HIV Infection and Depression Among Opiate Users in a US Epicenter of the Opioid Epidemic.

Using a mobile research facility, we enrolled 141 opioid users from a neighborhood of Philadelphia, an urban epicenter of the opioid epidemic. Nearly all (95.6%) met DSM-5 criteria for severe opioid use disorder. The prevalence of HIV infection (8.5%) was more than seven times that found in the general population of the city. Eight of the HIV-positive participants (67.0%) reported receiving antiretroviral treatment but almost all of them had unsuppressed virus (87.5%). The majority of participants (57.4%) reported symptoms consistent with major depressive disorder. Severe economic distress (60.3%) and homelessness were common (57%). Polysubstance use was nearly universal, 72.1% had experienced multiple overdoses and prior medication for opioid use disorder (MOUD) treatment episodes (79.9%), but few currently engaged in addiction care. The prevalence, multiplicity and severity of chronic health and socioeconomic problems highlight consequences of the current opioid epidemic and underscore the urgent need to develop integrated models of treatment.

RESUMEN: Utilizando un Centro de Investigación Móvil, inscribimos a 141 usuarios de opioides del vecindario de Filadelfia, un epicentro urbano de la epidemia de opioides. Casi todos (95,6%) cumplieron con los criterios del DSM-5 para el trastorno del uso severo del consumo de opioides. La prevalencia de la infección de VIH (8,5%) fue másﹶ de 7 veces superior a las encontrada en la población general de la ciudad. Ocho de los participantes con VIH positivo (67,0%) reportaron haber recibido tratamiento antirretroviral pero casi todos tuvieron virus no suprimido (87,5%). La mayoría de los participantes (57,4%) informaron síntomas compatibles con el Desorden Depresivo Mayor. La angustia severa por lo económico (60,3%) y las personas sin hogar fueron comunes (57%). El uso de múltiples sustancias fue casi universal, el 721% había experimentado múltiples sobredosis y previos medicamentos para el tratamiento del trastorno por consumo de opioides (MOUD) (79,9%), pero muy pocos estaban comprometidos con la atención a las adicciones. La prevalencia, la multiplicidad y la seriedad de los problemas de salud crónica y los problemas socioeconómicos destacan las consecuencias de la actual epidemia de opioides y subrayan la urgente necesidad de desarrollar nuevos modelos de tratamiento integrados.

Going social: Success in online recruitment of men who have sex with men for prevention HIV vaccine research.

OBJECTIVE: To compare the use of four different social media sites to recruit men who have sex with men (MSM) and transgender women to a phase 2b HIV prevention vaccine trial, HVTN 505. DESIGN: Retrospective, observational study. METHODS: The University of Pennsylvania HIV Vaccine Trials Unit (Penn HVTU) employed street outreach and online recruitment methods to recruit participants for HVTN 505 using a combination of national recruitment images/messages with Philadelphia-specific language and imagery. We compared the efficiency (number of enrolled participants per number of completed phone screens) and effectiveness (number of enrolled participants per time interval employed) of each strategy, as well as the demographics and risk behaviors of the populations. RESULTS: Online recruitment strategies populated 37% (71/191) of trial participants at our site. Among the four social media strategies employed, 45.1% (32/71) were enrolled through Facebook, 16.9% (12/71) through Craigslist, 15.5% (11/71) through a web-based marketing company (WBMC), and 22.5% (16/71) via GRINDR. The number of participants enrolled per month of strategy and the months the strategy was employed were Facebook - 32(33months), Craigslist - 12(33months), WBMC - 11(6months), and GRINDR - 16(0.56months). In-person and online recruitment strategies yielded participants of similar demographics and levels of risk behavior. CONCLUSION: Use of several social media recruitment modalities produced large numbers of MSM engaging in high risk behavior and willing to participate in an HIV prevention vaccine trial. In comparison to other social media and online strategies, recruitment via GRINDR was the most effective.

Association Between Depression and Condom Use Differs by Sexual Behavior Group in Patients with HIV.

Identifying a relationship between depression and sexual risk behavior in HIV-infected patients could establish a mechanism to enhance prevention efforts. We conducted a cross-sectional analysis using data from the University of Pennsylvania Center for AIDS Research and used ordinal logistic regression to measure the association between depression and non-condom use. 716 men who have sex with men (MSM), 262 heterosexual men and 277 heterosexual women were included. The association between depression and non-condom use was strongest in heterosexual men with and without HIV-infected regular partners (OR 8.53, 95% CI 1.18-61.89 and OR 2.30, 95% CI 0.99-5.36 respectively), but absent in heterosexual women regardless of partner. Although the OR was low in MSM overall, an association was detected in MSM without HIV-infected regular partners (OR 2.44, 95% CI 1.39-4.31). In conclusion, we demonstrated an association between depression and non-condom use driven by heterosexual men and MSM without HIV-infected regular partners. Sexual risk should be addressed when intervening on depressive symptoms in these subgroups.

Individual and community factors associated with geographic clusters of poor HIV care retention and poor viral suppression.

BACKGROUND: Previous analyses identified specific geographic areas in Philadelphia (hotspots) associated with negative outcomes along the HIV care continuum. We examined individual and community factors associated with residing in these hotspots. METHODS: Retrospective cohort of 1404 persons newly diagnosed with HIV in 2008-2009 followed for 24 months after linkage to care. Multivariable regression examined associations between individual (age, sex, race/ethnicity, HIV transmission risk, and insurance status) and community (economic deprivation, distance to care, access to public transit, and access to pharmacy services) factors and the outcomes: residence in a hotspot associated with poor retention-in-care and residence in a hotspot associated with poor viral suppression. RESULTS: In total, 24.4% and 13.7% of persons resided in hotspots associated with poor retention and poor viral suppression, respectively. For persons residing in poor retention hotspots, 28.3% were retained in care compared with 40.4% of those residing outside hotspots (P < 0.05). Similarly, for persons residing in poor viral suppression hotspots, 51.4% achieved viral suppression compared with 75.3% of those outside hotspots (P < 0.0.05). Factors significantly associated with residence in poor retention hotspots included female sex, lower economic deprivation, greater access to public transit, shorter distance to medical care, and longer distance to pharmacies. Factors significantly associated with residence in poor viral suppression hotspots included female sex, higher economic deprivation, and shorter distance to pharmacies. CONCLUSIONS: Individual and community-level associations with geographic hotspots may inform both content and delivery strategies for interventions designed to improve retention-in-care and viral suppression.

Behind the cascade: analyzing spatial patterns along the HIV care continuum.

BACKGROUND: Successful HIV treatment as prevention requires individuals to be tested, aware of their status, linked to and retained in care, and virally suppressed. Spatial analysis may be useful for monitoring HIV care by identifying geographic areas with poor outcomes. METHODS: Retrospective cohort of 1704 people newly diagnosed with HIV identified from Philadelphia's Enhanced HIV/AIDS Reporting System in 2008-2009, with follow-up to 2011. Outcomes of interest were not linked to care, not linked to care within 90 days, not retained in care, and not virally suppressed. Spatial patterns were analyzed using K-functions to identify "hot spots" for targeted intervention. Geographic components were included in regression analyses along with demographic factors to determine their impact on each outcome. RESULTS: Overall, 1404 persons (82%) linked to care; 75% (1059/1404) linked within 90 days; 37% (526/1059) were retained in care; and 72% (379/526) achieved viral suppression. Fifty-nine census tracts were in hot spots, with no overlap between outcomes. Persons residing in geographic areas identified by the local K-function analyses were more likely to not link to care [adjusted odds ratio 1.76 (95% confidence interval: 1.30 to 2.40)], not link to care within 90 days (1.49, 1.12-1.99), not be retained in care (1.84, 1.39-2.43), and not be virally suppressed (3.23, 1.87-5.59) than persons not residing in the identified areas. CONCLUSIONS: This study is the first to identify spatial patterns as a strong independent predictor of linkage to care, retention in care, and viral suppression. Spatial analyses are a valuable tool for characterizing the HIV epidemic and treatment cascade.

The development of a culturally relevant, theoretically driven HPV prevention intervention for urban adolescent females and their parents/guardians.

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States, accounting for the large majority of cervical cancer and anogenital warts cases. Two HPV vaccines are currently licensed and recommended for women and girls. However, vaccination rates have been suboptimal, with evidence of disparities influencing both uptake and series completion among African American and Hispanic adolescents. There has been a dearth of theory-based, behavioral interventions targeted to prevent HPV infection and increase HPV vaccine uptake among urban adolescents. This article describes the development of two skills-based intervention curricula aimed to increase HPV prevention and vaccination among low-income urban adolescent females 9 to 18 years old. Guided by the theory of planned behavior, elicitation research was conducted to elucidate the social psychological factors that underlie HPV vaccination intentions (N = 141). The findings were subsequently used to identify theoretical mediators of behavioral change to drive the intervention. Culturally relevant strategies to promote HPV vaccination were translated into the curricula content. Both curricula were designed to motivate and empower participants to reduce risk of being infected with HPV. Targeting theoretical mediators of behavioral change, derived from the voices of the community, may prove to be successful in increasing HPV vaccination and preventing HPV.

An exploratory study of adolescent female reactions to direct-to-consumer advertising: the case of the Human Papillomavirus (HPV) Vaccine.

When the human papillomavirus (HPV) vaccine was approved in 2006, an extensive direct-to-consumer (DTC) advertising campaign raised awareness and promoted vaccination. This study explores adolescents' exposure to and understanding of the messages in these advertisements. Sixty-seven African American females participated in a focus group about DTC advertising for the HPV vaccine. Virtually all adolescents had seen an HPV vaccine DTC advertisement, but most did not understand the health information contained in it. If DTC advertising is to be an effective source of health information for adolescents in the future, it must take into account the unique features of an adolescent audience.

Selectively willing and conditionally able: HIV vaccine trial participation among women at "high risk" of HIV infection.

Efficacy studies of investigational HIV vaccines require enrollment of individuals at 'high risk' for HIV. This paper examines participation in HIV vaccine trials among women at 'high risk' for HIV acquisition. In-depth interviews were conducted with 17 African-American women who use crack cocaine and/or exchange sex for money/drugs to elicit attitudes toward medical research and motivators and deterrents to HIV vaccine trial participation. Interviews were digitally recorded and transcribed; data were coded and compiled into themes. Most women expressed favorable attitudes toward medical research in general. Motivators for trial participation included compensation; personal benefits including information, social services, and the possibility that the trial vaccine could prevent HIV; and altruism. Deterrents included: dislike of needles; distrust; concern about future consequences of participating. In addition, contingencies, care-giving responsibilities, and convenience issues constituted barriers which could impede participation. Respondents described varied, complex perspectives, and individual cases illustrate how these themes played out as women contemplated trial participation. Understanding factors which influence vaccine research participation among women at 'high risk' can aid sites to tailor recruitment procedures to local contexts. Concerns about future reactions can be addressed through sustained community education. Convenience barriers can be ameliorated by providing rides to study visits when necessary, and/or conducting study visits in accessible neighborhood locations. Women in this sample thought carefully about enrolling in HIV vaccine trials given the structural constraints within which they lived. Further research is needed regarding structural factors which influence personal agency and individuals' thinking about research participation.

Examining racial disparities in HIV: lessons from sexually transmitted infections research.

Racial differences in the prevalence and incidence of HIV infection and AIDS diagnoses in the United States are striking. These differences have been recognized for nearly 20 years, yet they are not well investigated. In this article, we examine 15 factors identified in the sexually transmitted infection (STI) literature to explain the presence of racial/ethnic disparities in STIs. We review findings from these studies and offer suggestions for future research, with the goal of further understanding and reducing disparities in HIV. In general, the STI literature shows that an evaluation of individual behavior is necessary but insufficient on its own to account for racial/ethnic disparities in STIs. Population parameters should be included within models that traditionally include individual-level factors. The 15 factors can be categorized into 3 broad overarching themes: behavioral, prevention participation, and biologic explanations of differentials in STI transmission and infection. Future research that focuses on only 1 of the 15 factors discussed in this review, to the exclusion of others, is likely to yield poor outcomes. Conversely, an emphasis on the interactions of several factors is more likely to produce effective public health interventions and reductions in HIV transmission.

Intra-couple communication dynamics of HIV risk behavior among injecting drug users and their sexual partners in Northern Vietnam.

This paper elucidates the social context of HIV risk behavior and intra-couple risk communication among injecting drug users (IDUs) and their main sex partner. Data on shared injection equipment, unprotected sex with multiple partners, unprotected sex with a main partner and couples' dynamics and risk communication were gathered through separate in-depth interviews with 11 active male IDUs and 11 of their primary female sex partners in Northern Vietnam. The majority of IDUs' sex partners does not inject drugs and is monogamous. In contrast, most IDUs reported a wide range of risky practices including needle sharing and unprotected sex with multiple, often concurrent, sex partners. Men rarely used condoms with primary partners. Many IDUs worried about their HIV-status, but none disclosed their injecting or sexual practices to their sex partners, leaving their partners unaware of their HIV risk. Among women who worried about HIV/AIDS, the vast majority was unable to influence their partner's needle sharing or extramarital affairs and most would not initiate condom use because they feared their partner's reaction. Couple-based interventions to facilitate risk communication combined with programs to promote condom use among male IDUs, may help to reduce HIV transmission from IDUs to their primary partners.