Publications by authors named "Demetria Cain"

99 Publications

Chronic High Risk Prescription Opioid Use Among Persons With HIV.

Front Sociol 2021 18;6:645992. Epub 2021 May 18.

Icahn School of Medicine at Mount Sinai, Division of Infectious Diseases, NY, NY, United States.

Persons with HIV (PWH) are a population at risk for adverse sequelae of opioid use. Yet, few studies have examined correlates of chronic high risk opioid use and its impact on HIV outcomes. Trends in prescribing patterns and identification of factors that impact the use of opioid prescriptions among PWH are crucial to determine prevention and treatment interventions. This study examined electronic medical records (EMR) of patients receiving HIV care to characterize prescribing patterns and identify risk factors for chronic high risk prescription opioid use and the impact on HIV outcomes among PWH in primary care from July 1, 2016-December 31, 2017. EMR were analyzed from 8,882 patients who were predominantly male and ethnically and racially diverse with half being 50 years of age or older. The majority of the 8,744 prescriptions (98% oral and 2% transdermal preparations) given to 1,040 (12%) patients were oxycodone (71%), 8% were morphine, 7% tramadol, 4% hydrocodone, 4% codeine, 2% fentanyl, and 4% were other opioids. The number of monthly prescriptions decreased about 14% during the study period. Bivariate analyses indicated that most demographic and clinical variables were associated with receipt of any opioid prescription. After controlling for patient socio-demographic characteristics and clinical factors, the odds of receipt of any prescription were higher among patients with pain diagnoses and opioid use and mental health disorders. In addition, the odds of receipt of high average daily morphine equivalent dose (MED) prescriptions were higher for patients with pain diagnoses. Lastly, patients with substance use disorders (SUD) had an increased likelihood of detectable viral load compared to patients with no SUD, after adjusting for known covariates. Our findings show that despite opioid prescribing guidelines and monitoring systems, additional efforts are needed to prevent chronic high risk prescriptions in patients with comorbid conditions, including pain-related, mental health and substance use disorders. Evidence about the risk for chronic high risk use based on prescribing patterns could better inform pain management and opioid prescribing practices for patients receiving HIV care.
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http://dx.doi.org/10.3389/fsoc.2021.645992DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8176351PMC
May 2021

Heterosexual Cisgender Men Partnered with Transgender Women Exhibit Higher HIV/STI Sexual Risk than Their Gay, Bisexual, and Queer Counterparts: Findings from a U.S.-Based Convenience Sample Recruited Online.

AIDS Behav 2021 May 28. Epub 2021 May 28.

Department of Psychology, Hunter College, City University of New York (CUNY), New York, NY, USA.

Cisgender men are frequently vectors for HIV transmission among transgender women. Despite this, the correlates of sexual risk among these men remain under-examined. The purpose of the present study was to explore potential differences in relationship characteristics, sexual risk-taking, and risk-reduction strategies among cisgender men partnered with transgender women. The study utilized secondary screening data provided by adult cis men who reported being in a primary relationship with a trans woman (N = 710). Gay men (18%) were comparatively older, and most likely to report both HIV seropositivity and committed pairings. Heterosexual men (14%) were more likely to report exchange sex, briefer relationships, extra-dyadic sex, lesser serostatus awareness or PrEP uptake. Queer men (7%) were youngest, and most likely to access PrEP. Heterosexual cis men with trans women partners may be subject to unique socio-cultural drivers of sexual risk, such as heteronormative pressures and relationship stigma.
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http://dx.doi.org/10.1007/s10461-021-03314-9DOI Listing
May 2021

Stress-Related Growth among Transgender Women: Measurement, Correlates, and Insights for Clinical Interventions.

J Homosex 2021 May 14:1-24. Epub 2021 May 14.

Department of Psychology, Hunter College of the City University of New York, New York, New York, USA.

Although transgender women (TGW), and especially TGW of color, are disproportionately exposed to discrimination and violence, many of them experience stress-related growth. However, little is known about the experience of stress-related growth and its correlates among TGW. Using data from a racially-diverse sample of 210 TGW, the short version of the Stress-Related Growth Scale was modified to assess growth as a result of coming to terms with one's transgender identity among TGW. The psychometric properties of the modified scale were examined, along with its associations with various cognitive, emotional, and social factors. A confirmatory factor analysis revealed a unidimensional factor, along with excellent reliability. A stepwise regression revealed that positive reappraisal, internal locus of control, social support, and emotional expression were associated with greater stress-related growth. Findings suggest that cognitive, emotional, and social resources are related to stress-related growth in TGW. Interventions to foster stress-related growth among TGW are discussed.
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http://dx.doi.org/10.1080/00918369.2021.1921511DOI Listing
May 2021

mHealth for transgender and gender-expansive youth: harnessing gender-affirmative cross-disciplinary innovations to advance HIV prevention and care interventions.

Mhealth 2021 20;7:37. Epub 2021 Apr 20.

Friends Research Institute, Inc., Los Angeles, CA, USA.

Transgender and gender-expansive (TGE) youth endure stark disparities in health and wellbeing compared to their cisgender peers. A key social determinant of health for TGE adolescents and emerging adults is gender affirmation, which encompasses multidimensional validations of an individual's lived gender. Lacking available resources for one's gender affirmation, TGE young people may engage in high-risk maladaptive coping behaviors, linked to their disproportionately high HIV-acquisition risk. A range of innovative mobile technologies are guided by the Gender-Affirmative Framework to promote the health of TGE communities, including through HIV prevention and care continuum outcomes. The aim of this review was to examine key features of existing mobile technologies that can be leveraged to advance the field of TGE-responsive mHealth. We systematically searched scientific records, gray literature, and the iOS and Android app distribution services. To be eligible, platforms and interventions needed to be tailored exclusively to a TGE user base, incorporate gender-affirming features, and be optimized for or adaptive to mobile technologies. Eligible interventions (N=24) were compared on evidence of utility, core functionalities, and dimensions of gender affirmation. Smartphone applications (apps) and webapps (n=16) were the most common delivery modality. Many interventions (n=9) aimed to address HIV-related outcomes and integrated gender-affirmative features. The most common gender-affirmative features originated in fields of human-computer interactions and informatics, or were crowdfunded by TGE developers. HIV-focused interventions incorporated evidence-based health behavior change strategies and utilized rigorous evaluation methods. Across modalities and disciplines, behavioral self-monitoring and access to HIV prevention services were the most frequent features. Over two-thirds of the interventions reviewed aimed to provide medical gender affirmation (e.g, provided guidance on obtaining medically sanctioned hormone therapies, or safely practicing non-medical options such as chest-binding) or psychological gender affirmation (e.g, provided linkage to mental health counseling). Our results show that mHealth and other technology-mediated interventions offer a diverse range of both evidence-based and innovative features; however, many have not been rigorously evaluated in a randomized controlled trial to support TGE users. A continuing commitment to evidence-based health behavior change strategies, exemplified by the HIV-focused interventions included in this review, is essential to advancing gender-affirmative mHealth. The unique and highly innovative features of platforms originating outside the fields of HIV prevention and care suggest new directions for TGE-responsive mHealth, and the need for more conscientious models of knowledge exchange with investigators across scientific disciplines, private-sector developers, and potential users.
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http://dx.doi.org/10.21037/mhealth-20-60DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8063017PMC
April 2021

mHealth for transgender and gender-expansive youth: harnessing gender-affirmative cross-disciplinary innovations to advance HIV prevention and care interventions.

Mhealth 2021 20;7:37. Epub 2021 Apr 20.

Friends Research Institute, Inc., Los Angeles, CA, USA.

Transgender and gender-expansive (TGE) youth endure stark disparities in health and wellbeing compared to their cisgender peers. A key social determinant of health for TGE adolescents and emerging adults is gender affirmation, which encompasses multidimensional validations of an individual's lived gender. Lacking available resources for one's gender affirmation, TGE young people may engage in high-risk maladaptive coping behaviors, linked to their disproportionately high HIV-acquisition risk. A range of innovative mobile technologies are guided by the Gender-Affirmative Framework to promote the health of TGE communities, including through HIV prevention and care continuum outcomes. The aim of this review was to examine key features of existing mobile technologies that can be leveraged to advance the field of TGE-responsive mHealth. We systematically searched scientific records, gray literature, and the iOS and Android app distribution services. To be eligible, platforms and interventions needed to be tailored exclusively to a TGE user base, incorporate gender-affirming features, and be optimized for or adaptive to mobile technologies. Eligible interventions (N=24) were compared on evidence of utility, core functionalities, and dimensions of gender affirmation. Smartphone applications (apps) and webapps (n=16) were the most common delivery modality. Many interventions (n=9) aimed to address HIV-related outcomes and integrated gender-affirmative features. The most common gender-affirmative features originated in fields of human-computer interactions and informatics, or were crowdfunded by TGE developers. HIV-focused interventions incorporated evidence-based health behavior change strategies and utilized rigorous evaluation methods. Across modalities and disciplines, behavioral self-monitoring and access to HIV prevention services were the most frequent features. Over two-thirds of the interventions reviewed aimed to provide medical gender affirmation (e.g, provided guidance on obtaining medically sanctioned hormone therapies, or safely practicing non-medical options such as chest-binding) or psychological gender affirmation (e.g, provided linkage to mental health counseling). Our results show that mHealth and other technology-mediated interventions offer a diverse range of both evidence-based and innovative features; however, many have not been rigorously evaluated in a randomized controlled trial to support TGE users. A continuing commitment to evidence-based health behavior change strategies, exemplified by the HIV-focused interventions included in this review, is essential to advancing gender-affirmative mHealth. The unique and highly innovative features of platforms originating outside the fields of HIV prevention and care suggest new directions for TGE-responsive mHealth, and the need for more conscientious models of knowledge exchange with investigators across scientific disciplines, private-sector developers, and potential users.
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http://dx.doi.org/10.21037/mhealth-20-60DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8063017PMC
April 2021

Developmental Barriers to Couples' HIV Testing and Counseling Among Adolescent Sexual Minority Males: A Dyadic Socio-ecological Perspective.

AIDS Behav 2021 Mar 17;25(3):787-797. Epub 2020 Sep 17.

Department of Psychology, University of Rhode Island, Kingston, RI, USA.

Couples HIV Testing and Counseling (CHTC) is now a standard of care for partnered sexual minority men. While adolescent sexual minority men (ASMM; ages 15-19) face disproportionate HIV risk, the emergent nature of relationships and communication skills may present challenges to accessing and engaging in CHTC. This study utilized qualitative data from 28 ASMM recruited in 4 urban centers in the USA during the formative stage of Adolescent Trials Network study ATN-156. Participants were cis-male, HIV-negative, and in a relationship with a similarly-aged cis-male partner. Thematic analysis indicated low and high levels of commitment were barriers to CHTC. Concerns about caregiver attitudes towards HIV testing were salient. Adolescents' perception of structural barriers highlighted reliance on caregiver resources, which limited access to sexual health services. Prevention programming must address structural barriers to access encountered by adolescents. ASMM in relationships may benefit from programming that includes options for individual and dyadic participation.
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http://dx.doi.org/10.1007/s10461-020-03044-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7887008PMC
March 2021

Evaluating the impact of COVID-19: A cohort comparison study of drug use and risky sexual behavior among sexual minority men in the U.S.A.

Drug Alcohol Depend 2020 11 28;216:108260. Epub 2020 Aug 28.

College of Health Professions, Medical University of South Carolina, Charleston, SC, USA.

Background: Sexual minority men who use drugs have high sexual HIV transmission risk. Sexual interactions may also increase COVID-19 risk.This study compared marijuana use, other illegal drugs use (i.e. cocaine/crack, methamphetamine, MDMA/ecstasy, GHB, and ketamine) and sexual behavior with casual partners among sexual minority cismen active on social networking and dating applications before and during the COVID-19 epidemic.

Methods: This cohort-control study compared 455 adult respondents (surveyed May 6th to 17th, 2020) and a matched sample selected from 65,707 respondents surveyed pre-COVID. Participants were recruited on social networking and dating applications and completed surveys online.

Results: The proportion reporting marijuana use declined significantly in the COVID cohort (34.5 % versus 45.7 % pre-COVID,p < .001) as did their illegal drug use (11.0 % versus 22.9 % pre-COVID, p < .001). While the number of casual partners per month was stable, the proportion reporting condomless anal sex with casual partners declined significantly during COVID (26.4 % versus 71.6 % pre-COVID, p < .001). The effect of illegal drug use (excluding marijuana) on number of casual partners per month (aRR = 1.45 pre-COVID versus 2.84, p < .01) and odds of condomless anal sex (aOR = 2.00 pre-COVID versus 5.22, p = .04) were significantly greater in the COVID cohort.

Conclusions: While the proportion of participants reporting drug use and condomless anal sex with casual partners declined in the COVID cohort, the association between drug use and sexual behavior was magnified. Sexual minority men who use drugs are significantly more likely to engage in sexual behaviors that place them at risk for HIV and COVID-19 transmission.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108260DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7453210PMC
November 2020

Evaluating the impact of COVID-19: A cohort comparison study of drug use and risky sexual behavior among sexual minority men in the U.S.A.

Drug Alcohol Depend 2020 11 28;216:108260. Epub 2020 Aug 28.

College of Health Professions, Medical University of South Carolina, Charleston, SC, USA.

Background: Sexual minority men who use drugs have high sexual HIV transmission risk. Sexual interactions may also increase COVID-19 risk.This study compared marijuana use, other illegal drugs use (i.e. cocaine/crack, methamphetamine, MDMA/ecstasy, GHB, and ketamine) and sexual behavior with casual partners among sexual minority cismen active on social networking and dating applications before and during the COVID-19 epidemic.

Methods: This cohort-control study compared 455 adult respondents (surveyed May 6th to 17th, 2020) and a matched sample selected from 65,707 respondents surveyed pre-COVID. Participants were recruited on social networking and dating applications and completed surveys online.

Results: The proportion reporting marijuana use declined significantly in the COVID cohort (34.5 % versus 45.7 % pre-COVID,p < .001) as did their illegal drug use (11.0 % versus 22.9 % pre-COVID, p < .001). While the number of casual partners per month was stable, the proportion reporting condomless anal sex with casual partners declined significantly during COVID (26.4 % versus 71.6 % pre-COVID, p < .001). The effect of illegal drug use (excluding marijuana) on number of casual partners per month (aRR = 1.45 pre-COVID versus 2.84, p < .01) and odds of condomless anal sex (aOR = 2.00 pre-COVID versus 5.22, p = .04) were significantly greater in the COVID cohort.

Conclusions: While the proportion of participants reporting drug use and condomless anal sex with casual partners declined in the COVID cohort, the association between drug use and sexual behavior was magnified. Sexual minority men who use drugs are significantly more likely to engage in sexual behaviors that place them at risk for HIV and COVID-19 transmission.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108260DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7453210PMC
November 2020

Adolescent Sexual Minority Males, Relationship Functioning, and Condomless Sex.

J Adolesc Health 2021 Feb 7;68(2):419-421. Epub 2020 Jul 7.

Department of Psychology, University of Rhode Island, Kingston, Rhode Island.

Purpose: Adolescent sexual minority males (SMMs) are at a high risk of contracting HIV through condomless sex. Many develop serious partnerships, and sex with main partners accounts for many new infections. Previous research with adolescent SMMs largely focused on relationship seriousness and found a positive association with sexual HIV risk. This study tested associations between three relationship functioning indicators and condomless sex.

Methods: Adolescent SMMs aged 15-19 years (n = 85) completed a brief online survey. Respondents rated commitment, seriousness, and satisfaction on 7-point Likert-type scales.

Results: Among adolescent SMMs who had sex in their lifetime, those who were more satisfied in their relationship were less likely to have condomless in the past 90 days (odds ratio = .56, p = .04).

Conclusions: Results support examining multiple domains of relationship functioning in this age group to identify relationship mechanisms that may serve as the target of HIV risk-reduction interventions among adolescent SMMs initiating relationships.
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http://dx.doi.org/10.1016/j.jadohealth.2020.05.052DOI Listing
February 2021

Measuring Experiences of Minority Stress for Transgender Women: Adaptation and Evaluation of Internalized and Anticipated Transgender Stigma Scales.

Transgend Health 2020 Mar 16;5(1):42-49. Epub 2020 Mar 16.

Private Consultant, Teaneck, New Jersey.

Transgender women (TGW) experience high rates of stigma based on their gender identity. Research has documented how transgender stigma and other discrimination negatively contribute to health inequities, including higher rates of depression compared with the general population. However, few scales measuring transgender stigma exist, even fewer that specifically assess anticipated or internalized transgender stigma. We sought to validate an adapted transgender stigma scale in a diverse sample of TGW. We adapted an existing stigma measure to capture experiences of anticipated and internalized transgender stigma for TGW. Adapted measures were completed by 213 diverse TGW. Factor analysis was completed to reduce the number of items in each scale and sociodemographic differences in each construct were explored. The final nine items comprising anticipated transgender stigma and the five items for internalized transgender stigma both showed evidence of adequate model fit, unidimensionality, and internal consistency. The two constructs were moderately correlated with one another (=0.36, <0.001). We identified educational and HIV status differences in anticipated transgender stigma but no sociodemographic differences in internalized transgender stigma. We developed brief measures of internalized and anticipated transgender stigma through initial adaptation by TGW themselves and subsequent psychometric evaluation, demonstrating evidence of unidimensionality and internal consistency. These subscales were only moderately associated with one another and may provide unique insights in future research on minority stress among TGW.
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http://dx.doi.org/10.1089/trgh.2019.0059DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7173692PMC
March 2020

Attachment as a Predictor of Psychological and Sexual Wellbeing Among Transgender Women in New York City.

J Sex Res 2019 Nov-Dec;56(9):1192-1202. Epub 2019 Aug 5.

Department of Psychology, Hunter College of the City University of New York (CUNY).

Transgender women are disproportionately affected by HIV and experience high rates of depression and anxiety. The importance of secure attachment in buffering against negative sexual and mental health outcomes is well established. However, few studies have examined attachment among transgender women. We recruited a community-based convenience sample of 213 transgender women in New York City (34.3; = 11.7). The majority were women of color (75.6%), almost half identified as heterosexual (47.4%), and 34.7% were HIV-positive. Preliminary analyses examined the sample distribution across attachment categories using the Revised Experiences in Close Relationships scale. Specifically, Brennan, Clark and Shaver's guidelines were used for categorization (43.19% fearful, 22.5% preoccupied, 21.6% dismissive, and 12.7% secure). Regression analyses examined the association of dimensional attachment anxiety, attachment avoidance, and their interaction with depression, anxiety, self-efficacy for condom use, temptations for condomless sex, and condomless sex acts. Results indicated a positive association between attachment anxiety and depression, anxiety, temptations and probability for condomless sex; and also between attachment avoidance and condomless sex probability. A significant interaction indicated that individuals with low attachment anxiety and attachment avoidance (i.e., secure) had the greatest condom use self-efficacy and the lowest probability of engaging in condomless sex.
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http://dx.doi.org/10.1080/00224499.2019.1644486DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6791782PMC
September 2020

Testing a Motivational Interviewing Implementation Intervention in Adolescent HIV Clinics: Protocol for a Type 3, Hybrid Implementation-Effectiveness Trial.

JMIR Res Protoc 2019 Jun 7;8(6):e11200. Epub 2019 Jun 7.

Center for HIV Educational Studies and Training, Hunter College, City University of New York, New York, NY, United States.

Background: Motivational interviewing (MI) has been shown to effectively improve self-management for youth living with HIV (YLH) and has demonstrated success across the youth HIV care cascade-currently, the only behavioral intervention to do so. Substantial barriers prevent the effective implementation of MI in real-world settings. Thus, there is a critical need to understand how to implement evidence-based practices (EBPs), such as MI, and promote behavior change in youth HIV treatment settings as risk-taking behaviors peak during adolescence and young adulthood.

Objective: This study aims to describe the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) protocol of a tailored MI (TMI) implementation-effectiveness trial (ATN 146 TMI) to scale up an EBP in multidisciplinary adolescent HIV settings while balancing flexibility and fidelity. This protocol is part of the Scale It Up program described in this issue.

Methods: This study is a type 3, hybrid implementation-effectiveness trial that tests the effect of TMI on fidelity (MI competency and adherence to program requirements) while integrating findings from two other ATN protocols described in this issue-ATN 153 Exploration, Preparations, Implementation, Sustainment and ATN 154 Cascade Monitoring. ATN 153 guides the mixed methods investigation of barriers and facilitators of implementation, while ATN 154 provides effectiveness outcomes. The TMI study population consists of providers at 10 adolescent HIV care sites around the United States. These 10 clinics are randomly assigned to 5 blocks to receive the TMI implementation intervention (workshop and trigger-based coaching guided by local implementation teams) utilizing the dynamic wait-listed controlled design. After 12 months of implementation, a second randomization compares a combination of internal facilitator coaching with the encouragement of communities of practice (CoPs) to CoPs alone. Participants receive MI competency assessments on a quarterly basis during preimplementation, during the 12 months of implementation and during the sustainment period for a total of 36 months. We hypothesize that MI competency ratings will be higher among providers during the TMI implementation phase compared with the standard care phase, and successful implementation will be associated with improved cascade-related outcomes, namely undetectable viral load and a greater number of clinic visits among YLH.

Results: Participant recruitment began in August 2017 and is ongoing. As of mid-May 2018, TMI has 150 active participants.

Conclusions: This protocol describes the underlying theoretical framework, study design, measures, and lessons learned for TMI, a type 3, hybrid implementation-effectiveness trial, which has the potential to scale up MI and improve patient outcomes in adolescent HIV settings.

Trial Registration: ClinicalTrials.gov NCT03681912; https://clinicaltrials.gov/ct2/show/NCT03681912 (Archived by WebCite at http://www.webcitation.org/754oT7Khx).

International Registered Report Identifier (irrid): DERR1-10.2196/11200.
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http://dx.doi.org/10.2196/11200DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6682301PMC
June 2019

Adolescent Male Couples-Based HIV Testing Intervention (We Test): Protocol for a Type 1, Hybrid Implementation-Effectiveness Trial.

JMIR Res Protoc 2019 Jun 7;8(6):e11186. Epub 2019 Jun 7.

Center for HIV Educational Studies and Training, Hunter College, City University of New York, New York, NY, United States.

Background: Young men who have sex with men (YMSM), particularly those who are partnered, are at unique risk for HIV. YMSM are among those at highest risk for HIV. Meanwhile, despite the fact that primary partners account for many-possibly most-new HIV infections, partnered men who have sex with men perceive themselves to be at much lower risk for HIV infection and therefore test less often than single men. In response to the risk of primary partner HIV transmission, couples HIV testing and counseling (CHTC) procedures have been developed for use in adult populations. Although promising, YMSM couples may require additional support to complete CHTC given their developmental context in which sexual and romantic relationships are relatively new, and communication skills are emergent.

Objective: The aim of this study was to test the additive benefit of adjunct treatment components tailored for YMSM, which enhance communication skills before the completion of CHTC. The intervention tests a continuum of prevention packages including assertive communication training videos and motivational interviewing focused on assisting with identification and development (MI-AID) before entering into the dyadic intervention components. This protocol is part of the Adolescent Medicine Trials Network (ATN) Scale It Up program described in this issue.

Methods: This is a comparative effectiveness trial that will be executed in 3 phases. Phase 1 will gather qualitative data related to intervention development and implementation from partnered YMSM at 4 subject recruitment venues (SRVs). Phase 2 will compare a continuum of these interventions in a pilot randomized controlled trial (RCT) at 2 SRVs. Phase 3 will compare the most successful adapted intervention package from phase 2 to CHTC as usual in a larger RCT at 4 SRVs. This phase is focused on implementation and sustainment phases of the Exploration, Preparation, Implementation, and Sustainment framework.

Results: Phase 1 data will be drawn from qualitative interviews with partnered YMSM (n=24) and staff from ATN sites (n=20). Baseline enrollment for phase 2 is expected to begin across 2 SRVs in June 2018 (n=36). In phase 2, survey data collection along with HIV and sexually transmitted infection (STI) testing will occur at baseline, and 1- and 3-month (postintervention) follow-ups. Phase 3 will begin enrollment across 4 SRVs in September 2019 (n=144) and follow-ups will occur at 1, 3, 6, and 9 months postintervention.

Conclusions: Although MI-AID, video-based assertive communication training, and CHTC have established efficacy when administered on their own, this study will be the first to evaluate the strongest adjunctive version of these interventions to address the specific developmental needs of partnered YMSM.

Trial Registration: ClinicalTrials.gov NCT03386110; http://clinicaltrials.gov/ct2/show/NCT03386110 (Archived by WebCite at http://www.webcitation.org/75mlO7GCx).

International Registered Report Identifier (irrid): DERR1-10.2196/11186.
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http://dx.doi.org/10.2196/11186DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6592501PMC
June 2019

Cascade Monitoring in Multidisciplinary Adolescent HIV Care Settings: Protocol for Utilizing Electronic Health Records.

JMIR Res Protoc 2019 May 30;8(5):e11185. Epub 2019 May 30.

College of Medicine, Florida State University, Tallahassee, FL, United States.

Background: Past research shows that youth living with HIV (YLH) are not as engaged in the HIV treatment cascade as other HIV-positive populations. To achieve the health benefits of rapid and widespread testing and advanced pharmacologic treatment, YLH must be fully engaged in every stage of the treatment cascade. Cascade monitoring provides an opportunity to assess the youth care cascade, including engagement in care and when youth commonly drop out of care, across 10 clinical sites in the United States. Collecting electronic health record (EHR) data for prevention and care across participant recruitment venues within the Adolescent Medicine Trials Network (ATN) allows for monitoring of the prevention and care cascades within the ATN, for comparing the ATN population to large-scale surveillance, for future integration of technology-based interventions into EHRs, and for informing ATN strategic planning.

Objective: The aim of this protocol study is to examine the trends in treatment cascade, including whether patients are receiving antiretroviral therapy, adhering to regimens, attending care appointments, and maintaining suppressed viral loads, to guide new protocol development and to facilitate community engagement. This protocol is part of the ATN Scale It Up (SIU) program described in this issue.

Methods: Deidentified EHR data of YLH, aged 15 to 24 years, will be collected annually (2017 to 2022) from 10 ATN clinical sites, resulting in patient data from 2016 to 2021. These data will be transferred and stored using Dropbox Business, a Health Insurance Portability and Accountability Act-compliant site and then analyzed by the SIU analytic core.

Results: This study was launched in December 2017 in 10 clinical sites, with 2016's EHR data due on January 31, 2017. All 10 sites electronically uploaded their EHR data. The mandatory variables requested to monitor cascade of care include date of visit, age, gender, height, weight, race, ethnicity, viral load, and International Classification of Diseases codes for other diagnosis. In total, 70% of the sites provided data for all mandatory variables. The remaining mandatory variables were manually extracted.

Conclusions: This study will provide a platform to determine how YLH across the nation progress through or drop out of the HIV treatment cascade. It will also provide a foundation for assessing impact of SIU projects on treatment cascade outcomes.

International Registered Report Identifier (irrid): DERR1-10.2196/11185.
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http://dx.doi.org/10.2196/11185DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6658287PMC
May 2019

Implementation Science Research Examining the Integration of Evidence-Based Practices Into HIV Prevention and Clinical Care: Protocol for a Mixed-Methods Study Using the Exploration, Preparation, Implementation, and Sustainment (EPIS) Model.

JMIR Res Protoc 2019 May 23;8(5):e11202. Epub 2019 May 23.

College of Medicine, Florida State University, Tallahassee, FL, United States.

Background: The Exploration, Preparation, Implementation, and Sustainment (EPIS) model is an implementation framework for studying the integration of evidence-based practices (EBPs) into real-world settings. The EPIS model conceptualizes implementation as a process starting with the earliest stages of problem recognition (Exploration) through the continued use of an EBP in a given clinical context (Sustainment). This is the first implementation science (IS) study of the integration of EBPs into adolescent HIV prevention and care settings.

Objective: This protocol (ATN 153 EPIS) is part of the Scale It Up program, a research program administered by the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN), described in this issue by Naar et al. The EPIS study is a descriptive study of the uptake of 4 EBPs within the Scale It Up program. The goal of EPIS is to understand the barriers and facilitators associated with the Preparation, Implementation, and Sustainment of EBPs into HIV prevention and clinical care settings.

Methods: The EPIS study is a convergent parallel mixed-methods IS study. Key implementation stakeholders, that is, clinical care providers and leaders, located within 13 ATN sites across the United States will complete a qualitative interview conducted by telephone and Web-based surveys at 3 key implementation stages. The Preparation assessment occurs before EBP implementation, Implementation occurs immediately after sites finish implementation activities and prepare for sustainment, and Sustainment occurs 1 year postimplementation. Assessments will examine stakeholders' perceptions of the barriers and facilitators to EBP implementation within their clinical site as outlined by the EPIS framework.

Results: The EPIS baseline period began in June 2017 and concluded in May 2018; analysis of the baseline data is underway. To date, 153 stakeholders have completed qualitative interviews, and 91.5% (140/153) completed the quantitative survey.

Conclusions: The knowledge gained from the EPIS study will strengthen the implementation and sustainment of EBPs in adolescent prevention and clinical care contexts by offering insights into the barriers and facilitators of successful EBP implementation and sustainment in real-world clinical contexts.

International Registered Report Identifier (irrid): DERR1-10.2196/11202.
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http://dx.doi.org/10.2196/11202DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6552408PMC
May 2019

Implementation Science Research Examining the Integration of Evidence-Based Practices Into HIV Prevention and Clinical Care: Protocol for a Mixed-Methods Study Using the Exploration, Preparation, Implementation, and Sustainment (EPIS) Model.

JMIR Res Protoc 2019 May 23;8(5):e11202. Epub 2019 May 23.

College of Medicine, Florida State University, Tallahassee, FL, United States.

Background: The Exploration, Preparation, Implementation, and Sustainment (EPIS) model is an implementation framework for studying the integration of evidence-based practices (EBPs) into real-world settings. The EPIS model conceptualizes implementation as a process starting with the earliest stages of problem recognition (Exploration) through the continued use of an EBP in a given clinical context (Sustainment). This is the first implementation science (IS) study of the integration of EBPs into adolescent HIV prevention and care settings.

Objective: This protocol (ATN 153 EPIS) is part of the Scale It Up program, a research program administered by the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN), described in this issue by Naar et al. The EPIS study is a descriptive study of the uptake of 4 EBPs within the Scale It Up program. The goal of EPIS is to understand the barriers and facilitators associated with the Preparation, Implementation, and Sustainment of EBPs into HIV prevention and clinical care settings.

Methods: The EPIS study is a convergent parallel mixed-methods IS study. Key implementation stakeholders, that is, clinical care providers and leaders, located within 13 ATN sites across the United States will complete a qualitative interview conducted by telephone and Web-based surveys at 3 key implementation stages. The Preparation assessment occurs before EBP implementation, Implementation occurs immediately after sites finish implementation activities and prepare for sustainment, and Sustainment occurs 1 year postimplementation. Assessments will examine stakeholders' perceptions of the barriers and facilitators to EBP implementation within their clinical site as outlined by the EPIS framework.

Results: The EPIS baseline period began in June 2017 and concluded in May 2018; analysis of the baseline data is underway. To date, 153 stakeholders have completed qualitative interviews, and 91.5% (140/153) completed the quantitative survey.

Conclusions: The knowledge gained from the EPIS study will strengthen the implementation and sustainment of EBPs in adolescent prevention and clinical care contexts by offering insights into the barriers and facilitators of successful EBP implementation and sustainment in real-world clinical contexts.

International Registered Report Identifier (irrid): DERR1-10.2196/11202.
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http://dx.doi.org/10.2196/11202DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6552408PMC
May 2019

Day-Level Associations Between Substance Use and HIV Risk Behavior Among a Diverse Sample of Transgender Women.

Transgend Health 2018 26;3(1):210-219. Epub 2018 Dec 26.

Center for HIV/AIDS Educational Studies & Training, Hunter College of the City University of New York (CUNY), New York, New York.

Transgender women in the United States face elevated rates of HIV and of substance use. Studies measuring overall or aggregate levels of substance use have linked use to increased HIV transmission risk behavior (TRB). Although intensive longitudinal studies in other populations have found day-level links between substance use and TRB, no study has yet explored such links among transgender women. This study aimed to fill this gap in the literature. Utilizing survey and 60-day timeline follow-back interview data from a sample of 214 transgender women in New York City, we tested whether day-level heavy drinking, marijuana use, and/or nonprescription stimulant use were associated with odds of engaging in any sex (vs. no sexual activity) or engaging in TRB (vs. sex without TRB), adjusting for overall levels of use. Multilevel models showed that each of the three substance types was associated with greater odds of engaging in sex on a given day-and more strongly so for heavy drinking among those with higher rates of heavy drinking, and for stimulant use among those with lower rates of stimulant use. Only marijuana use was associated with greater odds of TRB on a given day, but only among those with higher rates of use. These findings substantiate day-level links between substance use and engaging in sexual activity among transgender women, and importantly, between marijuana use and greater likelihood of TRB on a day when sexual activity occurs. This highlights the importance of addressing substance use for sexual health among transgender women especially focusing on marijuana use.
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http://dx.doi.org/10.1089/trgh.2018.0032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6308277PMC
December 2018

Gay and bisexual men's experiences using self-testing kits for HIV and rectal and urethral bacterial sexually transmitted infections: Lessons learned from a study with home-based testing.

Int J Sex Health 2019 8;31(3):308-318. Epub 2019 Aug 8.

Department of Community Health and Social Sciences, CUNY Graduate School of Public Health and Health Policy; The CUNY Institute for Implementation Science in Population Health, New York, NY, USA.

This study investigated the experiences of gay, bisexual, and other men who have sex with men (GBM) conducting HIV and sexually transmitted infection (STI) self-testing procedures. We analyzed mixed-methods data from 11 GBM who self-tested HIV-positive and 1,070 HIV-negative GBM who completed the HIV self-testing and STI self-sampling procedures. Nearly all (99%) reported ease in urine-based STI self-sampling and most (90%) found rectal swab self-collection easy. Most (94%) checked their rapid-HIV self-testing results during the correct window (20-40 minutes), and nearly all (99%) trusted their HIV results. Recommendations for future self-testing procedures are provided based on findings from free-response data.
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http://dx.doi.org/10.1080/19317611.2019.1645075DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7518382PMC
August 2019

Adolescent Medicine Trials Network for HIV/AIDS Interventions Data Harmonization: Rationale and Development of Guidelines.

JMIR Res Protoc 2018 Dec 21;7(12):e11207. Epub 2018 Dec 21.

Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.

Background: The Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) research program aims to defeat the rising HIV epidemic among adolescents and young adults in the United States.

Objective: This study aims to optimize cross-study analyses and comparisons of standardized measures (variables) collected in the ATN.

Methods: Guidelines were developed for harmonizing measures to be collected across ATN studies.

Results: Eight domains were identified for harmonization-Demographics and Socioeconomic Characteristics, Sexual Behavior and Risk, Substance Use and Abuse, HIV-Positive Cascade, HIV-Negative Cascade, Mental Health, Social Support and Isolation, and Pre-exposure Prophylaxis Cascade.

Conclusions: The collection of selected key measures in a uniform manner across studies facilitates the characterization of participant populations, comparisons between studies, and pooled analysis of data from multiple studies.
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http://dx.doi.org/10.2196/11207DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6320398PMC
December 2018

Adaptive Antiretroviral Therapy Adherence Interventions for Youth Living With HIV Through Text Message and Cell Phone Support With and Without Incentives: Protocol for a Sequential Multiple Assignment Randomized Trial (SMART).

JMIR Res Protoc 2018 Dec 20;7(12):e11183. Epub 2018 Dec 20.

Hunter College Center for HIV Educational Studies and Training, New York, NY, United States.

Background: Youth living with HIV (YLH) aged 13 to 24 years made up over a fifth (21%) of new HIV diagnoses in 2016, yet only 27% of YLH are virally suppressed. YLH have been shown to be poorly adherent to antiretroviral therapy (ART); however, there has been limited research investigating how to increase adherence in YLH. Mobile health (mHealth) interventions may be one promising way to do this.

Objective: This study (ATN [Adolescent Trials Network] 144 SMART) aimed to compare adaptive interventions that could increase ART adherence in YLH aged 15 to 24 years. This includes mHealth initiatives, the tapering of interventions, and the use of incentives. Cost-effectiveness of sequencing the interventions without incentives before providing incentives and the savings on societal costs due to suppressed viral loads will be determined. This protocol is part of the ATN Scale It Up program described in this issue by Naar et al.

Methods: This study uses a Sequential Multiple Assignment Randomized Trial design. Approximately 190 participants are being recruited, enrolled, and randomized to either cell phone support or text message support. Both intervention groups receive 3 months of intervention, followed by a second randomization based on response to the intervention. Responders test tapering their intervention, and nonresponders test receiving incentives.

Results: Data collection for this study is projected to begin in August 2018 and last until June 2020.

Conclusions: This is an innovative study, particularly in terms of population, intervention types, focus on cost-effectiveness, and recruitment. This study could be particularly effective in improving adherence in YLH while reducing long-term individual and societal costs.

Trial Registration: ClinicalTrials.gov NCT03535337; https://clinicaltrials.gov/ct2/show/NCT03535337 (Archived by WebCite at http://www.webcitation.org/74alXb92z).

International Registered Report Identifier (irrid): PRR1-10.2196/11183.
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http://dx.doi.org/10.2196/11183DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6320399PMC
December 2018

Syndemic Conditions, HIV Transmission Risk Behavior, and Transactional Sex Among Transgender Women.

AIDS Behav 2018 07;22(7):2056-2067

Center for HIV/AIDS Educational Studies & Training, Hunter College of the City University of New York (CUNY), New York, NY, USA.

This study examined the effect of four syndemic conditions-namely, polydrug use, depression, childhood sexual abuse, and intimate partner violence-on rates of HIV transmission risk behavior (TRB) and separately, transactional sex among transgender women. TRB was defined as the number of condomless penetrative sex events with a casual or main partner of discordant or unknown HIV status. Using data from 212 transgender women in New York City, multivariable analyses revealed that, compared to those with no syndemic conditions, dramatically higher rates of recent HIV TRB events (ARR = 8.84, p < 0.001) and recent transactional sex events (ARR = 8.32, p < 0.001) were reported by participants with all four syndemic conditions. These findings highlight the importance of considering the role of syndemic conditions in HIV risk among transgender women, and the need for comprehensive psychosocial interventions to improve sexual health among this population.
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http://dx.doi.org/10.1007/s10461-018-2100-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6021215PMC
July 2018

Alcohol and substance use diagnoses among HIV-positive patients receiving care in NYC clinic settings.

Drug Alcohol Depend 2017 11 24;180:62-67. Epub 2017 Aug 24.

The Center for HIV/AIDS Educational Studies and Training (CHEST), New York, NY, USA; Department of Psychology, Hunter College of the City University of New York (CUNY), New York, NY, USA; Health Psychology and Clinical Science Doctoral Program, The Graduate Center of the City University of New York (CUNY), New York, NY, USA. Electronic address:

Background: Substance use among HIV-positive persons exacerbates health problems. This study sought to estimate the prevalence of alcohol and drug-use diagnoses and examined hypothesized predictors associated with alcohol and drug-use diagnoses among HIV-positive patients in New York City (NYC).

Methods: This cohort study reviewed electronic medical records (EMRs) of 4965 HIV-positive patients based on diagnostic codes. These patients attended a comprehensive care clinic in NYC in 2012. Multinomial logistic regression was used to predict the odds of classification into substance use diagnosis grouping.

Results: Of the full sample, only 12.7% of patients had an alcohol use diagnosis documented in their EMR compared with more than one-quarter (26.4%) of patients having a recorded drug use diagnosis (p<0.001). Compared with the No Alcohol or Drugs group, the regression model showed that older age and having a recent inpatient hospital stay independently predicted being in the Alcohol Only group; years living with HIV, having an unsuppressed viral load, and having a recent inpatient hospital stay were associated with higher odds of being in the Drugs Only and Alcohol and Drugs groups; and being women and men who have sex with men (MSM) were associated with decreased odds of being in the Drugs Only and Alcohol and Drugs groups.

Conclusions: Substance use diagnosis was associated with viremia and low CD4 counts and hospital stays. This implies that providers should screen for substance use in HIV-positive patients with poor health. Further examination of the extent of such comorbidity is instrumental for intervention efforts.
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http://dx.doi.org/10.1016/j.drugalcdep.2017.07.034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5648608PMC
November 2017

Mediating Effects of Social Support and Internalized Homonegativity on the Association Between Population Density and Mental Health Among Gay and Bisexual Men.

LGBT Health 2017 10 9;4(5):352-359. Epub 2017 Aug 9.

1 Center for HIV/AIDS Educational Studies and Training, Hunter College of the City University of New York (CUNY) , New York, New York.

Purpose: Depression negatively impacts the health and well-being of gay and bisexual men (GBM). However, little is known about the contexts in which rural GBM live relative to those living in urban areas and their overall mental health. The aim of this study was to examine associations between population density and depressive symptoms and the role of internalized homonegativity and social support as potential mediators.

Methods: A nationally representative sample of 1071 GBM (mean age = 40.24) was enrolled. Participants provided their zip codes, which were categorized according to population density and rank-normalized.

Results: In a path analysis model adjusted for race/ethnicity, college education, age, and relationship status, higher population density was significantly associated with increased social support (B = 0.11, P = 0.002) and decreased internalized homonegativity (B = -0.06, P < 0.001). In turn, lower social support (B = -2.93, P < 0.001) and greater internalized homonegativity (B = 4.93, P < 0.001) were significantly associated with greater depressive symptoms. The indirect effects of population density on depression through social support (B = -0.33, P < 0.001) and internalized homonegativity (B = -0.31, P < 0.001) were statistically significant, suggesting evidence for mediation of the effects.

Conclusions: These results indicate that living in less inhabited areas acts on depressive symptoms through mechanisms of lower social support and higher internalized homonegativity. These findings suggest that social contexts in which GBM live can affect mental health outcomes and indicate the need for further support and inclusion of GBM, especially in less inhabited areas.
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http://dx.doi.org/10.1089/lgbt.2017.0002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5686449PMC
October 2017

Characteristics Associated With Urethral and Rectal Gonorrhea and Chlamydia Diagnoses in a US National Sample of Gay and Bisexual Men: Results From the One Thousand Strong Panel.

Sex Transm Dis 2016 Mar;43(3):165-71

From the Center for HIV/AIDS Educational Studies and Training, New York, NY.

Background: Gay and bisexual men are at elevated risk for Neisseria gonorrhoeae and Chlamydia trachomatis (GC/CT). Rectal GC/CT symptoms may be less obvious than urethral, increasing opportunities for undiagnosed rectal GC/CT.

Methods: A US national sample of 1071 gay and bisexual men completed urethral and rectal GC/CT testing and an online survey.

Results: In total, 6.2% were GC/CT positive (5.3% rectal, 1.7% urethral). We calculated adjusted (for education, race, age, relationship status, having health insurance, and income) odds ratios for factors associated with rectal and urethral GC/CT diagnoses. Age was inversely associated with urethral and rectal GC/CT. Compared with white men, Latinos had significantly greater odds of rectal GC/CT. Among men who reported anal sex, those reporting only insertive sex had lower odds of rectal GC/CT than did men who reported both insertive and receptive. There was a positive association between rectal GC/CT and number of male partners (<12 months), the number of anal receptive acts, receptive condomless anal sex (CAS) acts, and insertive CAS acts. Compared with those who had engaged in both insertive and receptive anal sex, those who engaged in only receptive anal sex had lower odds of urethral GC/CT. The number of male partners (<12 months) was associated with increased odds of urethral GC/CT.

Conclusions: Rectal GC/CT was more common than urethral and associated with some demographic and behavioral characteristics. Our finding that insertive CAS acts was associated with rectal GC/CT highlights that providers should screen patients for GC/CT via a full range of transmission routes, lest GC/CT go undiagnosed.
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http://dx.doi.org/10.1097/OLQ.0000000000000410DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4748382PMC
March 2016

Recruiting a U.S. national sample of HIV-negative gay and bisexual men to complete at-home self-administered HIV/STI testing and surveys: Challenges and Opportunities.

Sex Res Social Policy 2016 Mar;13(1):1-21

We describe enrollment for the panel, present characteristics of the panel relative to other large U.S. national studies of gay and bisexual men (GBM), and examine demographic and behavioral characteristics that were associated with passing enrollment milestones. A U.S. national sample of HIV-negative men were enrolled via an established online panel of over 22,000 GBM. Participants ( = 1071) passed three milestones to join our panel. Milestone 1 was screening eligible and providing informed consent. Milestone 2 involved completing an hour-long at-home computer-assisted self-interview (CASI) survey. Milestone 3 involved completing at-home self-administered rapid HIV testing and collecting/returning urine and rectal samples for gonorrhea and chlamydia testing. Compared to those who completed milestones: those not passing milestone 1 were more likely to be non-White and older; those not passing milestone 2 were less likely to have insurance or a primary care physician; and those not passing milestone 3 were less educated, more likely to be bisexual as opposed to gay, more likely to live in the Midwest, had fewer male partners in the past year, and less likely to have tested for HIV in the past year. Effect sizes for significant findings were small. We successfully enrolled a national sample of HIV-negative GBM who completed at-home CASI assessments and at-home self-administered HIV and urine and rectal STI testing. This indicates high feasibility and acceptability of incorporating self-administered biological assays into otherwise fully online studies. Differences in completion of study milestones indicate a need for further investigation into the reasons for lower engagement by certain groups.
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http://dx.doi.org/10.1007/s13178-015-0212-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4743043PMC
March 2016

Mediators of behavior change resulting from a sexual risk reduction intervention for STI patients, Cape Town, South Africa.

J Behav Med 2015 Apr 2;38(2):194-203. Epub 2014 Sep 2.

Division of Global Public Health, Department of Medicine, University of California San Diego, San Diego, CA, USA,

Theory-based sexual risk reduction interventions are often demonstrated effective, but few studies have examined the mechanisms that mediate their behavior changes. In addition, critical contextual factors, such as alcohol use, are often not accounted for by social cognitive theories and may add to the explanatory value of intervention effects. The purpose of this study is to examine the underlying mechanisms driving condom use following a brief sexual risk reduction intervention grounded in the information, motivation, behavioral skills (IMB) model of behavior change. We examined IMB theoretical constructs and alcohol-related contextual factors as potential mediators in separate models. Patients (n = 617) from an STI clinic in Cape Town, South Africa were randomly assigned to either a brief risk reduction intervention or an education-only control condition. We assessed IMB, and alcohol-related variables at baseline, 3, 6, 9, and 12 months and modeled IMB constructs and alcohol-related factors as mediators of behavior change. Results of growth-curve mediational modeling showed that 1 year after counseling, the intervention indirectly affected sexual risk behavior through alcohol-related constructs, but not IMB constructs. Alcohol use and related factors play critical roles in explaining HIV and STI risk reduction intervention effects. Interventions that directly address alcohol use as a factor in sexual risk behavior and behavior change should be the focus of future research.
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http://dx.doi.org/10.1007/s10865-014-9591-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4346550PMC
April 2015

Alcohol use disorder, contexts of alcohol use, and the risk of HIV transmission among South African male patrons of shebeens.

Drug Alcohol Depend 2014 Jul 5;140:198-204. Epub 2014 May 5.

Department of Psychology, University of Connecticut, Storrs, CT 06269-1020, United States.

Background: Shebeens in South Africa are settings in which alcohol use and sexual behavior often co-occur. The prevalence of alcohol use disorder (AUD), and the association between AUD, situations and settings, and sexual risk behavior, in shebeens remains unknown.

Methods: Men (n=763; mean age=30; 98% Black African) were recruited from townships in Cape Town, South Africa and completed a self-administered survey that assessed alcohol use, sexual risk behaviors, and situations and settings of alcohol use. The Alcohol Use Disorder and Associated Disabilities Interview Schedule DSV-IV Version (AUDADIS-IV) was used to identify the likelihood of AUD. Bivariate regression analyses assessed whether screening for AUD predicted sexual risk behaviors. Multivariate regression analyses examined whether AUD and/or situations/settings predicted risk behaviors.

Results: Nearly two-thirds of men (62%) endorsed sufficient criteria for AUD; 25%, 17%, and 20% were classified as having a mild, moderate, or severe AUD, respectively. AUD was associated with HIV risk such that men with AUD reported more unprotected sex than men without AUD. Analyses indicated that (a) individual (i.e., AUD) and (b) settings (i.e., frequency of having sex with a partner in a shebeen, tavern, or bottle store) interacted to predict unprotected sex.

Conclusions: The prevalence of AUD among shebeen patrons was high and was associated with unprotected sex. Findings suggest the need to integrate both individual and situational/setting factors to prevent HIV among patrons of shebeens.
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http://dx.doi.org/10.1016/j.drugalcdep.2014.04.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4079048PMC
July 2014

Exploring the relationships among food insecurity, alcohol use, and sexual risk taking among men and women living in South African townships.

J Prim Prev 2014 Aug;35(4):255-65

Center for Health, Intervention and Prevention, University of Connecticut, Storrs, CT, USA,

South African townships have among the highest rates of HIV infection in the world. Considerable research on understanding the high rates of HIV transmission in this country has identified alcohol use as a critical factor in driving the HIV epidemic. Although the relationship between alcohol use and sexual risk-taking is well documented, less is known about how other factors, such as food insecurity, might be important in understanding alcohol's role in sexual risk-taking. Furthermore, prior research has highlighted how patterns of alcohol use and sexual risk-taking tend to vary by gender. We examined how food insecurity is related to both alcohol use and sexual risk-taking. We administered anonymous community surveys to men (n = 1,137) and women (n = 458) residing within four contiguous Black African townships outside of Cape Town, South Africa. In multivariate linear regression, we found that food insecurity was related to having higher numbers of male sex partners and condom-protected sex acts among women only. These relationships, however, were fully mediated by women's alcohol use. Among men, we found that food insecurity was negatively related to unprotected sex; that is, men with greater food security reported more unprotected sex acts. Unlike the results found among women, this relationship was not mediated by alcohol use. Food insecurity appears to be an important factor in understanding patterns of sexual risk-taking in regards to gender and alcohol use, and may serve as an important point of intervention for reducing HIV transmission rates.
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http://dx.doi.org/10.1007/s10935-014-0346-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4104634PMC
August 2014

Beliefs about fetal alcohol spectrum disorder among men and women at alcohol serving establishments in South Africa.

Am J Drug Alcohol Abuse 2014 Mar;40(2):87-94

Human Development and Family Studies, University of Connecticut , Storrs, CT , USA .

Background: South Africa has one of the highest rates of fetal alcohol spectrum disorder (FASD) in the world. However, little is known about what men and women who attend alcohol serving establishments believe about alcohol use during pregnancy and how these beliefs may be related to alcohol use.

Objectives: To understand FASD beliefs and related behaviors among men and women attending alcohol-serving establishments.

Methods: We surveyed 1047 men (n = 565) and women (n = 482) -including pregnant women and men with pregnant partners- attending alcohol serving establishments in a township located in Cape Town, South Africa.

Results: Among both pregnant (n = 53) and non-pregnant (n = 429) women, 54% reported drinking alcohol at least 2-4 times per month, and 57% reported having at least 3-4 alcohol drinks during a typical drinking session. Pregnant women were less likely to believe that they should not drink alcohol and that alcohol can harm a fetus when compared to non-pregnant women. Similar findings were observed between men with pregnant partners compared to men without pregnant partners. Among women, beliefs about how much alcohol pregnant women can safely drink were associated with self-reported alcohol use.

Conclusions: Efforts to address FASD need to focus on understanding how men and women perceive alcohol use during pregnancy and situational factors that contribute to alcohol consumption among pregnant women attending alcohol serving establishments. Structural and individual-level interventions targeting women at alcohol serving establishments should be prioritized to mitigate alcohol use during pregnancy.
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http://dx.doi.org/10.3109/00952990.2013.830621DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4286322PMC
March 2014

HIV testing is associated with increased knowledge and reductions in sexual risk behaviours among men in Cape Town, South Africa.

Afr J AIDS Res 2013 Dec;12(4):195-201

a Centers for Behavioral and Preventive Medicine , The Miriam Hospital , CORO West, Suite 309, 164 Summit Avenue, Providence , Rhode Island , USA.

HIV testing benefits those who test positive, allowing them to receive treatment, but the benefits for those who test negative remain controversial. We evaluated the impact of testing on HIV knowledge and sexual risk among men in South Africa. Men were recruited from townships outside Cape Town and completed a survey that assessed testing history, knowledge, and sexual behaviours. Among the 820 participants, 516 (63%) reported being tested (82% tested negative, 6% tested positive, and 12% unknown). Compared to those who had never been tested for HIV, men who tested for HIV were more knowledgeable about HIV transmission, but did not differ on sexual risk behaviour. Knowledge moderated the effect of testing on sexual risk such that men reported fewer sexual partners (incidence rate ratio (IRR) = 0.91, 95% CI = 0.84, 0.98) and fewer unprotected anal sex events (IRR = 0.81, 95% CI = 0.66, 1.00) if they had been tested for HIV and were knowledgeable about HIV transmission. For men testing HIV-negative, knowledge predicted fewer sexual risk behaviours. Previous HIV testing is associated with enhanced knowledge, which moderates sexual risk behaviour among South African men living in Cape Town. Results suggest that HIV testing may increase knowledge and lead to reductions in sexual risk even when results are negative.
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http://dx.doi.org/10.2989/16085906.2013.863219DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4520431PMC
December 2013