Substance use and STI acquisition: Secondary analysis from the AWARE study.

OBJECTIVES: Sexually transmitted infections (STIs) are significant public health and financial burdens in the United States. This manuscript examines the relationship between substance use and prevalent and incident STIs in HIV-negative adult patients at STI clinics. METHODS: A secondary analysis of Project AWARE was performed based on 5012 patients from 9 STI clinics. STIs were assessed by laboratory assay and substance use by self-report. Patterns of substance use were assessed using latent class analysis. The relationship of latent class to STI rates was investigated using Poisson regression by population groups at high risk for STIs defined by participant's and partner's gender. RESULTS: Drug use patterns differed by risk group and substance use was related to STI rates with the relationships varying by risk behavior group. Substance use treatment participation was associated with increased STI rates. CONCLUSIONS: Substance use focused interventions may be useful in STI clinics to reduce morbidity associated with substance use. Conversely, gender-specific sexual health interventions may be useful in substance use treatment.

Effect of Patient Navigation With or Without Financial Incentives on Viral Suppression Among Hospitalized Patients With HIV Infection and Substance Use: A Randomized Clinical Trial.

IMPORTANCE: Substance use is a major driver of the HIV epidemic and is associated with poor HIV care outcomes. Patient navigation (care coordination with case management) and the use of financial incentives for achieving predetermined outcomes are interventions increasingly promoted to engage patients in substance use disorders treatment and HIV care, but there is little evidence for their efficacy in improving HIV-1 viral suppression rates. OBJECTIVE: To assess the effect of a structured patient navigation intervention with or without financial incentives to improve HIV-1 viral suppression rates among patients with elevated HIV-1 viral loads and substance use recruited as hospital inpatients. DESIGN, SETTING, AND PARTICIPANTS: From July 2012 through January 2014, 801 patients with HIV infection and substance use from 11 hospitals across the United States were randomly assigned to receive patient navigation alone (n = 266), patient navigation plus financial incentives (n = 271), or treatment as usual (n = 264). HIV-1 plasma viral load was measured at baseline and at 6 and 12 months. INTERVENTIONS: Patient navigation included up to 11 sessions of care coordination with case management and motivational interviewing techniques over 6 months. Financial incentives (up to $1160) were provided for achieving targeted behaviors aimed at reducing substance use, increasing engagement in HIV care, and improving HIV outcomes. Treatment as usual was the standard practice at each hospital for linking hospitalized patients to outpatient HIV care and substance use disorders treatment. MAIN OUTCOMES AND MEASURES: The primary outcome was HIV viral suppression (≤200 copies/mL) relative to viral nonsuppression or death at the 12-month follow-up. RESULTS: Of 801 patients randomized, 261 (32.6%) were women (mean [SD] age, 44.6 years [10.0 years]). There were no differences in rates of HIV viral suppression versus nonsuppression or death among the 3 groups at 12 months. Eighty-five of 249 patients (34.1%) in the usual-treatment group experienced treatment success compared with 89 of 249 patients (35.7%) in the navigation-only group for a treatment difference of 1.6% (95% CI, -6.8% to 10.0%; P = .80) and compared with 98 of 254 patients (38.6%) in the navigation-plus-incentives group for a treatment difference of 4.5% (95% CI -4.0% to 12.8%; P = .68). The treatment difference between the navigation-only and the navigation-plus-incentives group was -2.8% (95% CI, -11.3% to 5.6%; P = .68). CONCLUSIONS AND RELEVANCE: Among hospitalized patients with HIV infection and substance use, patient navigation with or without financial incentives did not have a beneficial effect on HIV viral suppression relative to nonsuppression or death at 12 months vs treatment as usual. These findings do not support these interventions in this setting. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01612169.

The incidence of Trichomonas vaginalis infection in women attending nine sexually transmitted diseases clinics in the USA.

OBJECTIVES: Trichomoniasis (TV) is associated with an increased risk of acquisition of sexually transmitted diseases (STDs) and HIV. The purpose of this study is to evaluate factors associated with incidence TV among female STD clinic attendees in the USA. METHODS: Data were collected from women participating in a randomised controlled trial evaluating brief risk reduction counselling at the time of HIV testing to reduce sexually transmitted infections (STIs) incidence in STD clinics. Participants recruited from STD clinics underwent STI testing at baseline and 6-month follow-up. TV testing was performed using Nucleic Acid Amplification Test. RESULTS: 1704 participants completed study assessments. Prevalence of TV was 14.6%, chlamydia 8.6%, gonorrhoea 3.0%, herpes simplex virus 2 44.7% and HIV 0.4%. Cumulative 6-month incidence of TV was 7.5%. Almost 50% of the incident TV cases had TV at baseline and had received treatment. Factors associated with incidence of TV were having chlamydia, TV and HIV at baseline: TV relative risk (RR)=3.37 (95% CI 2.35 to 4.83, p<0.001); chlamydia RR=1.92 (95% CI 1.23 to 2.99, p=0.04); and HIV=1.59 (95% CI 1.01 to 2.50, p=0.047). CONCLUSIONS: Prevalent and incident TV is common among STD clinic attendees; and baseline TV is the main risk factor for incident TV, suggesting high rates of reinfection or treatment failures. This supports the importance of rescreening women after treatment for TV, evaluating current treatment regimens and programmes to ensure treatment of sexual partners. CLINICAL TRIAL NUMBER: NCT01154296.

Internalised homophobia is differentially associated with sexual risk behaviour by race/ethnicity and HIV serostatus among substance-using men who have sex with men in the United States.

OBJECTIVES: There is a continuing need to identify factors associated with risk for HIV transmission among men who have sex with men (MSM), including a need for further research in the ongoing scientific debate about the association of internalised homophobia and sexual risk due partly to the lack of specificity in analysis. We assess the association of internalised homophobia by race/ethnicity within HIV serostatus for a large sample of substance-using MSM at high risk of HIV acquisition or transmission. METHODS: Convenience sample of substance-using (non-injection) MSM reporting unprotected anal sex in the prior 6 months residing in Chicago, Los Angeles, New York and San Francisco. The analytic sample included HIV-negative and HIV-positive black (n=391), Latino (n=220), and white (n=458) MSM. Internalised homophobia was assessed using a published four-item scale focusing on negative self-perceptions and feelings of their own sexual behaviour with men, or for being gay or bisexual. Analyses tested associations of internalised homophobia with recent risk behaviour, stratified by laboratory-confirmed HIV serostatus within race/ethnicity, and controlling for other demographic variables. RESULTS: In multivariate analysis, internalised homophobia was inversely associated (p<0.05) with recent unprotected anal sex among black MSM, and not significantly associated with sexual risk behaviour among white and Latino MSM. CONCLUSIONS: More research is needed to further identify nuanced differences in subpopulations of MSM, but these results suggest differentially targeted intervention messages for MSM by race/ethnicity.

The cost of implementing rapid HIV testing in sexually transmitted disease clinics in the United States.

INTRODUCTION: Rapid HIV testing in high-risk populations can increase the number of persons who learn their HIV status and avoid spending clinic resources to locate persons identified as HIV infected. METHODS: We determined the cost to sexually transmitted disease (STD) clinics of point-of-care rapid HIV testing using data from 7 public clinics that participated in a randomized trial of rapid testing with and without brief patient-centered risk reduction counseling in 2010. Costs included counselor and trainer time, supplies, and clinic overhead. We applied national labor rates and test costs. We calculated median clinic start-up costs and mean cost per patient tested, and projected incremental annual costs of implementing universal rapid HIV testing compared with current testing practices. RESULTS: Criteria for offering rapid HIV testing and methods for delivering nonrapid test results varied among clinics before the trial. Rapid HIV testing cost an average of US $22/patient without brief risk reduction counseling and US $46/patient with counseling in these 7 clinics. Median start-up costs per clinic were US $1100 and US $16,100 without and with counseling, respectively. Estimated incremental annual costs per clinic of implementing universal rapid HIV testing varied by whether or not brief counseling is conducted and by current clinic testing practices, ranging from a savings of US $19,500 to a cost of US $40,700 without counseling and a cost of US $98,000 to US $153,900 with counseling. CONCLUSIONS: Universal rapid HIV testing in STD clinics with same-day results can be implemented at relatively low cost to STD clinics, if brief risk reduction counseling is not offered.

A roadmap for adapting an evidence-based HIV prevention intervention: personal cognitive counseling (PCC) for episodic substance-using men who have sex with men.

Episodic (less than weekly) drug use and binge drinking increase HIV-related sexual risk behaviors among men who have sex with men (MSM), yet no evidence-based interventions exist for these men. We describe an adaptation process of the Personalized Cognitive Counseling (PCC) intervention for utilization with high-risk, HIV-negative episodic, substance-using MSM. Participants (N = 59) were racially diverse, and reported unprotected anal intercourse and concurrent binge drinking (85%), use of poppers (36%), methamphetamine (20%) and cocaine (12%). Semi-structured interviews with 20 episodic, substance-using MSM elicited sexual narratives for engaging in unprotected anal intercourse while using alcohol or drugs. Emergent qualitative themes were translated into self-justifications and included in a revised PCC self-justification elicitation instrument (SJEI). The adapted SJEI was pretested with 19 episodic, substance-using MSM, and the final adapted PCC was pilot-tested for acceptability and feasibility with 20 episodic, substance-using MSM. This process can be used as a roadmap for adapting PCC for other high-risk populations of MSM.

Effect of risk-reduction counseling with rapid HIV testing on risk of acquiring sexually transmitted infections: the AWARE randomized clinical trial.

IMPORTANCE: To increase human immunodeficiency virus (HIV) testing rates, many institutions and jurisdictions have revised policies to make the testing process rapid, simple, and routine. A major issue for testing scale-up efforts is the effectiveness of HIV risk-reduction counseling, which has historically been an integral part of the HIV testing process. OBJECTIVE: To assess the effect of brief patient-centered risk-reduction counseling at the time of a rapid HIV test on the subsequent acquisition of sexually transmitted infections (STIs). DESIGN, SETTING, AND PARTICIPANTS: From April to December 2010, Project AWARE randomized 5012 patients from 9 sexually transmitted disease (STD) clinics in the United States to receive either brief patient-centered HIV risk-reduction counseling with a rapid HIV test or the rapid HIV test with information only. Participants were assessed for multiple STIs at both baseline and 6-month follow-up. INTERVENTIONS: Participants randomized to counseling received individual patient-centered risk-reduction counseling based on an evidence-based model. The core elements included a focus on the patient's specific HIV/STI risk behavior and negotiation of realistic and achievable risk-reduction steps. All participants received a rapid HIV test. MAIN OUTCOMES AND MEASURES: The prespecified outcome was a composite end point of cumulative incidence of any of the measured STIs over 6 months. All participants were tested for Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum (syphilis), herpes simplex virus 2, and HIV. Women were also tested for Trichomonas vaginalis. RESULTS: There was no significant difference in 6-month composite STI incidence by study group (adjusted risk ratio, 1.12; 95% CI, 0.94-1.33). There were 250 of 2039 incident cases (12.3%) in the counseling group and 226 of 2032 (11.1%) in the information-only group. CONCLUSION AND RELEVANCE: Risk-reduction counseling in conjunction with a rapid HIV test did not significantly affect STI acquisition among STD clinic patients, suggesting no added benefit from brief patient-centered risk-reduction counseling. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01154296.

Correlates of HIV infection among transfemales, San Francisco, 2010: results from a respondent-driven sampling study.

OBJECTIVES: We evaluated the use of respondent-driven sampling (RDS) among a high-risk population of transfemales. We also obtained up-to-date epidemiological data on HIV infection and related correlates among this population. METHODS: We evaluated the utility of RDS in recruiting a sample of 314 transfemales in San Francisco, California, from August to December 2010 by examining patterns of recruitment and assessing network sizes and equilibrium. We used RDS weights to conduct bivariate and multivariate analyses of correlates of HIV infection. RESULTS: The sample had moderate homophily and reached equilibrium at the eighth wave of recruitment. Weighted HIV prevalence among transfemales was 39.5%. Being a transfemale of color, using injection drugs, and having low educational attainment were independently associated with HIV infection and having a high number of sexual partners and identifying as female were not. CONCLUSIONS: RDS performed well and allowed for analyses that are generalizable to the population from which the sample was drawn. Transfemales in San Francisco are disproportionately affected by HIV compared with all other groups except men who have sex with men who also inject drugs.

The cost-effectiveness of rapid HIV testing in substance abuse treatment: results of a randomized trial.

BACKGROUND: The President's National HIV/AIDS Strategy calls for coupling HIV screening and prevention services with substance abuse treatment programs. Fewer than half of US community-based substance abuse treatment programs make HIV testing available on-site or through referral. METHODS: We measured the cost-effectiveness of three HIV testing strategies evaluated in a randomized trial conducted in 12 community-based substance abuse treatment programs in 2009: off-site testing referral, on-site rapid testing with information only, on-site rapid testing with risk-reduction counseling. Data from the trial included patient demographics, prior testing history, test acceptance and receipt of results, undiagnosed HIV prevalence (0.4%) and program costs. The Cost-Effectiveness of Preventing AIDS Complications (CEPAC) computer simulation model was used to project life expectancy, lifetime costs, and quality-adjusted life years (QALYs) for HIV-infected individuals. Incremental cost-effectiveness ratios (2009 US $/QALY) were calculated after adding costs of testing HIV-uninfected individuals; costs and QALYs were discounted at 3% annually. RESULTS: Referral for off-site testing is less efficient (dominated) compared to offering on-site testing with information only. The cost-effectiveness ratio for on-site testing with information is $60,300/QALY in the base case, or $76,300/QALY with 0.1% undiagnosed HIV prevalence. HIV risk-reduction counseling costs $36 per person more without additional benefit. CONCLUSIONS: A strategy of on-site rapid HIV testing offer with information only in substance abuse treatment programs increases life expectancy at a cost-effectiveness ratio <$100,000/QALY. Policymakers and substance abuse treatment leaders should seek funding to implement on-site rapid HIV testing in substance abuse treatment programs for those not recently tested.

Aripiprazole for the treatment of methamphetamine dependence: a randomized, double-blind, placebo-controlled trial.

AIMS: To test aripiprazole for efficacy in decreasing use in methamphetamine-dependent adults, compared to placebo. DESIGN: Participants were randomized to receive 12 weeks of aripiprazole or placebo, with a 3-month follow-up and a platform of weekly 30-minute substance abuse counseling. SETTING: The trial was conducted from January 2009 to March 2012 at the San Francisco Department of Public Health. PARTICIPANTS: Ninety actively using, methamphetamine-dependent, sexually active adults were recruited from community venues. MEASUREMENTS: The primary outcome was regression estimated reductions in weekly methamphetamine-positive urines. Secondary outcomes were study medication adherence [by self-report and medication event monitoring systems (MEMS)], sexual risk behavior and abstinence from methamphetamine. FINDINGS: Participant mean age was 38.7 years, 87.8% were male, 50.0% white, 18.9% African American, and 16.7% Latino. Eighty-three per cent of follow-up visits and final visits were completed. By intent-to-treat, participants assigned to aripiprazole had similar reductions in methamphetamine-positive urines as participants assigned to placebo [risk ratio (RR) 0.88, 95% confidence interval (CI): 0.66-1.19, P = 0.41]. Urine positivity declined from 73% (33 of 45 participants) to 45% (18 of 40) in the placebo arm and from 77% (34 of 44) to 44% (20 of 35) in the aripiprazole arm. Adherence by MEMS and self-report was 42 and 74%, respectively, with no significant difference between arms (MEMS P = 0.31; self-report P = 0.17). Most sexual risk behaviors declined similarly among participants in both arms (all P > 0.05). There were no serious adverse events related to study drug, although participants randomized to aripiprazole reported more akathisia, fatigue and drowsiness (P < 0.05). CONCLUSION: Compared with placebo, aripiprazole did not reduce methamphetamine use significantly among actively using, dependent adults.

Correlates of unprotected vaginal or anal intercourse with women among substance-using men who have sex with men.

The role men who have sex with men and women (MSMW) play in heterosexual HIV transmission is not well understood. We analyzed baseline data from Project MIX, a behavioral intervention study of substance-using men who have sex with men (MSM), and identified correlates of unprotected vaginal intercourse, anal intercourse, or both with women (UVAI). Approximately 10 % (n = 194) of the men reported vaginal sex, anal sex, or both with a woman; of these substance-using MSMW, 66 % (129) reported UVAI. Among substance-using MSMW, multivariate analyses found unemployment relative to full/part-time employment (OR = 2.28; 95 % CI 1.01, 5.17), having a primary female partner relative to no primary female partner (OR = 3.44; CI 1.4, 8.46), and higher levels of treatment optimism (OR = 1.73; 95 % CI 1.18, 2.54) increased odds of UVAI. Strong feelings of connection to a same-race gay community (OR = 0.71; 95 % CI 0.56, 0.91) and Viagra use (OR = 0.31; 95 % CI 0.10, 0.95) decreased odds of UVAI. This work suggests that although the proportion of substance-using MSM who also have sex with women is low, these men engage in unprotected sex with women, particularly with primary female partners. This work highlights the need for further research with the substance using MSMW population to inform HIV prevention interventions specifically for MSMW.

Reaching black men who have sex with men: a comparison between respondent-driven sampling and time-location sampling.

OBJECTIVES: The authors explored whether respondent-driven sampling (RDS) can generate a more diverse sample of black men who have sex with men (MSM) than time-location sampling (TLS) by comparing sample characteristics accrued by each method in two independent studies. METHODS: The first study exclusively recruited black MSM through RDS (N=256), while the second recruited MSM through TLS including a subsample of black MSM (N=69). Crude and adjusted point estimates and 95% CIs were calculated for socio-demographic and behavioural characteristics, HIV prevalence and prevalence of unrecognised infections, and were compared using the Z-test. RESULTS: The samples differed significantly regarding all socio-demographic and some behavioural characteristics. Compared with TLS, RDS estimated higher proportions of older, less educated, poorer, currently homeless and self-identified bisexual black MSM. Participants in RDS were less likely to have a main partner, had fewer male partners, were more likely to have a female partner and have both male and female partners, and reported greater methamphetamine, crack and heroin use. Prevalence of HIV and unrecognised infections were slightly higher among RDS participants. CONCLUSIONS: The RDS sample comprised black MSM who were more diverse with respect to socio-demographic characteristics and may also be at higher risk for HIV. Thus, RDS has advantages in reaching higher risk black MSM who are most hidden from intervention research and service delivery. Future studies of black MSM using RDS could use steering strategies to recruit younger participants and other subgroups of greatest interest to public health and prevention.

Implementing rapid HIV testing with or without risk-reduction counseling in drug treatment centers: results of a randomized trial.

OBJECTIVES: We examined the effectiveness of risk reduction counseling and the role of on-site HIV testing in drug treatment. METHODS: Between January and May 2009, we randomized 1281 HIV-negative (or status unknown) adults who reported no past-year HIV testing to (1) referral for off-site HIV testing, (2) HIV risk-reduction counseling with on-site rapid HIV testing, or (3) verbal information about testing only with on-site rapid HIV testing. RESULTS: We defined 2 primary self-reported outcomes a priori: receipt of HIV test results and unprotected anal or vaginal intercourse episodes at 6-month follow-up. The combined on-site rapid testing participants received more HIV test results than off-site testing referral participants (P<.001; Mantel-Haenszel risk ratio=4.52; 97.5% confidence interval [CI]=3.57, 5.72). At 6 months, there were no significant differences in unprotected intercourse episodes between the combined on-site testing arms and the referral arm (P=.39; incidence rate ratio [IRR]=1.04; 97.5% CI=0.95, 1.14) or the 2 on-site testing arms (P=.81; IRR=1.03; 97.5% CI=0.84, 1.26). CONCLUSIONS: This study demonstrated on-site rapid HIV testing's value in drug treatment centers and found no additional benefit from HIV sexual risk-reduction counseling.

Using social networks to reach Black MSM for HIV testing and linkage to care.

Black men who have sex with men (MSM) are disproportionately affected by HIV infection. Black MSM in San Francisco may have higher rates of unrecognized HIV infections. Increased HIV testing among Black MSM may reduce the numbers of unrecognized infections, inform more men of their status and thus reduce the potential for ongoing transmissions. Social network HIV testing programs have focused on asking HIV-positive and/or high-risk negative men to recruit their social or sexual contacts. We used a network approach to deliver HIV testing to Black MSM in San Francisco and collected risk assessment data. Participants were asked to recruit any of their social contacts who were also Black MSM. Recruitment by risk level and HIV status was heterogeneous. HIV infection among this population is associated with older age, having a high school education or higher and currently being homeless. Fully 23% of HIV positive Black MSM are unaware of their infection. Only a third of unrecognized infections were recruited by a known HIV-positive participant. Linkage to care was a challenge and underscores the need for comprehensive systems and support to link Black MSM to care and treatment.

Mirtazapine to reduce methamphetamine use: a randomized controlled trial.

CONTEXT: No approved pharmacologic treatments for methamphetamine dependence exist. Methamphetamine use is associated with high morbidity and is a major cofactor in the human immunodeficiency virus epidemic among men who have sex with men (MSM). OBJECTIVE: To determine whether mirtazapine would reduce methamphetamine use among MSM who are actively using methamphetamine. DESIGN: Double-blind, randomized, controlled, 12-week trial of mirtazapine vs placebo conducted from September 5, 2007, to March 4, 2010. SETTING: San Francisco Department of Public Health. PARTICIPANTS: Participants were actively using, methamphetamine-dependent, sexually active MSM seen weekly for urine sample collection and substance use counseling. INTERVENTIONS: Random assignment to daily oral mirtazapine (30 mg) or placebo; both arms included 30-minute weekly substance use counseling. MAIN OUTCOME MEASURES: The primary study outcome was reduction in methamphetamine-positive urine test results. Secondary outcomes were study medication adherence (by self-report and medication event monitoring systems) and sexual risk behavior. RESULTS: Sixty MSM were randomized, 85% of follow-up visits were completed, and 56 participants (93%) completed the final visit. In the primary intent-to-treat analysis, participants assigned to the mirtazapine group had fewer methamphetamine-positive urine test results compared with participants assigned to the placebo group (relative risk, 0.57; 95% CI, 0.35-0.93, P = .02). Urine positivity decreased from 67% (20 of 30 participants) to 63% (17 of 27) in the placebo arm and from 73% (22 of 30) to 44% (12 of 27) in the mirtazapine arm. The number needed to treat to achieve a negative weekly urine test result was 3.1. Adherence was 48.5% by medication event monitoring systems and 74.7% by self-report; adherence measures were not significantly different between arms (medication event monitoring systems, P = .82; self-report, P = .92). Most sexual risk behaviors decreased significantly more among participants taking mirtazapine compared with those taking placebo (number of male partners with whom methamphetamine was used, P = .009; number of male partners, P = .04; episodes of anal sex with serodiscordant partners, P = .003; episodes of unprotected anal sex with serodiscordant partners, P = .003; episodes of insertive anal sex with serodiscordant partners, P = .001). There were no serious adverse events related to study drug or significant differences in adverse events by arm (P ≥ .99). CONCLUSION: The addition of mirtazapine to substance use counseling decreased methamphetamine use among active users and was associated with decreases in sexual risk despite low to moderate medication adherence. Trial Registration  clinicalTrials.gov Identifier NCT00497081.

Condom-use decision making in the context of hypothetical pre-exposure prophylaxis efficacy among substance-using men who have sex with men: Project MIX.

OBJECTIVE: To examine condom-use decision making in the context of hypothetical pre-exposure prophylaxsis (PrEP) efficacy among men who have sex with men who use alcohol and other substances during sex. METHODS: Substance-using men who have sex with men were recruited in 4 US cities for a behavioral intervention trial. Three groups were defined as follows: men who indicated that to not use a condom for receptive/insertive unprotected anal intercourse (UAI) while using PrEP, PrEP would need to be: (1) "almost always or always" effective (high efficacy); (2) effective "at least half the time or more but not almost always or always" (mid-range efficacy corresponding to recent PrEP trial results); (3) effective "less than half the time" (low efficacy). The mid-range efficacy group was compared with the low-efficacy group (as the reference) and to the-high efficacy group (as the reference). RESULTS: Among 630 men who never used PrEP, 15.2% were in the mid-range efficacy group for receptive UAI and 34.1% in the mid-range efficacy group for insertive UAI. Scores on difficulty communicating about safer sex while high were significantly higher in the mid-range efficacy group compared with each of the other groups for both receptive and insertive UAI. Men who seemed to be differentiating PrEP use by anal sex role also scored higher on communication difficulties, although scoring lower on condom intentions. CONCLUSIONS: Communication about safer sex while under the influence of alcohol or other substances and condom intentions are important factors to consider for HIV prevention interventions for PrEP users.

Performance of risk-based criteria for targeting acute HIV screening in San Francisco.

BACKGROUND: Federal guidelines now recommend supplemental HIV RNA testing for persons at high risk for acute HIV infection. However, many rapid HIV testing sites do not include HIV RNA or p24 antigen testing due to concerns about cost, the need for results follow-up, and the impact of expanded venipuncture on clinic flow. We developed criteria to identify patients in a municipal STD clinic in San Francisco who are asymptomatic but may still be likely to have acute infection. METHODS: Data were from patients tested with serial HIV antibody and HIV RNA tests to identify acute HIV infection. BED-CEIA results were used to classify non-acute cases as recent or longstanding. Demographics and self-reported risk behaviors were collected at time of testing. Multivariate models were developed and preliminarily evaluated using predictors associated with recent infection in bivariate analyses as a proxy for acute HIV infection. Multivariate models demonstrating ≥70% sensitivity for recent infection while testing ≤60% of patients in this development dataset were then validated by determining their performance in identifying acute infections. RESULTS: From 2004-2007, 137 of 12,622 testers had recent and 36 had acute infections. A model limiting acute HIV screening to MSM plus any one of a series of other predictors resulted in a sensitivity of 83.3% and only 47.6% of patients requiring testing. A single-factor model testing only patients reporting any receptive anal intercourse resulted in 88.9% sensitivity with only 55.2% of patients requiring testing. CONCLUSIONS: In similar high risk HIV testing sites, acute screening using "supplemental" HIV p24 antigen or RNA tests can be rationally targeted to testers who report particular HIV risk behaviors. By improving the efficiency of acute HIV testing, such criteria could facilitate expanded acute case identification.

Linkage and retention in HIV care among men who have sex with men in the United States.

Men who have sex with men (MSM) continue to be disproportionately affected by human immunodeficiency virus (HIV) infection. While the MSM population does better than other HIV infection risk groups with regard to linkage to and retention in care, little is known about engagement in care outcomes for important subpopulations of MSM. There is also a dearth of research on engagement in care strategies specific to the MSM population. Key MSM subpopulations in the United States on which to focus future research efforts include racial/ethnic minority, young, and substance-using MSM. Health care systems navigation may offer a promising engagement in care strategy for MSM and should be further evaluated. As is the case for HIV-infected populations in general, future research should also focus on identifying the best metrics for measuring engagement in care.

Racial/Ethnic differences in seroadaptive and serodisclosure behaviors among men who have sex with men.

We examined racial/ethnic differences in reported seroadaptive and serodisclosure behaviors among the partnerships of MSM recruited for a cross-sectional survey using time-location sampling (TLS) in San Francisco during 2007-2008. The sample (N = 1,199) consisted of 12.2% Asian/Pacific Islander (API), 52.4% White, 6.8% Black, 20.2% Latino, and 8.5% of "other" race/ethnicity. Pure serosorting was most common (about 20%) among HIV-negative men while seropositioning was most used (about 15%) by HIV-positive men. Reported seroadaptive behaviors did not differ significantly across races/ethnicities among both HIV-negative and HIV-positive men. However, HIV-positive Black and Latino men were significantly more likely to report no preventive, seroadaptive behavioral strategy (i.e., unprotected insertive anal intercourse with unknown status or serodiscordant partners). Among men who reported engaging in seroadaptive behaviors, they reported not discussing HIV status with a third of their partners-a major concern in that lack of disclosure undermines the effectiveness and means to practice serosorting. Partnerships of API and Black men were least likely to involve serodisclosure behaviors. Our study confirms that seroadaptive behaviors are common preventive strategies reported by MSM of all races/ethnicities, and does not find strong evidence that racial/ethnic differences in seroadaptive behaviors are enhancing disparities in HIV prevalence. The implications are that condom promotion and safe sex messages are not the only prevention measures adopted by MSM and that public health professionals should be well aware of current trends within the MSM community in order to better assist HIV prevention efforts.