated dollar amount differences in expenditures were calculated. All analyses were weighted to account for the complex sampling design of the MEPS. Data analysis was performed from December 1, 2019, to August 7, 2023. Exposure: Self-reported non-Hispanic Black or non-Hispanic White race. Main Outcomes and Measures: Presence and amount of patient out-of-pocket and insurance payments for annual total health care expenditures; office-based, outpatient, emergency department, inpatient hospital, or dental visits; and prescription medicines. ICE quintile 5 (Q5) reflected tracts that were mostly high income with mostly White individuals, whereas Q1 reflected tracts that were mostly low income with mostly Black individuals. Results: A total of 7062 MEPS respondents (mean [SD] age, 49 [18] years; 33.1% Black and 66.9% White; 56.1% female and 43.9% male) who lived in census tracts with a 5% or greater Black population in 2016 were studied. In Q5, Black adults had 56% reduced odds of having any health care expenditures (odds ratio, 0.44; 95% CI, 0.27-0.71) compared with White adults, at an estimated $2145 less per year, despite similar health status. Among those in Q5 with any expenditures, Black adults spent 30% less on care (cost ratio, 0.70; 95% CI, 0.56-0.86). In Q3 (most racially and economically integrated), differences in total annual health care spending were minimal ($79 annually; 95% CI, -$1187 to $1345). Conclusions and Relevance: In this cross-sectional study of Black and White adults in the US, health care expenditure disparities diminished or disappeared under conditions of both racial and economic equity and equitable health care access; in areas that were mostly high income and had mostly White residents, Black adults spent substantially less. Results underscore the continuing need to recognize place as a contributor to race-based differences in health care spending.

Barriers and facilitators to retention in care and treatment adherence among racially/ethnically diverse women with HIV in South Florida: a qualitative study.

Women, particularly those from racial/ethnic minority groups, experience disparities in HIV care and treatment, and in achieving viral suppression. This study identified barriers and facilitators influencing retention in HIV care and treatment adherence among women belonging to racial/ethnic minority groups. We conducted semi-structured interviews with 74 African American, Hispanic/Latina and Haitian cisgender women receiving care from the Ryan White HIV/AIDS Program in Miami-Dade County, Florida in 2019. Data were analyzed using a thematic analysis approach. The most salient barriers faced by women were competing life priorities, mental health and substance use issues, medication-related concerns and treatment burden, negative experiences with HIV care services, transportation and parking issues and stigma and discrimination. Important facilitators identified by women included taking personal responsibility for health, social support, and patient-friendly and supportive HIV care services. Our findings suggest that HIV care could be enhanced for this population by understanding the non-HIV needs of the women in care, provide more flexible and relevant services in response to the totality of these needs, and simplify and expand access to care and supportive services.

Clients' Perspectives on Patient-Centeredness: a Qualitative Study with Low-Income Minority Women Receiving HIV Care in South Florida.

Low-income, minority women living with HIV often experience multiple barriers in care that contribute to suboptimal care outcomes. Medical case managers (MCM) and medical providers are key players involved in care coordination and aid women along the HIV care continuum. The objective of this study was to identify current and potential patient-centered practices that facilitate adherence to medication and retention in care, from the perspective of racially and ethnically diverse women living with HIV. We implemented a qualitative study using semi-structured interviews with 75 African American, Hispanic/Latina, and Haitian women who were enrolled in the Ryan White HIV/AIDS Program in South Florida in 2019. We organized domains of exploration using a patient-centered care framework to identify practices in which providers acknowledged, respected, and responded to clients' preferences, needs, and values. Interviews were analyzed using consensual thematic analysis approach. Findings reflect women valued MCMs who were proactive and directive in care, provided motivation, and aided with navigation of shame, fear, and stigma. Women valued medical providers who upheld simple educational communication. Moreover, women reported that providers who reviewed medical results with clients, incorporated questions about families, and inquired about multiple physical and clinical needs beyond HIV created opportunities for women to feel respected, valued, and in turn, enhanced their involvement in their care. Findings identify specific interpersonal practices that can enhance the ability to better meet the needs of diverse groups of women, specifically those from racial/ethnic minority groups who face multiple sociocultural barriers while in care.

Factors Associated with Geographic Patterns of Poor Sustained Viral Suppression in Miami-Dade County Florida, 2017.

BACKGROUND: Identifying geographic locations most affected by the HIV epidemic is essential to addressing disparities that impact people living with HIV. This study sought to identify individual and neighborhood-level factors that are associated with residing in geographic hotspots of poor sustained HIV viral suppression. METHODS: Using data from the Miami-Dade County Ryan White HIV/AIDS program, spatial autocorrelation of poor sustained viral suppression (at least 1 laboratory test ≥ 200 copies/ml in 2017) was investigated using Global Moran's I followed by Local Moran's I and Getis Ord Gi* statistics by ZIP code tabulation areas (ZCTAs). Subsequently, multivariable logistic regression analysis was conducted to identify factors associated with residing in geographic hotspots of poor sustained viral suppression. RESULTS: Several ZCTAs in the northern part of the county, accounting for 1/3 of the Ryan White program clients, had significantly higher clustering of poor sustained viral suppression. Client-level sociodemographic characteristics such as race/ethnicity, age, and poverty, and neighborhood-level characteristics (socioeconomic disadvantage index, residential instability index, and racial/language homogeneity index) were significantly associated with living in a hotspot of poor sustained viral suppression. CONCLUSION: These findings highlight that spatial variation in sustained viral suppression exists within the county. Targeted strategies that address structural factors and the needs of people with HIV living in specified geographic areas may improve their HIV health outcomes and contribute towards local, regional, and national goals of ending the HIV epidemic.

Sex differences in psychosocial and demographic factors associated with sustained HIV viral suppression in the Miami-Dade County Ryan White Program, 2017.

This exploratory study examined sex differences in psychosocial and demographic factors associated with sustained HIV viral suppression (SVS). The study population included 6,489 Miami-Dade Ryan White Program (RWP) clients receiving services during 2017; administrative data was analyzed. SVS was defined as having all viral load tests during 2017 below 200 copies/ml. Multilevel logistic regression models accounted for clustering by medical case management site. Models were stratified by sex. Overall, a higher proportion of females did not achieve SVS (23.5%) than males (18.1%). For females (n = 1,503), having acquired HIV perinatally and not having a partner oradult household member were associated with not achieving SVS. For males (n = 4,986), lacking access to food, Black or Haitian race/ethnicity, problematic substance use, and unknown physician were associated with not achieving SVS. For both sexes, younger age, lower household income, ever having an AIDS diagnosis, feeling depressed or anxious, and experiencing homelessness were associated with not achieving SVS. Elements of the transition from adolescent to adult HIV care that may differentially impact female clients and factors associated with disclosure should be explored further. Male clients may require additional support for food security. Improving culturally specific care for Haitian and non-Hispanic Black male clients should also be explored.

Person-time spent with HIV viral load above 1500 copies/mL among Miami-Dade County Ryan White Program clients, 2017-2019: a retrospective analysis.

HIV transmission risk significantly increases at HIV viral load (VL) >1500 copies/mL. We sought to determine the percentage of person-time spent with VL >1500 copies/mL (pPT >1500) and the associations of demographic, clinical, and psychosocial factors and this outcome among persons with HIV receiving care. A retrospective analysis of data from clients enrolled in the Ryan White Program from 2017 to 2019 was performed. We assessed pPT >1500 in HIV care by utilizing consecutive VL pairs and calculating the length of time between each pair and the corresponding time spent for the observation period. The association between pPT >1500 and selected client characteristics were analyzed using a random-effects zero-inflated negative binomial model. Among the 6390 clients, 42% were aged 50 or older, 52% MSM, and 59% Hispanic. Overall, 7.5% of clients spent, on average, 27.4 days per year at substantial risk of transmitting HIV. Younger age, AIDS diagnosis, and reported drug use in the preceding 12 months were associated with higher pPT >1500. Tailored interventions should be implemented to meet the unique HIV needs of groups with consistent viremia to significantly minimize transmission risk.

Relationship between Housing Characteristics and Care Outcomes among Women Living with HIV: Latent Class Analysis.

Housing plays a critical role in the care outcomes of individuals living with a HIV, yet few studies have examined the unique housing profiles of women living with HIV (WLH), especially among those belonging to low-income racial/ethnic minority groups. In this study, authors conducted a latent class analysis to generate latent profiles of women (N = 1,501) according to their housing status and household characteristics and assessed associations between classes and sociodemographic and behavioral characteristics and between classes and three HIV care outcomes: retention in care, viral suppression, and sustained viral suppression. A three-class model was selected using five dichotomized housing indicators: housing status, head of household status, living with minors, living with another adult, and disclosure of HIV status to adults with whom they live. While class 1 and class 2 had comparable HIV care outcomes, women in class 3-who were predominately unstably housed, living alone, and did not disclose their HIV status with those with whom they lived-had significantly lower crude odds of successful care outcomes. When accounting for sociodemographic and behavioral factors, significant differences in retention in care persisted. Findings underscore the need for tailored interventions for subgroups of low-income WLH and provide contextual details around the role of housing experiences.

A Comparative Analysis of Different HIV Viral Load Suppression Definitions Among Clients Receiving Care in the Miami-Dade Ryan White HIV/AIDS Program.

The study's objective was to examine variations in viral load (VL) suppression definitions among clients in the Ryan White Program (RWP). Data from clients enrolled in the RWP during 2017 were examined to calculate the proportion of virally suppressed clients using three definitions: recent viral suppression, defined as having a suppressed VL (< 200 copies/mL) in the last test in 2017; maintained viral suppression, having a suppressed VL for both the first and last tests in 2017; and sustained viral suppression, having all tests in 2017 showing suppression. Relative differences across all three definitions were computed. Recent viral suppression measures were higher than maintained and sustained viral suppression measures by 7.0% and 10.1%, respectively. Significant relative differences in definitions by demographic, socioeconomic and clinical status were observed. It may be beneficial for care planning to report not only estimates of recent viral suppression but maintained and sustained viral suppression as well.

Social disorganization and new HIV diagnoses, 2013-2017, Florida: Rural-urban differences.

PURPOSE: To compare the role of neighborhood social disorganization factors on human immunodeficiency virus (HIV) diagnosis rates in urban and rural areas in Florida, we conducted an ecologic study of HIV diagnosis rates during 2013-2017 and social disorganization components, including concentrated disadvantage, ethnic heterogeneity, and residential instability. METHODS: Indices of social disorganization components were obtained from principal component analyses of American Community Survey variables for 910 postal codes. Rural/urban classification was based on the United States Department of Agriculture Rural Urban Commuting Area codes. Using multivariable linear regression, the relationship between social disorganization indices and HIV diagnosis rates was assessed. FINDINGS: The only social disorganization index that was significantly higher in rural than urban areas was concentrated disadvantage. In rural areas, the concentrated disadvantage index was significantly associated with HIV diagnosis rates (P = .007) when controlling for the other social disorganization factors but was no longer significant after additionally controlling for prevalence of people with an HIV diagnosis who were not virally suppressed. In urban areas, even after controlling for prevalence of people with HIV who were not virally suppressed, lower male-to-female population ratios and higher scores of residential instability, concentrated disadvantage, and LatinX/immigrant density indices were associated with higher HIV diagnosis rates (all P < .01). CONCLUSIONS: In addition to improving community levels of viral suppression, the community contextual environment, including the rurality of the environment, needs to be considered in strategies to end the HIV epidemic in the United States.

A Systematic Review and Meta-analysis to Estimate the Time from HIV Infection to Diagnosis for People with HIV.

Timely HIV diagnosis is critical to minimizing transmission events. We sought to estimate the meantime from HIV infection to diagnosis and its temporal trend among people with HIV. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a search of MEDLINE, Embase, and Google Scholar, supplemented by a hand search of bibliographies of articles, was conducted. Study information and outcome measures of time from HIV infection to diagnosis were synthesized. Random-effects metaanalyses were performed. The search identified 12 articles from 4541 unduplicated citations. Studies were conducted in the UK (k = 3), US (k = 3), France (k = 2), Australia (k = 1), Switzerland (k = 1), Netherlands (k = 1), and China (k = 1). The pooled meantime from HIV infection to diagnosis was 3.00 years (95% confidence interval: 2.16-3.84). From 1996 to 2002, meantime reduced from 4.68 to 2.66 years. Subsequently, it increased to 3.20 years in 2003 and remained relatively stable until 2015. In sub-group meta-analyses, men who have sex with men (MSM) had a meantime of 2.62 years (1.91-3.34), while for heterosexuals and people who inject drugs, it was 5.00 (4.15-5.86) and 4.98 (3.97-5.98) years, respectively. In the high- and upper-middle-income countries included in this study, persons live with undiagnosed HIV for about 3 year before being diagnosed. This period is shorter for MSM relative to people with infections attributable to other risk factors.

Neighborhood Factors Associated with Racial/Ethnic Disparities in Achieving Sustained HIV Viral Suppression Among Miami-Dade County Ryan White Program Clients.

Racial/ethnic minorities are disproportionately affected by poor HIV care outcomes. Studies have also examined the effects of neighborhood-level factor on an individual's health outcomes. Thus, the objective of this study was to assess the effects of neighborhood factors on the association between race/ethnicity and sustained viral suppression (all viral load tests <200 copies/mL per year). Data for 6491 people with HIV in the 2017 Miami-Dade County Ryan White Program and neighborhood-level data by ZIP code tabulated areas from the American Community Survey were utilized. Multi-level logistic regression models were used to assess the role of neighborhood factors on the association between race/ethnicity and sustained viral suppression. Results show that non-Hispanic Blacks had lower odds of sustained viral suppression in low socioeconomic disadvantage [adjusted odds ratio (aOR): 0.39; 95% confidence interval (CI): 0.20-0.74], moderate residential instability (aOR: 0.31; 95% CI: 0.15-0.65), and low and high racial/language homogeneity neighborhoods (aOR: 0.38; 95% CI: 0.16-0.88) and (aOR: 0.38; 95% CI: 0.19-0.75), respectively, when compared to non-Hispanic Whites (NHWs). Haitians also exhibited poor outcomes in neighborhoods characterized by moderate residential instability (aOR: 0.42; 95% CI: 0.18-0.97) and high racial/language homogeneity (aOR: 0.49; 95% CI: 0.26-0.93), when compared to NHWs. In conclusion, disparities in rates of sustained viral suppression were observed for racial/ethnic minorities within various neighborhood-level factors. These findings indicate the importance of addressing neighborhood characteristics to achieve optimal care for minorities.

Factors Associated with Viral Suppression Among Racial/Ethnic Minority Women in the Miami-Dade County Ryan White Program, 2017.

The study's objective was to identify factors associated with differences in the rate of viral suppression among minority women with HIV/AIDS in care in the Miami-Dade County Ryan White Program (RWP). A retrospective cohort study was conducted using social characteristics and laboratory data of minority women enrolled in the Miami-Dade County RWP in 2017. Viral suppression was defined as <200 copies/mL using the last viral load test of 2017. Multilevel logistic regression models were used to estimate adjusted odds ratio (aOR) and 95% confidence intervals (CIs). Of the 1,550 racial/ethnic minority women in the study population, 43.1% were African American, 31.3% were Hispanic, and 25.6% were Haitian. The proportion of women virally suppressed was lower among African Americans (80.8%) than among Hispanics (86.4%) and Haitians (85.1%). Viral suppression rates were significantly lower among women aged 18-34 years (aOR: 0.41, CI: 0.27-0.64) and 35-49 years (0.63, 0.45-0.90) vs. ≥50 years, born in the United States (0.48, 0.30-0.78), having a household income of <100% the federal poverty level (0.54, 0.30-0.95), previously diagnosed with AIDS (0.60, 0.44-0.81), reporting problematic drug use (0.23, 0.08-0.69), and living in a residentially unstable neighborhood (0.77, 0.64-0.93). Race/ethnicity was not associated with viral suppression after adjusting for other factors. Factors associated with lack of viral suppression were similar among minority racial/ethnic groups. Interventions at the individual level focusing on young, U.S. born individuals, and those who report drug use, and at the neighborhood level for those living in residentially unstable neighborhoods are needed to improve viral suppression outcomes.

Latent Class Analysis of Syndemic Factors Associated with Sustained Viral Suppression among Ryan White HIV/AIDS Program Clients in Miami, 2017.

The study's objective was to identify the association between sustained viral suppression (all viral load tests < 200 copies/ml per year) and patterns of co-occurring risk factors including, mental health, substance use, sexual risk behavior, and adverse social conditions for people with HIV (PWH). Latent class analysis followed by multivariable logistic regression was conducted for 6554 PWH in the Miami-Dade County Ryan White Program during 2017, and a five-class model was selected. Compared to Class 1 (no risk factors), the odds of achieving sustained viral suppression was significantly lower for Class 2 (mental health) (aOR: 0.67; 95% CI 0.54-0.83), Class 3 (substance use and multiple sexual partners) (0.60; 0.47-0.76), Class 4 (substance use, multiple sexual partners, and domestic violence) (0.71; 0.55-0.93), and Class 5 (mental health, substance use, multiple sexual partners, domestic violence, and homelessness) (0.26; 0.19-0.35). Findings indicate the need for targeted interventions that address these syndemic factors.

Identifying patterns of retention in care and viral suppression using latent class analysis among women living with HIV in Florida 2015-2017.

The study objective was to classify women with newly diagnosed HIV into patterns of retention in care (≥2 HIV care visits ≥3 months apart) and viral suppression over time and identify factors associated with class membership. Florida HIV/AIDS surveillance data were used to conduct Latent Class Analysis to classify women into patterns, and multinomial regression was used to compare the prevalence of class membership by demographic and clinical factors. Four classes were selected based on model fit parameters: (Class 1) consistently retained and suppressed (>90% probability of being retained and suppressed), (Class 2) not consistently retained or suppressed (≤10% probability of being retained and suppressed), (Class 3) increasingly retained and suppressed, and (Class 4) decreasingly retained and suppressed. The proportion of women in each class was 48.6%, 24.9%, 14.3%, and 12.2%, respectively. Women aged 25-34 compared to 35-49 years old, injection drug use mode of exposure, US born, and not linked to care three months post-diagnosis had a lower prevalence of belonging to the consistently retained and suppressed class. Findings may be useful in tailoring and targeting interventions to increase the prevalence of women who are consistently retained in care and virally suppressed.

Influence of Tobacco Marketing on Nepalese Adolescents: Cigarette Use and Susceptibility to Cigarette Use.

BACKGROUND: Tobacco advertising, promotion, and sponsorship (TAPS) are common tactics of the tobacco industry to encourage adolescents to use tobacco products. OBJECTIVE: The objective of the study is to assess the influence of TAPS on cigarette use and susceptibility to cigarette use among Nepalese adolescents. MATERIALS AND METHODS: Data (n=2,878) were drawn from the Global Youth Tobacco Survey for Nepal (GYTS, 2011). Channel-specific and cumulative TAPS exposure were the primary exposures of the study. Six multivariate logistic regression analyses were performed to examine current and ever cigarette use outcome with exposure to TAPS. Six binary logistic regression analyses were applied to determine the susceptibility to cigarette use when exposed to TAPS. RESULTS: Channel-specific TAPS analyses show that indirect TAPS increases the odds of all the three outcomes; current cigarette use (OR=1.68, 95% CI=1.10-2.58), ever cigarette use (OR=1.81, 95% CI=1.23-2.65) and susceptibility to cigarette use (OR=1.65, 95% CI=1.25-2.19) after adjusting for the covariates. Television (TV) and movies exposure decreases the odds of susceptibility to cigarette use (OR=0.55, 95% CI=0.31-0.97). Cumulative TAPS analyses show that exposure to 5 sources of TAPS increases the odds of current cigarette use (OR=2.53, 95% CI=1.21-5.29). Being male increases the odds of all the three outcomes; current (OR=3.52, 95% CI=2.11-5.87), ever (OR=2.51, 95% CI=1.69-3.73) and susceptibility to cigarette use (OR=1.31, 95% CI=1.01-1.69). Social influence is likely to increase current (OR=6.47, 95% CI=2.50-16.74), ever (OR=1.79, 95% CI=1.10-2.93) and susceptibility to cigarette use (OR=1.66, 95% CI=1.25-2.21). CONCLUSION: Indirect TAPS exposure increased the current, ever, and susceptibility to cigarette use among Nepalese adolescents. Overall, the current use of cigarettes followed a dose-response relationship with TAPS exposure. The result implies a requirement of active surveillance of tobacco products and future research on adolescent-focused tobacco marketing in Nepal.

Differential Role of Psychosocial, Health Care System and Neighborhood Factors on the Retention in HIV Care of Women and Men in the Ryan White Program.

We investigated potential differential impact of barriers to HIV care retention among women relative to men. Client intake, health assessment, service, and laboratory information among clients receiving medical case management during 2017 in the Miami-Dade County Ryan White Program (RWP) were obtained and linked to American Community Survey data by ZIP code. Cross-classified multilevel logistic regression analysis was conducted. Among 1609 women and 5330 men, 84.6% and 83.7% were retained in care. While simultaneously controlling for all demographic characteristics, vulnerable/enabling factors, and neighborhood indices in the model, younger age, being US born, not working, and having a medical provider with low volume (<10) of clients remained associated with non-retention in care among women and men; while having ≥3 minors in the household and being perinatally infected were additionally associated with retention only for women. Both gender-specific and gender-non-specific barriers should be considered in efforts to achieve higher retention rates.