Human Immunodeficiency Virus-Experienced Clinician Workforce Capacity: Urban-Rural Disparities in the Southern United States.

BACKGROUND: Human immunodeficiency virus (HIV)-experienced clinicians are critical for positive outcomes along the HIV care continuum. However, access to HIV-experienced clinicians may be limited, particularly in nonmetropolitan areas, where HIV is increasing. We examined HIV clinician workforce capacity, focusing on HIV experience and urban-rural differences, in the Southern United States. METHODS: We used Medicaid claims and clinician characteristics (Medicaid Analytic eXtract [MAX] and MAX Provider Characteristics, 2009-2011), county-level rurality (National Center for Health Statistics, 2013), and diagnosed HIV cases (AIDSVu, 2014) to assess HIV clinician capacity in 14 states. We assumed that clinicians accepting Medicaid approximated the region's HIV workforce, since three-quarters of clinicians accept Medicaid insurance. HIV-experienced clinicians were defined as those providing care to ≥ 10 Medicaid enrollees over 3 years. We assessed HIV workforce capacity with county-level clinician-to-population ratios, using Wilcoxon-Mann-Whitney tests to compare urban-rural differences. RESULTS: We identified 5012 clinicians providing routine HIV management, of whom 28% were HIV-experienced. HIV-experienced clinicians were more likely to specialize in infectious diseases (48% vs 6%, P < .001) and practice in urban areas (96% vs 83%, P < .001) compared to non-HIV-experienced clinicians. The median clinician-to-population ratio for all HIV clinicians was 13.3 (interquartile range, 38.0), with no significant urban-rural differences. When considering HIV experience, 81% of counties had no HIV-experienced clinicians, and rural counties generally had fewer HIV-experienced clinicians per 1000 diagnosed HIV cases (P < .001). CONCLUSIONS: Significant urban-rural disparities exist in HIV-experienced workforce capacity for communities in the Southern United States. Policies to improve equity in access to HIV-experienced clinical care for both urban and rural communities are urgently needed.

What we talk about when we talk about durable viral suppression.

: As policies built on 'Undetectable = Untransmittable' become more popular, use of durable viral suppression (DVS) as an outcome in analyses is increasing. We identified a case series of recent HIV-related publications that study the DVS outcome. The majority did not distinguish between a definition of DVS and the operationalization of that definition. Clearer discussion of DVS, including a formal definition, is needed to ensure better comparability across studies and ultimately better public health outcomes.

Prevalence and Predictors of Provider-Initiated HIV Test Offers Among Heterosexual Persons at Increased Risk for Acquiring HIV Infection - Virginia, 2016.

Since 2006, CDC has recommended routine, provider-initiated human immunodeficiency virus (HIV) screening (i.e., HIV screening at least once in lifetime) for all patients aged 13-64 years in all health care settings (1). Whereas evidence related to the frequency of HIV testing is available, less is known about the prevalence and predictors of providers' HIV test offers to patients (2). National HIV Behavioral Surveillance (NHBS) data from Virginia were used to examine the prevalence and predictors of provider-initiated HIV test offers to heterosexual adults aged 18-60 years at increased risk for HIV acquisition. In a sample of 333 persons who visited a health care provider in the 12 months before their NHBS interview, 194 (58%) reported not receiving an HIV test offer during that time, approximately one third of whom (71, 37%) also reported never having had an HIV test in their lifetime. In multivariable analysis, the prevalence of HIV test offers was significantly lower among men than among women (adjusted prevalence ratio [aPR] = 0.72; 95% confidence interval [CI] = 0.53-0.97). Provider-initiated HIV test offers are an important strategy for increasing HIV testing among heterosexual populations; there is a need for increased provider-initiated HIV screening among heterosexual adults who are at risk for acquiring HIV, especially men, who were less likely than women to be offered HIV screening in this study.

Comprehensive Ryan White Assistance and Human Immunodeficiency Virus Clinical Outcomes: Retention in Care and Viral Suppression in a Medicaid Nonexpansion State.

Background: Knowledge gaps remain about how the Ryan White human immunodeficiency virus (HIV)/AIDS Program (RW) contributes to health outcomes. We examined the association between different RW service classes and retention in care (RiC) or viral suppression (VS). Methods: We identified Virginians engaged in any HIV care between 1 January and 31 December 2014. RW beneficiaries were classified by receipt of ≥1 service from 3 classes: Core medical, Support, and insurance and/or direct medication assistance through the AIDS Drug Assistance Program (ADAP). Receipt of all RW classes was defined as comprehensive assistance. We used multivariable logistic regression to compare the odds of RiC and of VS by comprehensive assistance and by RW classes alone and in combination. Results: Among 13104 individuals, 58% received any RW service and 17% comprehensive assistance. Comprehensive assistance is significantly associated with RiC (adjusted odds ratio [aOR], 8.8 [95% confidence interval {CI}, 7.2-10.8]) and viral suppression (aOR, 3.3 [95% CI, 2.9-3.8]). Receiving any 2 RW classes or Core alone is significantly associated with RiC and VS, with the strength of association decreasing as the number of classes decreases. Recipients of Support alone are significantly less likely to have VS (aOR, 0.75 [95% CI, .59-.96]). For ADAP recipients also receiving Core and/or Support, insurance assistance is significantly associated with VS compared to receiving direct medication only (aOR, 1.6 [95% CI, 1.3-1.9]); this relationship is not significant for those who receive ADAP alone. Conclusions: Receiving more classes of RW-funded services is associated with improved HIV outcomes. For some populations with insurance, RW-funded services may still be required for optimal health outcomes.

Parole officer-parolee relationships and HIV risk behaviors during community supervision.

We tested if good parole officer (PO)-parolee relationships reduce HIV risk behaviors during parole, as they do for risk of rearrest. Analyses used data from 374 parolees enrolled in a randomized clinical trial. Past month HIV risk behaviors were assessed by interview at baseline, 3- and 9-months after parole initiation. The Working Alliance Inventory and the Dual-Role Relationships Inventory measured PO relationship. Gender-stratified multivariate regressions tested associations of PO-parolee relationship with sex with multiple partners, unprotected sex with risky partner(s), and drug injection. Women parolees (n = 65) who reported better PO relationship characteristics were less likely to report having multiple sex partners [adjusted odds ratio: 0.82 (0.69, 0.98) at 3-months, 0.89 (0.80, 0.99) at 9-months], and, among those reporting multiple sex partners, had fewer partners on average [adjusted relative risk 0.98 (0.96, 0.99)]. These effects were not found among men. PO-parolee relationship quality can influence sexual risk behaviors among women parolees.

Limiting options: sex ratios, incarceration rates, and sexual risk behavior among people on probation and parole.

BACKGROUND: To investigate how incarceration may affect risk of acquiring HIV and other sexually transmitted infections, we tested associations of ex-offenders' sexual risk behavior with the male-female sex ratio and the male incarceration rate. METHODS: Longitudinal data from 1287 drug-involved persons on probation and parole as part of the Criminal Justice Drug Abuse Treatment Studies were matched by county of residence with population factors, and stratified by race/ethnicity and gender. Generalized estimating equations assessed associations of having unprotected sex with a partner who had HIV risk factors, and having >1 sex partner in the past month. RESULTS: Among non-Hispanic black men and women, low sex ratios were associated with greater risk of having unprotected sex with a risky partner (adjusted relative risk [ARR] = 1.76, 95% confidence interval [CI] = 1.29, 2.42; ARR = 2.48, 95% CI = 1.31, 4.73, respectively). Among non-Hispanic black and non-Hispanic white (NHW) women, low sex ratios were associated with having >1 sex partner (ARR = 2.00, 95% CI = 1.02, 3.94; ARR = 1.71, 95% CI = 1.06, 2.75, respectively). High incarceration rates were associated with greater risk of having a risky partner for all men (non-Hispanic black: ARR = 2.14, 95% CI = 1.39, 3.30; NHW: ARR = 1.39, 95% CI: 1.05, 1.85; Hispanic: ARR = 3.99, 95% CI = 1.55, 10.26) and having >1 partner among NHW men (ARR = 1.92, 95% CI = 1.40, 2.64). CONCLUSIONS: Low sex ratios and high incarceration rates may influence the number and risk characteristics of sex partners of ex-offenders. HIV-prevention policies and programs for ex-offenders could be improved by addressing structural barriers to safer sexual behavior.

Collaborative behavioral management among parolees: drug use, crime and re-arrest in the Step'n Out randomized trial.

AIMS: To determine whether collaborative behavioral management (CBM) reduces substance use, crime and re-arrest among drug-involved parolees. DESIGN: Step'n Out was a randomized behavioral trial of CBM versus standard parole (SP) during 2004-08. CBM adapted evidence-based role induction, behavioral contracting and contingent reinforcement to provide parole officer/treatment counselor dyads with positive tools in addition to sanctions to manage parolees' behavior over 12 weeks. SETTING: Six parole offices in five states in the USA. PARTICIPANTS: Parolee volunteers with a mandate for addiction treatment and a minimum of 3 months of parole (n = 476). Follow-up was 94% at 3 months and 86% at 9 months. MEASUREMENTS: Drug use and crime in a given month from calendar interviews 3 and 9 months after parole initiation, and re-arrests from criminal justice administrative data. FINDINGS: The CBM group had fewer months in which they used their primary drug [adjusted risk ratio (ARR) 0.20, 95% confidence interval (CI): 0.05, 0.78, P = 0.02] and alcohol (ARR 0.38, 95% CI: 0.22, 0.66, P = 0.006) over follow-up. CBM had its greatest effects among parolees who reported marijuana or another 'non-hard' drug as their primary drug; parolees who preferred stimulants or opiates did not benefit. No differences were seen in total crime, re-arrests or parole revocations. CONCLUSIONS: Collaborative behavioral management may reduce substance use among primary marijuana or other 'non-hard' drug-using parolees without increasing revocations. Because the majority of drug violation arrests in the United States are for marijuana, these findings have important implications for the management of a substantial proportion of the US community correctional population.

Collaborative behavioral management: integration and intensification of parole and outpatient addiction treatment services in the Step'n Out study.

Integration of community parole and addiction treatment holds promise for optimizing the participation of drug-involved parolees in re-entry services, but intensification of services might yield greater rates of technical violations. Collaborative behavioral management (CBM) integrates the roles of parole officers and treatment counselors to provide role induction counseling, contract for pro-social behavior, and to deliver contingent reinforcement of behaviors consistent with contracted objectives. Attendance at both parole and addiction treatment are specifically reinforced. The Step'n Out study of the Criminal Justice-Drug Abuse Treatment Studies (CJ-DATS) randomly allocated 486 drug-involved parolees to either collaborative behavioral management or traditional parole with 3-month and 9-month follow-up. Bivariate and multivariate regression models found that, in the first 3 months, the CBM group had more parole sessions, face-to-face parole sessions, days on which parole and treatment occurred on the same day, treatment utilization and individual counseling, without an increase in parole violations. We conclude that CBM integrated parole and treatment as planned, and intensified parolees' utilization of these services, without increasing violations.

Egocentric networks of Chinese men who have sex with men: network components, condom use norms, and safer sex.

Research on risk behaviors among men who have sex with men (MSM) is often based on individualistic models of health behavior, but sexual behavior is inherently social in nature and often determined by constituents of social networks. The objective of this study was to examine relationships among social networks, network norms of condom use, and safer sex. A respondent-driven sampling study recruited 350 MSM in the Shenzhen region of China between November and December 2007 and collected information on network components (relations, structures, and functions) and HIV risk behavior among egos (those interviewed) and their network alters. A total of 2385 alters were nominated by the 350 egos. Egos reported an average of 4 nonsexual relation alters and 2 sexual-partner alters. Egos perceived receiving more tangible and emotional support from nonsexual relation alters than from sexual-partner alters. Two thirds (69%) of egos consistently used condoms. Sixty-seven percent of egos reported having 1 or more alters who always encouraged egos to use condoms, 84% had 1 or more alters who consistently used condoms, and 55% had 1 or more alters who insisted on condom use. Both subjective and descriptive norms were positively associated with consistent condom use. Network components were associated with the levels of the two norms. These findings suggest that social network components may activate or strengthen condom use norms within networks, which, in turn, determine consistent condom use among MSM. HIV behavioral interventions need to target the promotion of safer sex practices through enhancing peer norms of condom use within networks.

Money boys, HIV risks, and the associations between norms and safer sex: a respondent-driven sampling study in Shenzhen, China.

Money boys (MBs) are male sex workers who sell sex to men who have sex with men (MSM). This study estimates the proportion of MBs in the Chinese MSM, compares HIV risks between MBs and non-MB MSM, and examines the associations between practicing safer sex and peer norms of condom use. Respondent-driven sampling (RDS) was used to sample 351 MSM in the city of Shenzhen in 2007. The RDS-adjusted proportion of MBs among MSM was 9%. Compared to non-MB MSM, more MBs reported having had multiple male and female sexual partners. Half of MBs and non-MB MSM had consistently used condoms. Both descriptive and subjective norms were positively associated with condom use. The MB proportion of 9% in MSM implies a relatively large population of MBs in China. The association between peer norms and consistent condom use can assist with the development of culturally competent HIV interventions that promote safer sex.

Collaborative Behavioral Management for Drug-Involved Parolees: Rationale and Design of the Step'n Out Study.

This article describes the rationale, study design, and implementation for the Step'n Out study of the Criminal Justice Drug Abuse Treatment Studies. Step'n Out tests the relative effectiveness of collaborative behavioral management of drug-involved parolees. Collaborative behavioral management integrates the roles of parole officers and treatment counselors to provide role induction counseling, contract for pro-social behavior, and deliver contingent reinforcement of behaviors consistent with treatment objectives. The Step'n Out study will randomize 450 drug-involved parolees to collaborative behavioral management or usual parole. Follow-up at 3-and 9-months will assess primary outcomes of rearrest, crime and drug use. If collaborative behavioral management is effective, its wider adoption could improve the outcomes of community reentry of drug-involved ex-offenders.

HCV in incarcerated populations: an analysis of gender and criminality on risk.

While studies have explored the prevalence and correlates for hepatitis C (HCV) infection in substance-using and incarcerated populations these studies have not examined the attributes of criminal histories for those with HCV infection. This study examines the HCV infection rate as it relates to criminal risk factors using baseline data from a randomized trial of re-entering offenders and examines how these risk factors vary by gender. The HCV-positive population had a longer amount of time in confinement (105 vs. 61 months) than those who tested negative. HCV positive men were more likely to currently be receiving drug treatment than women. Criminal risk was positively associated with HCV infection while controlling for major risk factors (OR 1.25,95% CI: 1.07, 1.46), suggesting that the relationship was not spurious. While criminologists tend to examine risk relative to public safety threats, it appears that the public health needs equally require attention. Policy issues are examined regarding how services can be delivered to treat those with HCV infections within the correctional system and address criminal risk factors.