Comorbidities in a sample of adults with HIV in Puerto Rico: an exploratory study.

BACKGROUND: Puerto Rico is among the areas with the highest estimated rates of people living with HIV in the United States. Despite the epidemiologic data available, there is limited real-world information that can help understand the comorbidities of people with HIV. In this study, we describe common comorbidities among adults with HIV attending treatment clinics in Puerto Rico. METHODS: An exploratory, retrospective, cross-sectional study was conducted at five HIV clinics in Puerto Rico. A random sample of medical records was reviewed. Descriptive statistics were used to summarize patient demographics, morbidity, and clinical characteristics. Multivariate analyses were conducted to explore comorbidities by age and sex. RESULTS: A total of 250 (179 men; 71 women) medical records were reviewed. Participants' mean age was 47.9 years and on average they had been living with HIV for 9 years. Most (97.6%) had at least one comorbidity. The most common comorbidities were dyslipidemia and hypertension. Men were more likely to have been diagnosed with alcohol misuse while women were more likely to have been diagnosed with obesity, human papillomavirus (HPV), hypothyroidism, and osteoporosis. Participants younger than 50 years of age were more likely to have history of alcohol misuse while older individuals (50 years and old) were more likely to have been diagnosed with dyslipidemia, hypertension, and diabetes. Adjusting by sex and age, women were more likely to have been diagnosed with obesity and depression and those older than 50 years were more likely to have had a diagnosis of dyslipidemia, hypertension, HPV, and diabetes. CONCLUSIONS: This is one of the few studies assessing comorbidities among adults with HIV in Puerto Rico, among Latino/Hispanics within the United States, and Latin America. Consistent with other studies, cardiovascular diseases are common among adults with HIV in Puerto Rico. Findings support the need for awareness and real-world evidence about comorbidities among people with HIV when implementing screenings and prescribing drugs.

Sexual health knowledge and stigma in a community sample of HIV-positive gay, bisexual and other men who have sex with men in Puerto Rico.

Gay, bisexual and other men who have sex with men (GBMSM) are at increased risk for HIV infection and disease progression. Also, HIV-positive GBMSM are among those less likely to be retained in care. In this study we analyzed sexual health knowledge (SHK) and various manifestations of stigma in a community sample of HIV-positive GBMSM in Puerto Rico. The sample reports overall low SHK scores, and lower score were associated with low educational attainment, unemployment, low income, and with self-identifying heterosexual participants. Almost half of the sample reported moderate to severe perceived gay stigma, 68.4% reported moderate to severe hidden-gay stigma, and 30.6% reported moderate to severe HIV-felt stigma. Further research is recommended to obtain culturally congruent information and develop interventions addressing the multiple layers of stigma in the social context where the interventions will be delivered.

Discrimination and Health among Lesbian, Gay, Bisexual and Trans People in Puerto Rico.

OBJECTIVE: To identify the experiences of discrimination among and the perceived priorities for the health of lesbian, gay, bisexual, and trans (LGBT) people in Puerto Rico (PR). METHODS: Data were collected during the 2013 LGBT Pride Parade in San Juan, using a brief self-administered survey that included questions on sociodemographic characteristics, the disclosure of sexual orientation/gender identity, experiences of discrimination, experiences while receiving social and health services, and perceived healthcare priorities and needs. RESULTS: Most participants reported that they had disclosed their sexual orientation to at least one person. Discrimination due to sexual orientation/gender identity was most frequently reported to have occurred in school settings. At least 25% of the sample reported regular or negative experiences based on sexual orientation/gender identity when receiving government services and when looking for support from relatives. HIV/AIDS, mental health, and sexual health were identified as healthcare priorities. In bivariate analyses, mental health services and aging were the priorities most frequently reported among older participants. HIV/AIDS was the main priority only for gay men; sexual health was the main priority for bisexuals; and mental health was the main priority for lesbians. Most participants reported that their preferred modalities for health service provision were support groups and health education. CONCLUSION: The experiences of discrimination among LGBT people in PR were consistent across age groups and sexual orientation/gender identity. Policies and interventions to address discrimination in different settings are necessary. The findings also suggest the need to prioritize HIV services among gay men and to address mental and sexual health needs among lesbian and bisexual people.

Male Escorts' and Male Clients' Sexual Behavior During Their Last Commercial Sexual Encounter: Comparing and Contrasting Findings from Two Online Studies.

Much of what is known about commercial sexual encounters between men is based on data gathered from escorts. With few exceptions, studies have not compared male clients' reports of behavior during commercial sexual encounters with male escorts'. The present study draws from two datasets, a 2012 survey of clients (n = 495) and a 2013 survey of escorts (n = 387)--both used virtually identical measures of sexual behavior during the most recent commercial sexual encounter. For clients and escorts, the majority eschewed having sex without a condom, and kissing and oral sex were among the most common behaviors reported. Using logistic regression, both samples were compared across 15 sexual behaviors, finding significant differences in six--the escort sample had greater odds of reporting their last commercial sexual encounter involved watching the client masturbate, viewing porn, role play (dad/son, dominant/submissive), and having prior sexual experience with their commercial partner. The escort sample had lower odds of reporting that the client watched the escort masturbate, and being told partner's HIV status. In multivariable modeling, both samples did not significantly differ in reports of condomless anal sex. Male-male commercial sexual encounters appear to be involved in a wide range of sexual behaviors, many of which convey low-to-no risk of HIV transmission.

Sexual health and socioeconomic-related factors among HIV-positive men who have sex with men in Puerto Rico.

Most of the research among HIV-positive populations has been approached from behavioral risk models. This is particularly true for those otherwise socially vulnerable groups like men who have sex with men (MSM). As a response to this pattern, we examined data from an ongoing health promotion research being conducted in Puerto Rico (PR). The study is limited to HIV-positive MSM and consists of the participation in a survey interview that includes domains used to assess indicators of socio-economic-related factors (age, educational level, employment, religion, and partnership status) and sexual health (sexual satisfaction, condom use, and sexual health knowledge(SHK)). Participants reported a relatively high level (75 %) of sexual satisfaction and inconsistent condom use (50.9 % reported always using a condom). A deficient (61 %) SHK was also reported. In multivariate analyses, a higher educational level was associated with higher sexual satisfaction (aß = 3.223; 95 % CI 0.291-6.156) and higher levels of SHK (aß = 1.328; 95 % CI 0.358-2.297), while unemployment was associated with less condom use (aOR 0.314; 95 % CI 0.122-0.810). Not having a primary sexual partner was associated with less sexual satisfaction (aß = -3.871; 95 % CI -7.534-0.208) and more condom use (aOR 4.292; 95 % CI 1.310-14.068). Findings support the notion that men of a disadvantaged socioeconomic position may have a poorer sexual health status; with a lower level of education and unemployment leading this disparity. Findings also evidence that partnership status may have a role in the sexual health of HIV-positive MSM. To our knowledge, this is the first comprehensive analysis of sexual health and socioeconomic indicators among Hispanic/Latino HIV-positive MSM in PR and in the Caribbean. Findings provide valuable information to address the sexual health needs of an underserved population.

Comparing male escorts' sexual behaviour with their last male client versus non-commercial male partner.

Apart from research suggesting that male escorts are less likely to have condomless anal sex (CAS) with their male clients compared with male non-clients, little is known about how male escorts' behaviour differs between their clients and non-clients. In spring 2013, 387 Internet-based male escorts completed an online survey that included identical questions about their sexual behaviour with their last male client and male non-client. Encounters with non-commercial partners were significantly more likely to involve a greater range of sexual behaviours, including giving oral sex to partner, kissing, anal receptive sex and sex without condoms. These findings suggest that escorts may display a greater sexual repertoire with non-commercial partners compared to their clients. Encounters with non-commercial partners were also rated as more satisfying than with clients. Condomless anal sex was less common with clients, suggesting that escorts and clients may take active roles in mitigating risks for HIV and STI transmission with each other. Although the modal response for CAS was to abstain, more than half of participants reported CAS during at least one of the two encounters assessed. Behavioural and/or biomedical HIV-prevention strategies would be appropriate for some male escorts to reduce HIV transmission risk.

Risk factors for suicide attempts in a clinic-based sample of people living with HIV in Puerto Rico.

Puerto Rico (PR) has a large and rapidly growing population of people living with HIV. However, relatively little behavioral or clinical research has been done in this population. As treatment for HIV increasingly moves into a chronic condition model, it is becoming increasingly important to understand the needs of this population so critical social and behavioral interventions can be developed, thus enabling the individual and community-level benefits of antiretroviral (ARV) treatment to be fully realized. To date, however, there has been very little research on the mental health needs of people living with HIV in PR, a fact that constrains intervention development and implementation. This paper describes data from a public sexually transmitted infection (STI) and HIV clinic study in the San Juan metropolitan area between April 2010 and December 2012 (n = 1185), roughly a third (36%) of whom are living with HIV. Descriptive statistics, chi-square, t-tests, and binary logistic regressions were used to assess associations between HIV status and a history of suicide attempt. The overall prevalence of a history of suicide attempt was 20.4%. No statistically significant relationship was found between a history of suicide attempt and being HIV positive, although people with HIV infection did evidence a higher prevalence of attempts than HIV-negative subjects (23.4% vs. 19.0%). Factors associated with having a history of suicide attempt within the overall sample included gender, current employment status, a lifetime history of drug use, and a lifetime history of sex work. Similar patterns were seen in the HIV-positive subsample. There was a nonsignificant trend toward increased risk for a post-diagnosis suicide attempt. These findings suggest that additional research on mental health risks among populations at risk for HIV in PR is needed.

A preliminary profile of HIV risk in a clinic-based sample of MSM in Puerto Rico: implications for sexual health promotion interventions.

OBJECTIVE: Puerto Rico has one of the fastest growing HIV epidemics in the United States and--consistent with patterns observed in the Caribbean region as a whole--data on new infections shows the increased influence of sexual transmission in the local epidemic. Historically, both epidemiology and prevention activities have focused primarily on the islands' large heroin injector population. Although the available surveillance data indicate high rates of STIs and HIV among men who have sex with men (MSM), there has been little social and behavioral research among MSM and hence little empirical information to inform intervention development and planning. METHODS: Given the absence of data on MSM and their importance in the emerging epidemic on the island, this paper describes a sample of MSM patients in an STI/HIV treatment center in the San Juan metropolitan area between October 2009 and June 2011 (n = 120). Assessment of sexual risk includes measures of onset of oral, vaginal, and anal sex, as well as current sexual practices and partner characteristics. Self-reported history of STI diagnoses and current HIV status are described. RESULTS: Overall, MSM evidenced relatively large numbers of multiple, concurrent sexual partners, substantial age-discordance among partners, and limited condom use. Relative to HIV-negative MSM, HIV-positive MSM have had more cumulative male sexual partners in anal intercourse (p = 0.005). HIV-negative MSM were more likely to have had sex without a condom at last receptive anal intercourse (p = 0.012) as well as at last insertive anal sex intercourse (p = 0.001). CONCLUSION: Priorities for advancing HIV interventions for MSM are delineated, including the need for targeted sexual health interventions, mental health services, and improved strategies for engaging and retaining MSM in health services.

More than foreskin: circumcision status, history of HIV/STI, and sexual risk in a clinic-based sample of men in Puerto Rico.

INTRODUCTION: Circumcision among adult men has been widely promoted as a strategy to reduce human immunodeficiency virus (HIV) transmission risk. However, much of the available data derive from studies conducted in Africa, and there is as yet little research in the Caribbean region where sexual transmission is also a primary contributor to rapidly escalating HIV incidence. AIM: In an effort to fill the void of data from the Caribbean, the objective of this article is to compare history of sexually transmitted infections (STI) and HIV diagnosis in relation to circumcision status in a clinic-based sample of men in Puerto Rico. METHODS: Data derive from an ongoing epidemiological study being conducted in a large STI/HIV prevention and treatment center in San Juan in which 660 men were randomly selected from the clinic's waiting room. MAIN OUTCOME MEASURES: We assessed the association between circumcision status and self-reported history of STI/HIV infection using logistic regressions to explore whether circumcision conferred protective benefit. RESULTS: Almost a third (32.4%) of the men were circumcised (CM). Compared with uncircumcised (UC) men, CM have accumulated larger numbers of STI in their lifetime (CM = 73.4% vs. UC = 65.7%; P = 0.048), have higher rates of previous diagnosis of warts (CM = 18.8% vs. UC = 12.2%; P = 0.024), and were more likely to have HIV infection (CM = 43.0% vs. UC = 33.9%; P = 0.023). Results indicate that being CM predicted the likelihood of HIV infection (P value = 0.027). CONCLUSIONS: These analyses represent the first assessment of the association between circumcision and STI/HIV among men in the Caribbean. While preliminary, the data indicate that in and of itself, circumcision did not confer significant protective benefit against STI/HIV infection. Findings suggest the need to apply caution in the use of circumcision as an HIV prevention strategy, particularly in settings where more effective combinations of interventions have yet to be fully implemented.

Sexually transmitted infections clinics as strategic venues for targeting high risk populations for HIV research and sexual health interventions.

Puerto Rico has one of the highest incidence rates of HIV in the U.S. Concurrent with increases in sexually transmitted infections (STI), an increasing share of the new infections in PR are associated with sexual transmission. Much of the available research on sexual risk in PR derives from STI/HIV surveillance data. There is limited social and epidemiological research on sexual risk in PR, particularly in hidden and often hard-to-reach populations at high risk. Despite the absence of substantial resources that most epidemiological studies require, a research collaboration was initiated in 2007 between researchers in the School of Public Health at the University of Puerto Rico and the Centro Latinoamericano de Enfermedades de Transmisión Sexual (CLETS), one of the largest publicly funded centers for STI/HIV screening and treatment in the San Juan metropolitan area. Structured as a case study in the development of community-based research collaborations, this paper describes the early history and development of the project, including formative research, recruitment and training of students, and evolution in the study design that contributed to the current configuration of the ongoing "Core" study. Preliminary data are presented, highlighting data from a number of subpopulations that may contribute to our understanding of the role of behavioral risk in the STI/HIV epidemics in PR. More generally, the paper may guide the development of similar collaboration elsewhere in the Caribbean where HIV risk is increasing but where resources for research in high risk settings and groups are scarce.

Preliminary Evidence of Significant Gaps in Continuity of HIV Care among Excarcerated Populations in Puerto Rico.

OBJECTIVE: Puerto Rico has high HIV prevalence and incidence rates, including a large prison population living with HIV. While HIV treatment is available within the prisons, there are no linkages to care or treatment preparedness interventions following release. METHODS: In an effort to assess the risk of treatment discontinuity in this group, we examined data from an ongoing epidemiological study in the largest, publicly funded HIV/sexually transmitted infection (STI) treatment center in the San Juan area. RESULTS: Among the newly enrolled, HIV-positive patients with a history of incarceration, there was an average 4-year gap in reengagement in treatment. Drug and sexual risk behaviors were prevalent, as was evidence of significant immune impairment (including high viral load and low CD4 count). CONCLUSIONS: Treatment discontinuity may contribute to poor health outcomes in this group and also fuel new infections. There is an urgent need for interventions to retain HIV-positive inmates in community HIV care following release.