Discrepancies between HIV prevention communication attitudes and actual conversations about HIV testing within social and sexual networks of African American men who have sex with men.

BACKGROUND: Promoting communication among African American men who have sex with men (AA MSM) and their social networks about HIV testing is an avenue for altering HIV prevention social norms. This study examined the attitudes of AA MSM on talking with peers about HIV testing and characteristics of their network members with whom they have these conversations. METHODS: Data came from a cross-sectional survey of 226 AA MSM who were 18 years or older and self-reported sex with another male in the prior 90 days. Participants completed an inventory to characterize network members with whom they had conversations about HIV testing and HIV status. RESULTS: Most of the sample reported that it was important/very important to talk to male friends about HIV (85%) and that they were comfortable/very comfortable talking with their friends about sexual behaviors (84%). However, a small proportion of the social network had been talked to by the participant about HIV testing (14%). Among sexual networks, 58% had been talked to about their HIV status, and this was positively associated with main and casual partner type compared with partners with whom money or drugs were exchanged. CONCLUSIONS: Findings suggest that positive attitudes about communication may be necessary but not sufficient for actual conversations to occur. Designing interventions that increase communication with social networks is warranted.

A comparison of the social and sexual networks of crack-using and non-crack using African American men who have sex with men.

The role of crack cocaine in accelerating the HIV epidemic among heterosexual populations has been well documented. Little is known about crack use as an HIV risk factor among African American men who have sex with men (AA MSM), a group disproportionately infected with HIV. We sought to compare the social and sexual network characteristics of crack-using and non-crack using AA MSM in Baltimore, MD, USA and to examine associations of crack use with sexual risk. Participants were recruited using street-based and internet-based outreach, printed advertisements, word of mouth. Inclusion criteria were being aged 18 years or older, African American or of black race/ethnicity, and have self-reported sex with another male in the prior 90 days. Crack use was operationalized as self-report of crack in the prior 90 days. Logistic regression was used to identify variables that were independently associated with crack use. Of 230 enrolled AA MSM, 37% (n = 84) reported crack use. The sexual networks of crack-using AA MSM were composed of a greater number of HIV-positive sex partners, exchange partners, and partners who were both sex and drug partners and fewer networks with whom they always use condoms as compared to non-crack using AA MSM. Crack use was independently associated with increased odds of bisexual identity and networks with a greater number of exchange partners, overlap of drug and sex partners, and lesser condom use. Results of this study highlight sexual network characteristics of crack-smoking AA MSM that may promote transmission of HIV. HIV interventions are needed that are tailored to address the social context of crack-smoking AA MSM risk behaviors.

"To Speak of Death Is to Invite It": Provider Perceptions of Palliative Care for Cardiovascular Patients in Western Kenya.

CONTEXT: Cardiovascular disease (CVD) is the leading cause of death globally and a significant health burden in Kenya. Despite improved outcomes in CVD, palliative care has limited implementation for CVD in low-income and middle-income countries. This may be partly because of providers' perceptions of palliative care and end-of-life decision making for patients with CVD. OBJECTIVES: Our goal was to explore providers' perceptions of palliative care for CVD in Western Kenya to inform its implementation. METHODS: We conducted eight focus group discussions and five key informant interviews. These were conducted by moderators using structured question guides. Qualitative analysis was performed using the constant comparative method. A coding scheme was developed and agreed on by consensus by two investigators, each of whom then independently coded each transcript. Relationships between codes were formulated, and codes were grouped into distinct themes. New codes were iteratively added with successive focus group or interview until thematic saturation was reached. RESULTS: Four major themes emerged to explain the complexities of integrating of palliative care for patients with CVD in Kenya: 1) stigma of discussing death and dying, 2) mismatch between patient and clinician perceptions of disease severity, 3) the effects of poverty on care, and 4) challenges in training and practice environments. All clinicians expressed a need for integrating palliative care for patients with CVD. CONCLUSION: These results suggest that attainable interventions supported by local providers can help improve CVD care and quality of life for patients living with advanced heart disease in low-resource settings worldwide.

Impact of a Short-Term Domestic Service-Learning Program on Medical Student Education.

PURPOSE: The number of global health opportunities offered to medical students has increased over the past 20 years. Recognizing the growing prevalence of these experiences, a number of studies have shown that these types of exposures have a significant impact on medical students' education. However, there is a paucity of literature on the educational impacts of short-term domestic service-learning trips, which can be more accessible due to fewer logistical and financial barriers. This mixed-methods qualitative/quantitative study aims to understand the impact of a domestic one-week service learning program on medical students' educational development and career choices. METHODS: The authors conducted a qualitative analysis of journal entries written by a cohort of students during a domestic weeklong service trip. They also administered a survey to all students who had participated in the program between 2009-2016. RESULTS: In 88.6% (n = 31) of the journal entries, students reported learning about border town life, Native American health, and rural medical practice. In 42.8% (n = 15) of entries, participants described experiences they felt would impact their future medical career decisions. The students' reflections also revealed implicit benefits such as becoming aware of privilege within society (n = 14, 40.0%). The majority of survey respondents reported that the trip improved their medical education and influenced the field and location of their future/current practice. CONCLUSION: This study suggests that domestic short-term service-learning trips impact medical students' immediate educational development and may influence their future career plans. Further investigation into the local community's perceptions of this service-learning trip will provide greater understanding of the impact on all involved.

An examination of spatial concentrations of sex exchange and sex exchange norms among drug users in Baltimore, Maryland.

Baltimore, Maryland consistently ranks highest nationally in rates of sexually transmitted diseases and HIV infection. Prior studies have identified geographic areas where STI and HIV infection in the city is most prevalent. It is well established that sex exchange behavior is associated with HIV and STIs, yet it is not well understood how sex exchangers are spatially distributed within the high-risk areas. We sought to examine the spatial distribution of individuals who report sex exchange compared to those who do not exchange. Additionally we examined the spatial context of perceived norms about sex exchange. Data for the study came from a baseline sample of predominately injection drug users (n=842). Of these, 21% reported sex exchange in the prior 90 days. All valid baseline residential addresses of participants living within Baltimore city boundaries were geocoded. The Multi-Distance Spatial Cluster Analysis (Ripley's K-function) was used to separately calculate the K-functions for the addresses of participants reporting sex exchange or non-sex exchange, relative to the recruited population. Evidence of spatial clustering of sex exchangers was observed and norms aligned with these clusters. Of particular interest was the high density of sex exchangers in one specific housing complex of East Baltimore, which happens to be the oldest in Baltimore. These findings can inform targeted efforts for screening and testing for HIV and STIs and placement of both individual and structural level interventions that focus on increasing access to risk reduction materials and changing norms about risk behaviors.

The STEP into Action study: a peer-based, personal risk network-focused HIV prevention intervention with injection drug users in Baltimore, Maryland.

AIMS: To assess the effectiveness of a peer-based, personal risk network-focused HIV prevention intervention to (i) train injection drug users (IDUs) to reduce injection and sex risk behaviors, (ii) conduct outreach to behaviorally risky individuals in their personal social networks [called risk network members (RNM)], and (iii) reduce RNM HIV risk behaviors. DESIGN: Randomized controlled trial with prospective data collection at 6, 12 and 18 months. Intervention condition consisted of five group sessions, one individual session and one session with Index and the RNM. SETTING: This study was conducted in Baltimore, Maryland from March 2004 to March 2006. PARTICIPANTS: (i) Index participants were aged ≥ 18 years and self-reported injection drug use in the prior 6 months and (ii) their RNM who were aged ≥ 18 years and drug users or sex partners of Index. MEASUREMENTS: Outcomes included: (i) injection risk based on sharing needles, cookers and cotton for injection and drug splitting, (ii) sex risk based on number of sex partners, condom use and exchanging sex and (iii) Index HIV outreach behaviors. FINDINGS: A total of 227 Index participants recruited 336 RNM. Retention of Index at 18-month follow-up exceeded 85%. Findings suggest that the experimental condition was efficacious at 18 months in reducing Index participant injection risk [odds ratio (OR) = 0.38; 95% confidence interval (CI) = 0.18-0.77), drug-splitting risk (OR = 0.46; 95% CI = 0.25-0.88) and sex risk among Index (OR = 0.53; 95% CI = 0.34-0.86). Significant intervention effect on increased condom use among female RNM was observed (OR = 0.34; 95% CI = 0.18-0.62). CONCLUSIONS: Training active IDU to promote HIV prevention with behaviorally risky individuals in their networks is feasible, efficacious and sustainable.