Adherence to Antiretroviral Therapy Among Children Living with HIV in South India.

Adherence to ART, fundamental to treatment success, has been poorly studied in India. Caregivers of children attending HIV clinics in southern India were interviewed using structured questionnaires. Adherence was assessed using a visual analogue scale representing past-month adherence and treatment interruptions >48 h during the past 3 months. Clinical features, correlates of adherence and HIV-1 viral-load were documented. Based on caregiver reports, 90.9 % of the children were optimally adherent. In multivariable analysis, experiencing ART-related adverse effects was significantly associated with suboptimal adherence (p = 0.01). The proportion of children who experienced virological failure was 16.5 %. Virological failure was not linked to suboptimal adherence. Factors influencing virological failure included running out of medications (p = 0.002) and the child refusing to take medications (p = 0.01). Inclusion of drugs with better safety profiles and improved access to care could further enhance outcomes.

Differences in testing, stigma, and perceived consequences of stigmatization among heterosexual men and women living with HIV in Bengaluru, India.

Approximately 2.4 million people in India are living with HIV. Gender inequality affects HIV prevention, detection, and management. The purpose of this paper was to describe gender differences in the experience of living with HIV in Bengaluru, India. A subsample of n = 313 (159 men and 154 women) from a larger cohort was used for these analyses. Participants were recruited through AIDS service organizations. They completed an interviewer-administered survey assessing HIV testing experience, types of stigma, and perceived consequences of stigmatization. The majority of men (67%) reported getting HIV tested because of illness, while women were more likely to be tested after learning their spouse's HIV-positive status (42%). More men (59%) than women (45%, p<0.05) were tested in private care settings. Men reported significantly higher mean levels of internalized stigma (men: M=0.71, SD = 0.63; women: M=0.46, SD = 0.55; p<0.001), whereas the women reported significantly higher scores for enacted stigma (men: M=1.30, SD = 1.69; women: M=2.10, SD = 2.17; p<0.001). These differences remained significant after controlling for potential socio-demographic covariates. Following their diagnosis, more women reported moving out of their homes (men: 16%; women: 26%; p<0.05). More men (89%) than women (66%; p<0.001) reported to have modified their sexual behavior after being diagnosed. These findings suggest that the experience of living with HIV and HIV stigma varies by gender in this population. Suggestions for a gender-based approach to HIV prevention and stigma reduction are provided.

Epidermal growth factor receptor function in the human urothelium.

PURPOSE: Epidermal growth factor receptor (EGFr)-targeted therapy may be used in subgroups of patients with urinary bladder cancer. Here we assessed the role of EGFr in urothelial proliferation and migration in a two- and three-dimensional cell culture system. METHODS: UROtsa cells derived from normal urothelium and malignant T24 cells were cultured in a Type I collagen gel. Proliferation and migration of urothelial cells, in the absence and presence of the EGFr inhibitor cetuximab, were assessed with a proliferation test (ATCC) and with the Axioplan 2 imaging microscope with a motorized stage (Carl Zeiss), respectively. The expressions of cytokeratin (CK) 17, CK20, EGFr, pEGFr, laminin, occludin and zonula occludens 1 (ZO-1) were assessed with immunohistochemistry and/or western blot. RESULTS: UROtsa spheroids were formed after 7 days in culture, while T24 cells did not form spheroids. UROtsa expressed CK20 but not laminin or CK17 and consequently resembled umbrella cells. In UROtsa and T24, cetuximab inhibited urothelial proliferation, induced cleavage of EGFr and/or pEGFR but did not affect urothelial migration. The tight junction protein occludin was cleaved, and the formation of cellular spheroids was inhibited in UROtsa by the presence of cetuximab. CONCLUSIONS: EGFr modulates urothelial proliferation and the formation of the three-dimensional structure of the urothelium possibly by interfering with occludin. The present data also show a cell culture technique enabling phenotypically normal urothelial cells to form epithelial structures in contrast to malignant urothelial cells.

The Role of Sex Work Pay in Moderating the Effect of Mobile Phone Solicitation on Condom Practices: An Analysis of Female Sex Workers in India.

Mobile phones remain a largely untapped resource in the ongoing challenge to address Female Sex Worker (FSW) health, including HIV prevention services, in India. An important step towards designing effective mobile phone-based initiatives for FSWs is clarifying the contextual influences of mobile phone solicitation on sexual risk behavior. In this paper, we extend previously identified associations between mobile phone solicitation and condom practices by examining whether this association is moderated by sex work pay and offer key considerations for future research and implementation. Specifically, we conducted an analysis among 589 Indian FSWs, where FSWs who did not use mobile phones to solicit clients had the lowest mean sex work pay (INR 394/ USD 6.54) compared to FSWs who used both mobile and traditional strategies (INR 563/ USD 9.34). Our analysis indicate low paid FSWs who used mobile phones concurrently with traditional strategies had 2.46 times higher odds of inconsistent condom use compared to low paid FSWs who did not use mobile phones for client solicitation. No such effect was identified among high paid FSWs. These findings also identified group level differences among FSWs reporting different mobile phone solicitation strategies, including violence, client condom use and HIV status. Our results indicate that low pay does moderate the association between mobile phone solicitation and condom practices, but only among a sub-set of low paid FSWs. These findings also demonstrate the utility of classification by different mobile phone solicitation strategies for accurate assessment of sexual risk among mobile phone soliciting FSWs. In turn, this paves the way for novel approaches to utilize mobile phones for FSW HIV prevention. We discuss one such example, a mobile phone-based rapid screening tool for acute HIV infection targeting Indian FSWs.

Developing a scalable training model in global mental health: pilot study of a video-assisted training Program for Generalist Clinicians in Rural Nepal.

BACKGROUND: In low- and middle-income countries, mental health training often includes sending few generalist clinicians to specialist-led programs for several weeks. Our objective is to develop and test a video-assisted training model addressing the shortcomings of traditional programs that affect scalability: failing to train all clinicians, disrupting clinical services, and depending on specialists. METHODS: We implemented the program -video lectures and on-site skills training- for all clinicians at a rural Nepali hospital. We used Wilcoxon signed-rank tests to evaluate pre- and post-test change in knowledge (diagnostic criteria, differential diagnosis, and appropriate treatment). We used a series of 'Yes' or 'No' questions to assess attitudes about mental illness, and utilized exact McNemar's test to analyze the proportions of participants who held a specific belief before and after the training. We assessed acceptability and feasibility through key informant interviews and structured feedback. RESULTS: For each topic except depression, there was a statistically significant increase (Δ) in median scores on knowledge questionnaires: Acute Stress Reaction (Δ = 20, p = 0.03), Depression (Δ = 11, p = 0.12), Grief (Δ = 40, p < 0.01), Psychosis (Δ = 22, p = 0.01), and post-traumatic stress disorder (Δ = 20, p = 0.01). The training received high ratings; key informants shared examples and views about the training's positive impact and complementary nature of the program's components. CONCLUSION: Video lectures and on-site skills training can address the limitations of a conventional training model while being acceptable, feasible, and impactful toward improving knowledge and attitudes of the participants.

Late-onset corticohippocampal neurodepletion attributable to catastrophic failure of oxidative phosphorylation in MILON mice.

We generated mitochondrial late-onset neurodegeneration (MILON) mice with postnatal disruption of oxidative phosphorylation in forebrain neurons. They develop normally and display no overt behavioral disturbances or histological changes during the first 5 months of life. The MILON mice display reduced levels of mitochondrial DNA and mitochondrial RNA from 2 and 4 months of age, respectively, and severely respiratory chain-deficient neurons from 4 months of age. Surprisingly, these respiratory chain-deficient neurons are viable for at least 1 month without showing signs of neurodegeneration or major induction of defenses against oxidative stress. Prolonged neuronal respiratory chain deficiency is thus required for the induction of neurodegeneration. Before developing neurological symptoms, MILON mice show increased vulnerability to excitotoxic stress. We observed a markedly enhanced sensitivity to excitotoxic challenge, manifest as an abundance of terminal deoxynucleotidyl transferase-mediated biotinylated UTP nick end labeling (TUNEL) reactive cells after kainic acid injection, in 4-month-old MILON mice, showing that respiratory chain-deficient neurons are more vulnerable to stress. At approximately 5-5.5 months of age, MILON mice start to show signs of disease, followed by death shortly thereafter. The debut of overt disease in MILON mice coincides with onset of rapidly progressive neurodegeneration and massive cell death in hippocampus and neocortex. This profound neurodegenerative process is manifested as axonal degeneration, gliosis, and abundant TUNEL-positive nuclei. The MILON mouse model provides a novel and powerful tool for additional studies of the role for respiratory chain deficiency in neurodegeneration and aging.

Safer sex maintenance among gay men: are we making any progress?

PIP: Although early acquired immunodeficiency syndrome (AIDS) prevention programs produced dramatic reductions in unsafe sexual practices on the part of homosexual men, there is evidence that new behaviors have not been maintained consistently. Various cohort studies have related risky sex relapse to low self-efficacy, emotional depression, and relationship issues. Unprotected sex is widely perceived as more pleasurable than condom use and is likely to be practiced by gay men concerned with their partner's presumed preferences. This finding suggests a need to identify ways of increasing the pleasure associated with safe sex by eroticizing condom use. Approaches that include erotic descriptions of safe sex (e.g., pamphlets with explicit photographs, mass media campaigns that use sexually explicit language, and attractively packaged condoms) have been found to increase behavioral risk reduction practices. All interventions aimed at preventing risky sex relapse should be empirically based and delivered in a fashion acceptable to the homosexual community.^ieng

Traditional Balinese youth groups as a venue for prevention of AIDS and other sexually transmitted diseases.

OBJECTIVES: Our aims were to assess the feasibility of conducting peer-led educational interventions against AIDS and other sexually transmitted diseases (STDs) through traditional Balinese youth groups and to gather information on sexual risk-taking and its correlates among Balinese youth. DESIGN: A cross-sectional survey was conducted, with follow-up questionnaires for pilot intervention participants. SUBJECTS AND METHODS: A self-administered questionnaire was given to 375 subjects (aged 16-25 years) from 12 youth groups representing four main resort areas in Bali. Post-intervention data were collected from 97 of these subjects who had taken part in pilot educational programs. Focus groups supplemented survey data in evaluating the intervention and understanding risk behaviors. RESULTS: In a cross-sectional survey, one-quarter of males and few females reported sexual activity; subsequent focus groups suggested under-reporting by females. While knowledge and worries about HIV/AIDS were high, only 10% of sexually active males and no females reported consistent condom use. The mean age of first sexual intercourse was highly correlated with first alcohol consumption (P = 0.0003). Peer educators from selected youth groups planned and implemented interventions for their own groups. Post-intervention data indicated significant increases in communication about sexual issues with friends and parents. Condom attitudes became less negative and efficacy increased. Participants reported this as a first experience with peer-led health education, preferred interactive activities to adult-led lectures and recommended follow-up educational sessions. CONCLUSIONS: Peer educators from traditional youth groups can plan and conduct prevention programs for HIV/STDs that are well-received by their group memberships. Using such venues may be an efficient way to reach a wide range of pre-sexual Balinese youth, as well as those already at risk for HIV/STD due to unprotected sex, alcohol consumption and multiple sexual partners.

PIP: In a 1995 survey of Balinese youth, 75% expressed a desire to discuss sexual issues and AIDS/sexually transmitted diseases (STDs) with their peers. A cross-sectional survey of 375 young people 16-25 years of age assessed the feasibility of using traditional Balinese youth groups as a vehicle for peer-led AIDS education. In Bali virtually all youth, regardless of educational level or socioeconomic status, join the youth group in their neighborhood at puberty and remain members until they marry. The average age at first intercourse reported in the baseline survey was 18.8 years for males and 20.0 years for females. For 46% of sexually active males, intercourse was accompanied by alcohol consumption. Although youth had adequate knowledge of AIDS before the intervention, only 10% of sexually active males reported consistent condom use. Follow-up interviews with 97 young people from 3 resort areas of Bali who were exposed to the peer-led intervention revealed significant increases in communication about sexual matters with friends and family, more positive attitudes toward condoms, and increased condom use. Exposed youth who participated in focus group discussions expressed a preference for peer-led interactive activities over lectures and indicated they felt more comfortable asking their peers questions about sex. Use of peer educators from Balinese youth groups appears to represent an efficient way to reach young people before the initiation of sexual activity as well as those at high risk of AIDS and other STDs as a result of unprotected sex, alcohol consumption, and multiple sexual partners.

Actual versus perceived HIV status, sexual behaviors and predictors of unprotected sex among young gay and bisexual men who identify as HIV-negative, HIV-positive and untested.

OBJECTIVES: To compare the prevalence and predictors of HIV sexual risk behavior among young gay and bisexual men who perceived themselves to be HIV-negative, HIV-positive, or who were untested. DESIGN: Population-based sample of young gay and bisexual men. METHODS: Using multi-stage probability sampling, 408 gay and bisexual men aged 18-29 years in San Francisco were recruited and interviewed, and blood samples for HIV-testing from 364 participants were obtained. RESULTS: HIV prevalence was 18.7%, although 25% of the men who were HIV-positive did not know it. Thirty-seven per cent reported engaging in unprotected anal intercourse during the past year, including 59% of the men who knew they were HIV-positive, 35% of the men who perceived themselves HIV-negative and 28% of the untested men. Logistic regressions found similar predictors of unprotected intercourse for HIV-negatives and HIV-positives, including sexual impulsivity, substance use, sexual enjoyment and communication problems. CONCLUSIONS: The high rates of unprotected intercourse, particularly among the HIV-positive men, attest to the urgent need for HIV-prevention interventions for young gay and bisexual men. The findings suggest that many of the important variables to target in interventions are similar for both HIV-positive and HIV-negative men.

Safer sex among gay men: what is the ultimate goal?

PIP: Sex between homosexual partners in anything other than a mutually monogamous relationship between 2 HIV-negative people involves some risk of virus transmission; a condom must be used during anal intercourse to be considered safe. People, however, have the right to take risks and harm reduction is a long-term, stepwise process. Gay men receive multiple messages which either advocate risk-taking or preach that their sexual needs are bad. Instead of blaming people who occasionally engage in unprotected anal intercourse, people should be trained in skills to reduce their risk; safe sex should be eroticized; and attention should be given to interpersonal or social conditions which may lead to unsafe sex. Society must be challenged to support the messages of risk reduction and the sexual needs of all members of society. The authors further call for the recognition of various risk reduction strategies such as negotiated safety taken by gay men despite the potential problem of this strategy which relies upon the ability of sex partners to reveal their serostatus. The authors also stress that while the goal of eliminating unsafe sex and new HIV infections must be upheld, it is untenable. The understanding that this goal will never be realized, however, does not mean that efforts should not continue to educate and convince people to take better care of themselves. While no infringing upon individual rights, researchers should help prevent all future HIV infections.^ieng

Gay men report high rates of unprotected anal sex with partners of unknown or discordant HIV status.

OBJECTIVE: To examine patterns and factors that correlate with unprotected anal intercourse (UAI) practices among San Francisco gay men, including UAI with partners of unknown or different HIV antibody status. DESIGN: A longitudinal cohort recruited for the San Francisco Young Men's Health Study in 1992; re-assessed annually. PARTICIPANTS AND METHODS: A sample of 510 unmarried gay men who were 18 to 29 years at baseline were originally recruited as part of a larger population and referral-based sample. Subjects participated in four consecutive waves of data collection. RESULTS: The prevalence of reported unprotected anal intercourse (UAI) increased from 37% to 50% between 1993-1994 and 1996-1997. Almost half of all men who reported UAI in 1996-1997 indicated that it occurred with a partner of unknown or discordant HIV antibody status. This high-risk practice correlated with greater numbers of male sex partners, use of nitrite inhalants, sex in commercial sex environments, perceived difficulty controlling sexual risk-taking, and negative emotional reactions following UAI. CONCLUSIONS: These data on increasing rates of sexual risk-taking further confirm trends in sexual behavior previously suggested by rising rates of rectal gonorrhea in this population. Additional and sustained prevention efforts are urgently needed in light of the very high background rates of HIV infection found among gay men in San Francisco.

Relapse from safer sex: the next challenge for AIDS prevention efforts.

Prevention campaigns to reduce sexual transmission of human immunodeficiency virus (HIV) typically emphasize the initial adoption of safer sex techniques. We present data from a 5-year prospective study to show that the vast majority of resident gay men in San Francisco have made these initial risk reductions. Rather, relapse from safer sex techniques is now the predominant predominant kind of high-risk sex, accounting for approximately two thirds of all prevalent high-risk sex in the 1988 wave of data collection. Predictors of relapse from safer sex are identified, and these are discussed in terms of their implications for preventing relapse from the exclusive practice of safe sex. In communities that have already manifested widespread behavioral risk reductions and in which HIV infection is highly prevalent, finding ways to prevent relapse of behavioral risk reductions will be the next important challenge in the fight against acquired immune deficiency syndrome.

Changes in sexual practices over 5 years of follow-up among heterosexual men in San Francisco.

This report describes changes in sexual behavior of 209 heterosexual men enrolled in a prospective study since 1984. Data were analyzed separately for men who married during the 60 months of follow-up. Study subjects reported fewer total sexual partners and an increase in condom use in the more recent time periods compared to the first period. The proportion of never married men reporting two or more partners in the previous 6 months decreased from 53.2 to 40.7%. All of these men were human immunodeficiency virus seronegative on entry and only one documented seroconversion occurred during the follow-up.

Differences between gay men in primary relationships and single men: implications for prevention.

This study describes psychological and behavioral differences between gay men in primary relationships and single men from 1985 through 1989. In addition, differences in sexual behavior, relationship status, and relationship quality between HIV positive and HIV negative men were investigated. Data are from the San Francisco Men's Health Study and included only men who were gay identified and who participated in the longitudinal surveys in 1985, 1987 and 1989 (N = 452). Participants were stratified by relationship status and by HIV status. HIV positive men were less likely than HIV negative men to be in primary relationships (38.9% vs. 52.9%, respectively in 1989). In addition, men in relationships had higher rates of unprotected anal intercourse than single men (32.6% vs. 17.0%, respectively in 1989). Differences in psychosocial and behavioral variables were found and have considerable implications for prevention programs and mental health services trying to meet the needs of the gay men's community.

An investigation of the construct validity of the Dutch Restrained Eating Scale.

In the present investigation, the scores of 50 men and 50 women on the Restraint, Dutch Restrained Eating and Crowne-Marlowe Social Desirability scales were compared in an effort to determine the convergent and discriminant validity of the Dutch Restrained Eating Scale. The obtained results suggest that, although both restraint scales are independent of body weight and social desirability, the convergent validity of the Dutch Restrained Eating Scale with the Restraint Scale is questionable, particularly with female subjects. The implications of these psychometric findings are discussed.

Maintenance of safer sexual behaviors and predictors of risky sex: the San Francisco Men's Health Study.

This paper describes the sexual behavior changes made by 686 gay and bisexual men in San Francisco between 1984 and 1988, focusing on the individual maintenance of this behavior change over time. There were drastic reductions in insertive and receptive unprotective anal intercourse over time and the vast majority of subjects were able to maintain these changes for at least 12 months prior to the last interview. A total of 12 percent of participants admitted to relapsing to unprotected receptive anal intercourse following initial behavior change; 10 percent reported engaging in unprotected receptive anal sex during every year of the study period. Men were more likely to practice unprotected anal intercourse in 1988 if at baseline they were younger, practiced unprotected anal intercourse, reported more sex partners, did not have a close friend or lover with AIDS, and engaged in fewer other health-related behaviors.