Strengths and Challenges of Implementing a Learning Collaborative in the Ryan White HIV/AIDS Program.

Learning collaboratives (LCs) are a popular tool for supporting collaboration and shared learning among health programs. Many variations of LCs have been reported in the literature. However, descriptions of key LC components and implementation lack standardization, making it hard to compare and contrast different LC approaches. To advance the field's understanding of how primary elements of LCs are implemented, we describe the implementation of an LC in the Ryan White HIV/AIDS Program using a recently established taxonomy of four primary elements of LCs-innovation, social systems, communication, and time. Additionally, we explain the strengths and challenges we encountered with regard to each of these elements when implementing this LC. We then offer recommendations to others on how to leverage LC facilitators and mitigate challenges in future projects. This information can guide other programs to replicate beneficial practices and avoid pitfalls in future LC projects.

High rates of retention and viral suppression in the US HIV safety net system: HIV care continuum in the Ryan White HIV/AIDS Program, 2011.

BACKGROUND: In the human immunodeficiency virus (HIV) care continuum, retention in HIV medical care and viral suppression are key goals to improve individual health outcomes and reduce HIV transmission. National data from clinical providers are lacking. METHODS: HIV providers funded by the Ryan White HIV/AIDS Program (RWHAP) annually report demographic, service, and clinical data using encrypted unique client identifiers, and data are processed and de-duplicated to create a single record for each client. We calculated retention and viral suppression for clients who received RWHAP-funded HIV medical care in 2011. We conducted multivariate logistic regression to identify factors associated with these outcomes. RESULTS: In 2011, an estimated 512 911 HIV-infected clients received at least 1 RWHAP-funded non-AIDS Drug Assistance Program service. Of these, 317 458(61.8%) were seen for at least 1 HIV medical care visit. Of these, 82.2% were retained in HIV medical care, and 72.6% achieved viral suppression. Viral suppression was higher among retained clients (77.7%) vs clients who were not retained (58.3%). The lowest levels of retention and viral suppression were among individuals aged 13-34 years. CONCLUSIONS: The RWHAP provides HIV medical care and support services for more than half a million poor and underinsured individuals living with HIV in the United States. Rates of retention and viral suppression are relatively high compared with other national estimates but demonstrate room for improvement, especially among youth and racial minorities. Additional improvements in retention and viral suppression will contribute to achieving the goals of the National HIV/AIDS Strategy and improve individual and public health.

Sentencing risk: history of incarceration and HIV/STD transmission risk behaviours among Black men who have sex with men in Massachusetts.

This study investigated the role of incarceration in HIV/STD risk among 197 Black men who have sex with men in Massachusetts, USA. More than half (51%) reported a history of incarceration (28% < 90 days in jail/prison; 23% ≥ 90 days in jail/prison). Multivariable logistic regression models adjusted for age and sexual orientation examined associations between demographic, behavioural, social-psychological and cultural factors and incarceration history. Factors associated with < 90 days of incarceration were: unprotected sex with a man, STD history, injection drug use and substance abuse treatment. Factors associated with ≥ 90 days of incarceration were: unprotected sex with a woman, crack use during sex, STD history, injection drug use, substance abuse treatment, depressive symptoms, post-traumatic stress symptoms, HIV fatalism and social capital. Black men who have sex with men with incarceration histories may be at increased risk for HIV/STDs compared to those without such histories. HIV prevention efforts that focus on individual risk and cultural-contextual issues among Black men who have sex with men are warranted.

Sex parties among urban MSM: an emerging culture and HIV risk environment.

Private sex parties are an emerging risk environment for HIV among men who have sex with men (MSM). In 2009, 103 participants who reported attending at least one sex party in Massachusetts in the prior 12 months completed an in-depth, interviewer-administered quantitative assessment. Multivariable logistic regression analyses were conducted to examine associations with having engaged in one or more serodiscordant unprotected anal sex (SDUAS) acts at the most recent sex party attended. Nearly one-third (32%) of the sample reported engaging in SDUAS at the most recent sex party attended. Adjusting for age, race/ethnicity, and educational attainment, variables associated with an increased odds of engaging in SDUAS at the most recent sex party were: total number of unprotected anal receptive sex acts at sex parties in the past 12 months, self-perception of being at-risk for transmitting or acquiring HIV, and sexual sensation seeking. Examined in the same model, if condoms were provided/available at the most recent sex party attended, participants were at a decreased odds of engaging in SDUAS at that sex party. The majority (80%) expressed an interest in HIV prevention activities for MSM who attend sex parties. HIV prevention interventions are needed to reach MSM who attend sex parties and should take into account individual and contextual factors that may contribute to sexual risk. Environmental factors in the sex party setting, in particular the presence and availability of condoms, may potentially mitigate individual-level factors such as unprotected anal sex.

"It's a quick way to get what you want": a formative exploration of HIV risk among urban Massachusetts men who have sex with men who attend sex parties.

Community-based studies with men who have sex with men (MSM) suggest that between 8% and 25% of MSM have met recent male sexual partners at private sex parties. Little is known about HIV sexual risk behaviors of MSM who attend sex parties and whether risk reduction interventions can be delivered in this setting. In 2008, 40 MSM who reported attending and/or hosting sex parties in Massachusetts in the past 12 months completed a qualitative interview and quantitative assessment. Participants reported attending a mean number of 10 sex parties in Massachusetts in the past 12 months. A significant percentage (43%) reported also hosting sex parties. Participants had made sexual partner connections across multiple venues, including public cruising areas, bars/clubs, and the Internet. At the most recent sex party attended, the majority had used alcohol (58%) and/or drugs (50%), and one quarter (25%) put themselves at risk of acquiring or transmitting HIV or other sexually transmitted infections (STIs) by having unprotected anal sex with a mean number of three serodiscordant male sex partners. Although many participants perceived that communicating about sexual health in the sex party context would "ruin the mood," the majority (80%) considered some form of HIV prevention at sex parties to be appropriate and necessary, as well as acceptable. Nonintrusive prevention and education activities were especially endorsed (i.e., condoms, lubricants, and coupons for free HIV/STI testing). The majority of participants (75%) expressed some interest in "safer sex" parties. MSM attending sex parties appear to be a subpopulation at high risk for HIV and STI acquisition and transmission. Risk reduction interventions responsive to the needs of MSM who attend sex parties are warranted.

Problematic alcohol use and HIV risk among Black men who have sex with men in Massachusetts.

This analysis was designed to explore the frequency of problem drinking and its role in potentiating HIV risk among a community-recruited sample of Black men who have sex with men (MSM) in Massachusetts. Black MSM (n=197) recruited via modified respondent-driven sampling between January and July 2008 completed an interviewer-administered survey, including HIV sexual behavior, the Center for Epidemiologic Studies Depression Scale (CES-D), and the CAGE alcohol screener. Bivariate and multivariable logistic regression procedures examined the association of behavioral HIV-risk factors and other psychosocial variables with problematic alcohol use (CAGE score 3 or 4). Overall, 29% of the sample was found to abuse alcohol. In a multivariable model adjusting for demographic and behavioral variables, factors associated with increased odds of problem drinking were: (1) depressive symptoms (CES-D 16); (2) one or more episodes of serodiscordant unprotected anal sex during last sexual encounter with a casual male partner; and (3) one or more episodes of unprotected anal or vaginal sex with a female partner in the past 12 months. Black MSM who engaged in HIV risk behaviors may be more likely to have concurrent problematic alcohol use. HIV prevention interventions with Black MSM may benefit from incorporating screening and/or treatment for alcohol problems, as well as screening for co-morbid depressive symptoms.

Walking the line: stimulant use during sex and HIV risk behavior among Black urban MSM.

BACKGROUND: Although the association of stimulant use to sexual risk taking and HIV transmission has been well documented among white gay men, stimulant use during sex continues to be under-explored among Black men who have sex with men (MSM). METHODS: Black MSM (n=197) recruited via modified respondent-driven sampling between January and July 2008 completed an interviewer-administered quantitative assessment and optional HIV counseling and testing. Bivariate logistic regression procedures were employed to examine the association of demographics, sexual risk, and other psychosocial factors with stimulant use (at least monthly during sex in the past 12 months). Variable elimination using the backward selection process was used to fit two separate final multivariable logistic regression models examining stimulant use as the outcome and HIV sexual risk in the past 12 months by gender as the primary predictor: (1) Model 1: HIV sexual risk behavior with a casual male sex partner as a primary, forced predictor; (2) Model 2: HIV sexual risk behavior with a female sex partner as primary, forced predictor. RESULTS: One-third (34%) of Black MSM reported using stimulants monthly or more frequently during sex in the past 12 months. The following factors were independently associated with stimulant use during sex: (1) Model 1: unprotected anal sex with a casual male sex partner in the past 12 months (AOR=2.61; 95% CI=1.06-6.42; p=0.01), older age (AOR=1.09; 95% CI=1.05-1.15; p<0.001), erectile dysfunction (ED) medication use monthly or more during sex in the past 12 months (AOR=7.81; 95% CI=1.46-41.68; p=0.02), problematic alcohol use (AOR=3.31; 95% CI=1.312-8.38; p=0.005), and higher HIV treatment optimism (AOR=0.86; 95% CI=0.76-0.97; p=0.01). (2) Model 2: unprotected vaginal or anal sex with a female partner in the past 12 months (AOR=3.54; 95% CI=1.66-7.56; p=0.001), older age (AOR=1.10; 95% CI=1.05-1.14; p<0.001), ED use monthly or more during sex in the past 12 months (AOR=3.70; 95% CI=1.13-12.13; p=0.03), clinically significant depressive symptoms (CES-D) at the time of study enrollment (AOR=3.11; 95% CI=1.45-6.66; p=0.004), and supportive condom use norms (AOR=0.69; 95% CI=0.49-0.97; p=0.03). CONCLUSION: Frequent stimulant use is an important factor in HIV and STD sexual risk among Black MSM, particularly for older men and those with co-occurring psychosocial morbidities. HIV and STD prevention interventions in this population may benefit from addressing the precipitants of stimulant use and sexual risk taking.

Health system and personal barriers resulting in decreased utilization of HIV and STD testing services among at-risk black men who have sex with men in Massachusetts.

Testing for HIV and other sexually transmitted diseases (STD) remains a cornerstone of public health prevention interventions. This analysis was designed to explore the frequency of testing, as well as health system and personal barriers to testing, among a community-recruited sample of Black men who have sex with men (MSM) at risk for HIV and STDs. Black MSM (n = 197) recruited via modified respondent-driven sampling between January and July 2008 completed an interviewer-administered assessment, with optional voluntary HIV counseling and testing. Logistic regression procedures examined factors associated with not having tested in the 2 years prior to study enrollment for: (1) HIV (among HIV-uninfected participants, n = 145) and (2) STDs (among the entire mixed serostatus sample, n = 197). The odds ratios and their 95% confidence intervals obtained from this analysis were converted to relative risks. (1) HIV: Overall, 33% of HIV-uninfected Black MSM had not been tested for HIV in the 2 years prior to study enrollment. Factors uniquely associated with not having a recent HIV test included: being less educated; engaging in serodiscordant unprotected sex; and never having been HIV tested at a community health clinic, STD clinic, or jail. (2) STDs: Sixty percent had not been tested for STDs in the 2 years prior to study enrollment, and 24% of the sample had never been tested for STDs. Factors uniquely associated with not having a recent STD test included: older age; having had a prior STD; and never having been tested at an emergency department or urgent care clinic. Overlapping factors associated with both not having had a recent HIV or STD test included: substance use during sex; feeling that using a condom during sex is "very difficult"; less frequent contact with other MSM; not visiting a health care provider (HCP) in the past 12 months; having a HCP not recommend HIV or STD testing at their last visit; not having a primary care provider (PCP); current PCP never recommending they get tested for HIV or STDs. In multivariable models adjusting for relevant demographic and behavioral factors, Black MSM who reported that a HCP recommended getting an HIV test (adjusted relative risk [ARR] = 0.26; p = 0.01) or STD test (ARR = 0.11; p = 0.0004) at their last visit in the past 12 months were significantly less likely to have not been tested for HIV or STDs in the past 2 years. Many sexually active Black MSM do not regularly test for HIV or STDs. HCPs play a pivotal role in encouraging testing for Black MSM. Additional provider training is warranted to educate HCPs about the specific health care needs of Black MSM, in order to facilitate access to timely, culturally competent HIV and STD testing and treatment services for this population.

Sexual mixing patterns and partner characteristics of black MSM in Massachusetts at increased risk for HIV infection and transmission.

Black men who have sex with men (MSM) are at increased risk for HIV infection in the United States compared to other MSM. The aim of this study was to investigate Black MSM's sexual mixing patterns and partner characteristics in relation to sexual risk taking, as a possible explanation for this observed increase in HIV incidence. Between January and July 2008, 197 Black MSM were recruited via modified respondent-driven sampling and completed optional pretest and post-test HIV serological testing, counseling, and a demographic, behavioral, and psychosocial assessment battery. Bivariate and multivariable logistic regression procedures were used to examine predictors of risky sex across partner types. Overall, 18% of the sample was HIV-infected; 50% reported unprotected intercourse with men, 30% with women, and 5% with transgender partners. Fifty-three percent identified as bisexual or straight, although all reported oral or anal sex with another man in the prior 12 months. Significant predictors of engaging in at least one episode of: (1) serodiscordant unprotected anal sex (UAS) with a male partner in the past 12 months: individuals at risk for social isolation (AOR = 4.23; p = 0.03), those with unstable housing (AOR = 4.19; p = 0.03), and those who used poppers at least weekly during sex (AOR = 5.90; p = 0.05); (2) UAS and/or unprotected vaginal intercourse with a female partner in the past 12 months: those with unstable housing (AOR = 4.85; p = 0.04), those who used cocaine at least weekly during sex (AOR = 16.78; p = 0.006), being HIV-infected (AOR = 0.07; p = 0.02), and feeling social norms favor condom use (AOR = 0.60; p = 0.05); (3) UAS with the participants' most recent nonmain male sex partner: use of alcohol and drugs during last sex by participant (AOR = 4.04; p = 0.01), having sex with a Hispanic/Latino male (AOR = 2.71; p = 0.04) or a Black male (AOR = 0.50; p = 0.05) compared to a White male, and lower education (AOR = 1.31; p = 0.02). Findings suggest that sexual risk behaviors of Black MSM differ across partner type and by the characteristics of their sexual networks and that this subpopulation of MSM are at high risk for HIV acquisition and transmission. Effective prevention strategies need to address the distinct sexual and behavioral risk patterns presented by different sexual partnerships reported by Black MSM.

Clinically significant depressive symptoms as a risk factor for HIV infection among black MSM in Massachusetts.

High rates of depression have been observed among men who have sex with men (MSM) relative to the general adult male population; however, a dearth of research has explored depression among Black MSM. Black MSM (n = 197) recruited via modified respondent-driven sampling between January and July 2008 completed an interviewer-administered quantitative assessment and voluntary HIV counseling and testing. Bivariate and multivariable logistic regression procedures examined the associations of demographics, behavioral HIV risk factors, and psychosocial variables with depressive symptoms by severity, using the 20-item Center for Epidemiologic Studies Depression Scale (CES-D). Adjusting for demographic and behavioral variables, significant factors associated with (1) clinically significant depressive symptoms (33%; CES-D score > or = 16): being publicly insured by Medicaid, having serodiscordant anal sex with a casual male partner, and being diagnosed with an STD in the prior 12 months; (2) moderate depressive symptoms (19%; CES-D score 16-26): having serodiscordant unprotected anal sex with a casual male partner and being diagnosed with an STD in the prior 12 months; (3) severe depressive symptoms (14%; CES-D score 27+): being publicly insured by Medicaid and reporting difficulty accessing healthcare in the past 12 months. Moderately depressed Black MSM may be more likely to engage in behaviors that place them at increased risk for HIV and other STDs. HIV prevention interventions for Black MSM may benefit from incorporating screening and/or treatment for depression, allowing MSM who are depressed to respond more effectively to behavioral change approaches.

Estimation of unmet need for HIV primary medical care: a framework and three case studies.

Reauthorization of the Ryan White Comprehensive AIDS Resources Emergency Act requires that each jurisdiction estimate the number of people living with HIV/AIDS who have unmet need for care. Past assessments of unmet need have used various definitions of care, relied on qualitative evaluations, or examined nonrepresentative subpopulations. This article outlines a single, flexible framework designed to quantitatively estimate unmet need in varied settings. The framework adopts a definition of unmet need which focuses on HIV primary medical care (CD4 test, viral load test, or antiretroviral therapy in a 12-month period), employs a standard analytic structure to integrate population and care data, and allows use of locally available data. We report on three field tests (Louisiana, Atlanta, and San Francisco). The field tests suggest that the unmet need framework provides an approach which can be used by states and metropolitan areas to estimate the number of individuals with unmet need for HIV primary medical care.