Publications by authors named "Michael B Blank"

54 Publications

Stigma, Structural Vulnerability, and "What Matters Most" Among Women Living With HIV in Botswana, 2017.

Am J Public Health 2021 Jun 10:e1-e9. Epub 2021 Jun 10.

Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. Ohemaa B. Poku is with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Supriya Misra is with San Francisco State University, San Francisco, CA. Haitisha T. Mehta is with the Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY. Shathani Rampa is with the Department of Psychology, University of Botswana, Gaborone, Botswana. Marlene M. Eisenberg and Michael B. Blank are with the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Lyla S. Yang is with the Columbia School of Social Work, Columbia University. Thi Xuan Dai Cao is with the Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada. Lilo I. Blank is with the College of Arts and Sciences, University of Rochester, Rochester, NY. Timothy D. Becker is with the Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY. Bruce G. Link is with the Department of Sociology, University of California Riverside. Patlo Entaile is with the Botswana‒UPenn Partnership, Gaborone. Philip R. Opondo is with the Department of Psychiatry, University of Botswana. Tonya Arscott-Mills is with the Perelman School of Medicine, University of Pennsylvania. Ari R. Ho-Foster is with the Faculty of Medicine, University of Botswana.

To explore whether beneficial health care policies, when implemented in the context of gender inequality, yield unintended structural consequences that stigmatize and ostracize women with HIV from "what matters most" in local culture. We conducted 46 in-depth interviews and 5 focus groups (38 individuals) with men and women living with and without HIV in Gaborone, Botswana, in 2017. Cultural imperatives to bear children bring pregnant women into contact with free antenatal services including routine HIV testing, where their HIV status is discovered before their male partners'. National HIV policies have therefore unintentionally reinforced disadvantage among women with HIV, whereby men delay or avoid testing by using their partner's status as a proxy for their own, thus facilitating blame toward women diagnosed with HIV. Gossip then defines these women as "promiscuous" and as violating the essence of womanhood. We identified cultural and structural ways to resist stigma for these women. Necessary HIV testing during antenatal care has inadvertently perpetuated a structural vulnerability that propagates stigma toward women. Individual- and structural-level interventions can address stigma unintentionally reinforced by health care policies. (. Published online ahead of print June 10, 2021: e1-e9. https://doi.org/10.2105/AJPH.2021.306274).
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http://dx.doi.org/10.2105/AJPH.2021.306274DOI Listing
June 2021

Stigma, Structural Vulnerability, and "What Matters Most" Among Women Living With HIV in Botswana, 2017.

Am J Public Health 2021 Jun 10:e1-e9. Epub 2021 Jun 10.

Lawrence H. Yang is with the Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY. Ohemaa B. Poku is with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Supriya Misra is with San Francisco State University, San Francisco, CA. Haitisha T. Mehta is with the Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY. Shathani Rampa is with the Department of Psychology, University of Botswana, Gaborone, Botswana. Marlene M. Eisenberg and Michael B. Blank are with the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Lyla S. Yang is with the Columbia School of Social Work, Columbia University. Thi Xuan Dai Cao is with the Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada. Lilo I. Blank is with the College of Arts and Sciences, University of Rochester, Rochester, NY. Timothy D. Becker is with the Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY. Bruce G. Link is with the Department of Sociology, University of California Riverside. Patlo Entaile is with the Botswana‒UPenn Partnership, Gaborone. Philip R. Opondo is with the Department of Psychiatry, University of Botswana. Tonya Arscott-Mills is with the Perelman School of Medicine, University of Pennsylvania. Ari R. Ho-Foster is with the Faculty of Medicine, University of Botswana.

To explore whether beneficial health care policies, when implemented in the context of gender inequality, yield unintended structural consequences that stigmatize and ostracize women with HIV from "what matters most" in local culture. We conducted 46 in-depth interviews and 5 focus groups (38 individuals) with men and women living with and without HIV in Gaborone, Botswana, in 2017. Cultural imperatives to bear children bring pregnant women into contact with free antenatal services including routine HIV testing, where their HIV status is discovered before their male partners'. National HIV policies have therefore unintentionally reinforced disadvantage among women with HIV, whereby men delay or avoid testing by using their partner's status as a proxy for their own, thus facilitating blame toward women diagnosed with HIV. Gossip then defines these women as "promiscuous" and as violating the essence of womanhood. We identified cultural and structural ways to resist stigma for these women. Necessary HIV testing during antenatal care has inadvertently perpetuated a structural vulnerability that propagates stigma toward women. Individual- and structural-level interventions can address stigma unintentionally reinforced by health care policies. (. Published online ahead of print June 10, 2021: e1-e9. https://doi.org/10.2105/AJPH.2021.306274).
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http://dx.doi.org/10.2105/AJPH.2021.306274DOI Listing
June 2021

Identifying "What Matters Most" to Men in Botswana to Promote Resistance to HIV-Related Stigma.

Qual Health Res 2021 Mar 25:10497323211001361. Epub 2021 Mar 25.

Columbia University, New York, New York, USA.

Despite a comprehensive national program of free HIV services, men living with HIV in Botswana participate at lower rates and have worse outcomes than women. Directed content analysis of five focus groups ( = 38) and 50 in-depth interviews with men and women with known and unknown HIV status in Gaborone, Botswana in 2017 used the "what matters most" (WMM) and "structural vulnerability" frameworks to examine how the most valued cultural aspects of manhood interact with HIV-related stigma. WMM for manhood in Botswana included fulfilling male responsibilities by being a capable provider and maintaining social status. Being identified with HIV threatened WMM, which fear of employment discrimination could further exacerbate. Our findings indicate how cultural and structural forces interact to worsen or mitigate HIV-related stigma for urban men in Botswana. These threats to manhood deter HIV testing and treatment, but interventions could capitalize on cultural capabilities for manhood to promote stigma resistance.
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http://dx.doi.org/10.1177/10497323211001361DOI Listing
March 2021

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

AIDS Behav 2021 Jul 15;25(7):2230-2239. Epub 2021 Jan 15.

Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.

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.
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http://dx.doi.org/10.1007/s10461-020-03151-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7809894PMC
July 2021

'Mothers moving towards empowerment' intervention to reduce stigma and improve treatment adherence in pregnant women living with HIV in Botswana: study protocol for a pragmatic clinical trial.

Trials 2020 Oct 7;21(1):832. Epub 2020 Oct 7.

New York University, New York, NY, United States.

Background: With high rates of HIV and multiple vulnerable subgroups across diverse settings, there is a need for culturally based, HIV stigma reduction interventions. Pregnant women who are living with HIV are especially in need of services to protect not only their own but also their children's lives. Uptake of HIV services worldwide is hindered by stigma towards persons living with HIV/AIDS. While cultural context plays a key role in shaping HIV stigma, these insights have not yet been fully integrated into stigma reduction strategies. By utilizing the "What Matters Most" stigma framework, we propose that an intervention to counter culturally salient aspects of HIV stigma will improve treatment adherence and other relevant outcomes. A pragmatic clinical trial in Botswana will evaluate the "Mothers Moving towards Empowerment" (MME) intervention, which seeks to address HIV stigma in Botswana and to specifically engage pregnant mothers so as to promote antiretroviral therapy (ART) adherence in the postpartum period.

Methods: This study will test MME against treatment as usual (TAU) among pregnant mothers diagnosed with HIV and their infants. Outcomes will be assessed during pregnancy and 16 weeks postpartum. Women who meet eligibility criteria are assigned to MME or TAU. Women assigned to MME are grouped with others with similar estimated delivery dates, completing up to eight intervention group sessions scheduled before week 36 of their pregnancies. Primary outcomes among mothers include (i) reducing self-stigma, which is hypothesized to mediate improvements in (ii) psychological outcomes (quality of life, depression and social functioning), and (iii) adherence to antenatal care and ART. We will also examine a set of follow-up infant birth outcomes (APGAR score, preterm delivery, mortality (at < 16 weeks), birth weight, vaccination record, and HIV status).

Discussion: Our trial will evaluate MME, a culturally based HIV stigma reduction intervention using the "What Matters Most" framework, to reduce stigma and improve treatment adherence among pregnant women and their infants. This study will help inform further refinement of MME and preparation for a future large-scale, multisite, randomized controlled trial (RCT) in Botswana.

Trial Registration: ClinicalTrials.gov NCT03698981 . Registered on October 8, 2018.
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http://dx.doi.org/10.1186/s13063-020-04676-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7542742PMC
October 2020

Psychometric Validation of a Scale to Assess Culturally-Salient Aspects of HIV Stigma Among Women Living with HIV in Botswana: Engaging "What Matters Most" to Resist Stigma.

AIDS Behav 2021 Feb;25(2):459-474

Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.

Perceived stigma deters engagement in HIV care and is powerfully shaped by culture. Yet few stigma measures consider how cultural capabilities that signify "full personhood" could be engaged to resist stigma. By applying a theory conceptualizing how culturally-salient mechanisms can worsen or mitigate HIV stigma in relation to "what matters most" (WMM), we developed the WMM Cultural Stigma Scale for Women Living with HIV in Botswana (WMM-WLHIV-BW) and psychometrically evaluated it among 201 respondents with known and unknown HIV status. The two subscales, Cultural Factors Shape Stigma (CFSS) and Cultural Capabilities Protect against Stigma (CCPS) were reliable (both [Formula: see text]). Among WLHIV, the CFSS Subscale showed initial construct validity with depressive symptoms (r = .39, p = .005), similar to an established HIV stigma scale, whereas the CCPS Subscale showed initial construct validity with self-esteem (r = .32, p = .026) and social support number (r = .29, p = .047), suggesting that achieving local cultural capabilities mitigates stigma and is linked with positive psychosocial outcomes. This culturally-derived scale could help WLHIV in Botswana experience improved stigma-related outcomes.
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http://dx.doi.org/10.1007/s10461-020-03012-yDOI Listing
February 2021

Psychometric Validation of a Scale to Assess Culturally-Salient Aspects of HIV Stigma Among Women Living with HIV in Botswana: Engaging "What Matters Most" to Resist Stigma.

AIDS Behav 2021 Feb;25(2):459-474

Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.

Perceived stigma deters engagement in HIV care and is powerfully shaped by culture. Yet few stigma measures consider how cultural capabilities that signify "full personhood" could be engaged to resist stigma. By applying a theory conceptualizing how culturally-salient mechanisms can worsen or mitigate HIV stigma in relation to "what matters most" (WMM), we developed the WMM Cultural Stigma Scale for Women Living with HIV in Botswana (WMM-WLHIV-BW) and psychometrically evaluated it among 201 respondents with known and unknown HIV status. The two subscales, Cultural Factors Shape Stigma (CFSS) and Cultural Capabilities Protect against Stigma (CCPS) were reliable (both [Formula: see text]). Among WLHIV, the CFSS Subscale showed initial construct validity with depressive symptoms (r = .39, p = .005), similar to an established HIV stigma scale, whereas the CCPS Subscale showed initial construct validity with self-esteem (r = .32, p = .026) and social support number (r = .29, p = .047), suggesting that achieving local cultural capabilities mitigates stigma and is linked with positive psychosocial outcomes. This culturally-derived scale could help WLHIV in Botswana experience improved stigma-related outcomes.
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http://dx.doi.org/10.1007/s10461-020-03012-yDOI Listing
February 2021

Free Format Submission for JCOP.

J Community Psychol 2020 03;48(2):167

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http://dx.doi.org/10.1002/jcop.22329DOI Listing
March 2020

Under-documentation of psychiatric diagnoses among persons living with HIV in electronic medical records.

AIDS Care 2021 03 13;33(3):311-315. Epub 2020 Jan 13.

Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA.

Persons living with HIV (PLWH) are significantly more likely to meet criteria for a psychiatric disorder compared to the general population. To our knowledge there are no prior studies that report rates of psychiatric diagnosis documentation in electronic medical records (EMRs) of PLWH. The goal for this study was to report the rates of a variety of psychiatric diagnoses among PLWH in electronic medical records. Participants (= 2,336) were enrolled in the Center for AIDS Research (CFAR) Longitudinal Database study at the University of Pennsylvania, Philadelphia, PA. Diagnostic codes were extracted from the EMR for depressive disorders, alcohol and substance use disorders, PTSD, sleep disorders, and adjustment disorders and were compared to rates from national epidemiological studies. Rates of Major Depressive Disorder in the EMR were comparable to prior reports on HIV-infected samples. In contrast, rates of PTSD, substance use disorders, alcohol use disorders, adjustment disorders and insomnia from the EMR were all markedly lower compared to national estimates for HIV-infected samples. While clinicians appropriately documented evidence of Major Depressive Disorder, other psychiatric comorbidities were largely overlooked. These findings suggest a potential bias in how clinicians either detect or document psychiatric disorders in PLWH.
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http://dx.doi.org/10.1080/09540121.2020.1713974DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7354895PMC
March 2021

The Mid-Atlantic Center for AIDS Research Consortium Scholars Program: A Multi-Institutional Approach to Mentoring the Next Generation of Underrepresented Scientists.

J Acquir Immune Defic Syndr 2019 12;82 Suppl 2:S124-S127

Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD.

Background: There is an urgent need to intentionally develop and expand mentoring for junior faculty from underrepresented communities in the area of HIV research. Such a goal is increasingly recognized as essential across all scientific fields because profound disparities exist regarding which doctorally prepared individuals ultimately end up entering research fields in academic settings. The purpose of this article is to describe a novel inter-Center for AIDS Research (CFAR) program designed to support underrepresented scientists in research to address the HIV epidemic in the Mid-Atlantic region.

Methods: Three CFARs in the Mid-Atlantic region (the District of Columbia, Johns Hopkins University CFAR, and University of Pennsylvania CFARs) developed a Scholars program designed for underrepresented minority scholars interested in studying the HIV epidemic in the region. The program provided resources for scholarship as well as cross-institutional mentoring and training.

Results: Scholars in the first cohort have been successful in implementing novel research that informs our understanding of the HIV epidemic in the region as well as increasing skills, publications, and grant submissions and funded applications. Lessons learned from the first cohort will inform future years of the MACC Scholars Program.

Conclusions: The MACC Scholars Program offers a model for other inter-CFAR collaborations wishing to find novel ways to support the next generation of scientists.
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http://dx.doi.org/10.1097/QAI.0000000000002171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6831038PMC
December 2019

Causal Pathways Between Severe Mental Illness and Behaviors Related to HIV: Patient Perspectives.

Community Ment Health J 2020 02 18;56(2):338-347. Epub 2019 Sep 18.

Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.

The purpose of this study was to identify causal pathways between HIV infection and severe mental illness. Data were collected through open-ended, semi-structured interviews. An integrated approach to the analysis, using inductive and deductive coding, was used to identify patterns among respondents. Standardized instruments were used to characterize the sample in terms of risk behaviors, physical and mental functioning and depression. Twenty-six men and women with a diagnosis of HIV and unipolar depression (n = 11) or schizophrenia/schizoaffective versus bipolar disorder (n = 15) participated. For persons with unipolar depression, the HIV diagnosis often preceded depressive symptoms. For persons with schizophrenia/schizoaffective versus bipolar disorder, mania and psychosis symptoms often preceded HIV. Substance use, incarceration and adverse childhood experiences were common across diagnoses. Attention to the directionality of effects between mental illness and HIV has important implications for anticipatory guidance for infectious disease specialists, primary care providers and public health practitioners as well as policymakers.
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http://dx.doi.org/10.1007/s10597-019-00466-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7756908PMC
February 2020

"It's When the Trees Blossom": Explanatory Beliefs, Stigma, and Mental Illness in the Context of HIV in Botswana.

Qual Health Res 2019 09 9;29(11):1566-1580. Epub 2019 Feb 9.

5 Columbia University, New York City, New York, USA.

Mental illness is a common comorbidity of HIV and complicates treatment. In Botswana, stigma impedes treatment of mental illness. We examined explanatory beliefs about mental illness, stigma, and interactions between HIV and mental illness among 42 adults, from HIV clinic and community settings, via thematic analysis of interviews. Respondents endorse witchcraft as a predominant causal belief, in addition to drug abuse and effects of HIV. Respondents describe mental illness as occurring "when the trees blossom," underscoring a conceptualization of it as seasonal, chronic, and often incurable and as worse than HIV. Consequently, people experiencing mental illness (PEMI) are stereotyped as dangerous, untrustworthy, and cognitively impaired and discriminated against in the workplace, relationships, and sexually, increasing vulnerability to HIV. Clinical services that address local beliefs and unique vulnerabilities of PEMI to HIV, integration with peer support and traditional healers, and rehabilitation may best address the syndemic by facilitating culturally consistent recovery-oriented care.
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http://dx.doi.org/10.1177/1049732319827523DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7577021PMC
September 2019

HIV Prevalence Among Hospitalized Patients at the Main Psychiatric Referral Hospital in Botswana.

AIDS Behav 2018 05;22(5):1503-1516

Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.

We examined HIV prevalence among patients 18-49 year olds admitted to a psychiatric hospital in Botswana in 2011 and 2012. The retrospective study analyzed females (F) and males (M) separately, comparing proportions with Chi square test and continuous variables with Wilcoxon rank-sum test, assessing significance at the 5% level. HIV seroprevalence among hospitalized psychiatric patients was much more common among females (53%) compared with males (19%) (p < 0.001). These women also appeared more vulnerable to infection compared with females in the general population (29%) (p < 0.017). Among both women and men, HIV-infection appeared most common among patients with organic mental disorders (F:68%, M:41%) and neurotic, stress related and somatoform disorders (F:68%, M:42%). The largest proportion of HIV infections co-occurred among patients diagnosed with schizophrenia, schizotypal and other psychotic disorders (F:48%; M:55%), mood (affective) disorders (F:21%; M:16%) and neurotic, stress-related and somatoform disorders (F:16%; M:20%). Interventions addressing both mental health and HIV among women and men require development.
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http://dx.doi.org/10.1007/s10461-017-1878-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6348889PMC
May 2018

How Do Social Capital and HIV/AIDS Outcomes Geographically Cluster and Which Sociocontextual Mechanisms Predict Differences Across Clusters?

J Acquir Immune Defic Syndr 2017 09;76(1):13-22

*Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA;†Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;‡Department of Behavioral Sciences and Health Education, Emory University Rollins School of Public Health, Atlanta, GA;§Department of Psychiatry, University of Pennsylvania Pearlman School of Medicine, Pennsylvania, PA; and‖Department of Behavioral and Social Sciences, Brown University School of Public Health, Rhode Island Public Health Institute, Providence, RI.

Background: Place of residence has been associated with HIV transmission risks. Social capital, defined as features of social organization that improve efficiency of society by facilitating coordinated actions, often varies by neighborhood, and hypothesized to have protective effects on HIV care continuum outcomes. We examined whether the association between social capital and 2 HIV care continuum outcomes clustered geographically and whether sociocontextual mechanisms predict differences across clusters.

Methods: Bivariate Local Moran's I evaluated geographical clustering in the association between social capital (participation in civic and social organizations, 2006, 2008, 2010) and [5-year (2007-2011) prevalence of late HIV diagnosis and linkage to HIV care] across Philadelphia, PA, census tracts (N = 378). Maps documented the clusters and multinomial regression assessed which sociocontextual mechanisms (eg, racial composition) predict differences across clusters.

Results: We identified 4 significant clusters (high social capital-high HIV/AIDS, low social capital-low HIV/AIDS, low social capital-high HIV/AIDS, and high social capital-low HIV/AIDS). Moran's I between social capital and late HIV diagnosis was (I = 0.19, z = 9.54, P < 0.001) and linkage to HIV care (I = 0.06, z = 3.274, P = 0.002). In multivariable analysis, median household income predicted differences across clusters, particularly where social capital was lowest and HIV burden the highest, compared with clusters with high social capital and lowest HIV burden.

Discussion: The association between social participation and HIV care continuum outcomes cluster geographically in Philadelphia, PA. HIV prevention interventions should account for this phenomenon. Reducing geographic disparities will require interventions tailored to each continuum step and that address socioeconomic factors such as neighborhood median income.
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http://dx.doi.org/10.1097/QAI.0000000000001463DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5584611PMC
September 2017

Sociodemographic Characteristics and Health Outcomes Among Lesbian, Gay, and Bisexual U.S. Adults Using Healthy People 2020 Leading Health Indicators.

LGBT Health 2017 08 20;4(4):283-294. Epub 2017 Jul 20.

9 Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania.

Purpose: This study aimed to characterize the sociodemographic characteristics of sexual minority (i.e., gay, lesbian, bisexual) adults and compare sexual minority and heterosexual populations on nine Healthy People 2020 leading health indicators (LHIs).

Methods: Using a nationally representative, cross-sectional survey (National Health Interview Survey 2013-2015) of the civilian, noninstitutionalized population (228,893,944 adults), nine Healthy People 2020 LHIs addressing health behaviors and access to care, stratified using a composite variable of sex (female, male) and sexual orientation (gay or lesbian, bisexual, heterosexual), were analyzed individually and in aggregate.

Results: In 2013-2015, sexual minority adults represented 2.4% of the U.S.

Population: Compared to heterosexuals, sexual minorities were more likely to be younger and to have never married. Gays and lesbians were more likely to have earned a graduate degree. Gay males were more likely to have a usual primary care provider, but gay/lesbian females were less likely than heterosexuals to have a usual primary care provider and health insurance. Gay males received more colorectal cancer screening than heterosexual males. Gay males, gay/lesbian females, and bisexual females were more likely to be current smokers than their sex-matched, heterosexual counterparts. Binge drinking was more common in bisexuals compared to heterosexuals. Sexual minority females were more likely to be obese than heterosexual females; the converse was true for gay males. Sexual minorities underwent more HIV testing than their heterosexual peers, but bisexual males were less likely than gay males to be tested. Gay males were more likely to meet all eligible LHIs than heterosexual males. Overall, more sexual minority adults met all eligible LHIs compared to heterosexual adults. Similar results were found regardless of HIV testing LHI inclusion.

Conclusion: Differences between sexual minorities and heterosexuals suggest the need for targeted health assessments and public health interventions aimed at reducing specific negative health behaviors.
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http://dx.doi.org/10.1089/lgbt.2016.0087DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5564038PMC
August 2017

Does Diagnosis Make a Difference? Estimating the Impact of an HIV Medication Adherence Intervention for Persons with Serious Mental Illness.

AIDS Behav 2018 01;22(1):265-275

Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.

The heightened risk of persons with serious mental illness to contract and transmit human immunodeficiency virus (HIV) is a public health problem. Here we evaluate the interaction between psychiatric diagnosis and response to a community based-intervention targeted at treatment adherence in 236 HIV+ persons with co-occurring mental illness. To examine differential effectiveness of the intervention for categories of patient diagnosis, we reanalyzed the data after stratifying participants into two diagnostic groups: (1) participants with depressive disorders without psychosis and (2) participants with a psychotic or bipolar disorder. Outcomes included viral load and mental health quality of life (SF-12 Mental Health). We found that HIV+ persons with non-psychotic depressive disorders demonstrated a larger decrease in HIV viral load and more improvement in measures of mental health quality of life when compared to HIV+ persons with psychotic and bipolar disorders. We suggest that successful adherence interventions should be informed by psychiatric symptomatology.

Trial Registration: clinicaltrials.gov 29 identifier NCT00264823.
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http://dx.doi.org/10.1007/s10461-017-1795-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6281165PMC
January 2018

Coercion or Caring: The Fundamental Paradox for Adherence Interventions for HIV+ People with Mental Illness.

AIDS Behav 2017 Jun;21(6):1530-1539

Department of Psychiatry, University of Pennsylvania, 3535 Market Street, Philadelphia, PA, 19104, USA.

To determine if an escalating HIV treatment adherence intervention would be considered by participants from a caring or coercive perspective, perceived coercion was examined in 238 community-based dually diagnosed individuals (HIV+ and a serious mental illness) randomized to a treatment-as-usual (TAU) control group or preventing AIDS through health for HIV+ persons (PATH+) Intervention that increased intervention intensity when adherence fell below 80 %. Minor differences were observed in perceived coercion between the PATH+ Intervention and Control groups with perceived coercion marginally higher in the PATH+ group. Latent growth curve analyses indicate that perceived coercion was not related to duration of the intervention for either the PATH+ or Control group. The experience of coercion by HIV+ individuals receiving community-based mental health services was not related to the intensity or duration of delivered services.
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http://dx.doi.org/10.1007/s10461-016-1517-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6280194PMC
June 2017

Registries and syndemics: untapped potential for global health.

Lancet HIV 2015 Aug 2;2(8):e314-5. Epub 2015 Jul 2.

Department of Psychiatry, University of Pennsylvania, Philadelphia, PA 19104, USA.

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http://dx.doi.org/10.1016/S2352-3018(15)00110-1DOI Listing
August 2015

The CDC clearance process: an obstacle to progress in public health.

Am J Public Health 2015 Apr 25;105(4):614-5. Epub 2015 Feb 25.

Michael B. Blank and John B. Jemmott III are with the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia. John B. Jemmott III is also with the Annenberg School for Communication, University of Pennsylvania, Philadelphia.

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http://dx.doi.org/10.2105/AJPH.2015.302600DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4358190PMC
April 2015

Determining the Cost-Savings Threshold for HIV Adherence Intervention Studies for Persons with Serious Mental Illness and HIV.

Community Ment Health J 2016 May 23;52(4):439-45. Epub 2014 Dec 23.

Department of Psychiatry, Center for Mental Health Policy and Services Research, University of Pennsylvania, 3535 Market Street, #3103, Philadelphia, PA, 19104, USA.

Persons with serious mental illnesses are at increased risk for contracting and transmitting HIV and often have poor adherence to medication regimens. Determining the economic feasibility of different HIV adherence interventions among individuals with HIV and serious mental illness is important for program planners who must make resource allocation decisions. The goal of this study was to provide a methodology to estimate potential cost savings from an HIV medication adherence intervention program for a new study population, using data from prior published studies. The novelty of this approach is the way CD4 count data was used as a biological marker to estimate costs averted by greater adherence to anti-retroviral treatment. Our approach is meant to be used in other adherence intervention studies requiring cost modeling.
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http://dx.doi.org/10.1007/s10597-014-9788-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4478285PMC
May 2016

HIV testing among adults with mental illness in the United States.

AIDS Patient Care STDS 2014 Dec;28(12):628-34

1 Department of Medicine, Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania.

Nationally representative data from the 2007 National Health Interview Survey (NHIS) were used to compare HIV testing prevalence among US adults with mental illness (schizophrenia spectrum disorder, bipolar disorder, depression, and/or anxiety) to those without, providing an update of prior work using 1999 and 2002 NHIS data. Logistic regression modeling was used to estimate the probability of ever being tested for HIV by mental illness status, adjusting for age, sex, race/ethnicity, marital status, substance abuse, excessive alcohol or tobacco use, and HIV risk factors. Based on data from 21,785 respondents, 15% of adults had a psychiatric disorder and 37% ever had an HIV test. Persons with schizophrenia (64%), bipolar disorder (63%), and depression and/or anxiety (47%) were more likely to report ever being tested for HIV than those without mental illness (35%). In multivariable models, individuals reporting schizophrenia (adjusted prevalence ratio=1.68, 95% confidence interval=1.33-2.13), bipolar disease (1.58, 1.39-1.81), and depression and/or anxiety (1.31, 1.25-1.38) were more likely to be tested for HIV than persons without these diagnoses. Similar to previous analyses, persons with mental illness were more likely to have been tested than those without mental illness. However, the elevated prevalence of HIV in populations with mental illness suggests that high levels of testing along with other prevention efforts are needed.
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http://dx.doi.org/10.1089/apc.2014.0196DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4250950PMC
December 2014

A multisite study of the prevalence of HIV with rapid testing in mental health settings.

Am J Public Health 2014 Dec 13;104(12):2377-84. Epub 2014 Feb 13.

Michael B. Blank and David S. Metzger are with the Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia. Seth S. Himelhoch is with the Department of Psychiatry, University of Maryland School of Medicine, Baltimore. Alexandra B. Balaji, Charles E. Rose, and James D. Heffelfinger are with the Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Lisa B. Dixon is with the Department of Psychiatry, Columbia University, New York, NY. Emeka Oraka is with ICF International, Atlanta. Annet Davis-Vogel is with the HIV/AIDS Prevention Research Division, University of Pennsylvania, Philadelphia. William W. Thompson is with the Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta.

Objectives: We estimated HIV prevalence and risk factors among persons receiving mental health treatment in Philadelphia, Pennsylvania, and Baltimore, Maryland, January 2009 to August 2011.

Methods: We used a multisite, cross-sectional design stratified by clinical setting. We tested 1061 individuals for HIV in university-based inpatient psychiatric units (n = 287), intensive case-management programs (n = 273), and community mental health centers (n = 501).

Results: Fifty-one individuals (4.8%) were HIV-infected. Confirmed positive HIV tests were 5.9% (95% confidence interval [CI] = 3.7%, 9.4%) for inpatient units, 5.1% (95% CI = 3.1%, 8.5%) for intensive case-management programs, and 4.0% (95% CI = 2.6%, 6.1%) for community mental health centers. Characteristics associated with HIV included Black race, homosexual or bisexual identity, and HCV infection.

Conclusions: HIV prevalence for individuals receiving mental health services was about 4 times as high as in the general population. We found a positive association between psychiatric symptom severity and HIV infection, indicating that engaging persons with mental illness in appropriate mental health treatment may be important to HIV prevention. These findings reinforce recommendations for routine HIV testing in all clinical settings to ensure that HIV-infected persons receiving mental health services are identified and referred to timely infectious disease care.
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http://dx.doi.org/10.2105/AJPH.2013.301633DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4133307PMC
December 2014

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

J Acquir Immune Defic Syndr 2013 Nov;64 Suppl 1:S42-51

*AIDS Activities Coordinating Office, Philadelphia Department of Public Health, Philadelphia, PA; †Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; ‡Philadelphia Veterans Affairs Center for Health Equity Research and Promotion, Philadelphia, PA; §University of Pennsylvania School of Design, Philadelphia, PA; ‖Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, and ¶Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and #Treatment Research Institute, Philadelphia, PA.

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.
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http://dx.doi.org/10.1097/QAI.0b013e3182a90112DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3891372PMC
November 2013

Treatment considerations for HIV-infected individuals with severe mental illness.

Curr HIV/AIDS Rep 2013 Dec;10(4):371-9

Center for Mental Health Policy and Services Research, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market St., room 3020, Philadelphia, PA, 19104-3309, USA,

There has been a general recognition of a syndemic that includes HIV/AIDS and serve mental illnesses including schizophrenia, major depression, bipolar disorder, post-traumatic stress disorder, and others. The pathophysiology and direction of effects between severe mental illness and HIV infection is less clear however, and relatively little work has been done on prevention and treatment for people with these complex, co-occurring conditions. Here we present the most recent work that has been published on HIV and mental illness. Further, we describe the need for better treatments for "triply diagnosed persons"; those with HIV, mental illness, and substance abuse and dependence. Finally, we describe the potential drug-drug interactions between psychotropic medications and anti-retrovirals, and the need for better treatment guidelines in this area. We describe one example of an individually tailored intervention for persons with serious mental illness and HIV (PATH+) that shows that integrated community-based treatments using advanced practice nurses (APNs) as health navigators can be successful in improving health-related quality of life and reducing the burden of disease in these persons.
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http://dx.doi.org/10.1007/s11904-013-0179-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3857330PMC
December 2013

Increasing quality of life and reducing HIV burden: the PATH+ intervention.

AIDS Behav 2014 Apr;18(4):716-25

Center for Mental Health Policy and Services Research, University of Pennsylvania, 3535 Market St., Philadelphia, PA, 19104-3309, USA,

The heightened risk of persons with serious mental illness (SMI) to contract and transmit human immunodeficiency virus (HIV) is a public health problem. Our objective was test the effectiveness of a community-based advanced practice nurse intervention to promote adherence to HIV and psychiatric treatment regimens call Preventing AIDS Through Health for Positives (PATH+). We enrolled 238 HIV-positive subjects with SMI who were in treatment at community HIV provider agencies from 2004 to 2009. Participants in the intervention group were assigned an advanced practice nurse who provided community-based care management at a minimum of one visit/week and coordinated their medical and mental healthcare for 12 months. A parallel process latent growth curve model using three data points for biomarkers (baseline, 12 and 24 months) and five data points for health related quality of life (baseline, 3, 6, 12, and 24 months) showed moderate to excellent fit for modeling changes in CD4, viral load, and mental and physical SF-12 subscales. Results suggest that positive effects for PATH+ persisted at 24 months; 12 months after the intervention ended. This project demonstrates the effectiveness of a nurse-led, community-based, individually tailored adherence intervention. We demonstrated improved outcomes in individuals with HIV/SMI and regarding health-related quality of life and reductions in disease burden.
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http://dx.doi.org/10.1007/s10461-013-0606-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3940688PMC
April 2014

Tailored treatment for HIV+ persons with mental illness: the intervention cascade.

J Acquir Immune Defic Syndr 2013 Jun;63 Suppl 1:S44-8

Department of Psychiatry, Center for Mental Health Policy and Services Research, University of Pennsylvania, Philadelphia, PA 19104, USA.

The public health literature demonstrates disturbingly high HIV risk for persons with a serious mental illness, who are concurrently comorbid for substance abuse. Many HIV positives have not been tested and therefore do not know their status, but for individuals who are triply diagnosed, adherence to HIV treatment results in meaningful reductions in viral loads and CD4 counts. Barriers to treatment compliance are reviewed, low-threshold/low-intensity community-based interventions are discussed, and preliminary evidence is presented for the efficacy of the intervention cascade, defined as an integrated intervention delivered by specially trained nurses who individualize a treatment compliance intervention in real time as an adaptive response to demand characteristics of the individual.
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http://dx.doi.org/10.1097/QAI.0b013e318293067bDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3667202PMC
June 2013

The social and behavioral sciences research network: translational research to reduce disparities in HIV.

J Acquir Immune Defic Syndr 2013 Jun;63 Suppl 1:S1-3

Center for Mental Health Policy and Services Research, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA 19104-3009, USA.

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http://dx.doi.org/10.1097/QAI.0b013e3182921554DOI Listing
June 2013

A randomized trial of a nursing intervention for HIV disease management among persons with serious mental illness.

Psychiatr Serv 2011 Nov;62(11):1318-24

Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104-3309, USA.

Objective: The heightened risk of persons with serious mental illness to contract and transmit HIV is recognized as a public health problem. Persons with HIV and mental illness may be at risk for poor treatment adherence, development of treatment-resistant virus, and worse outcomes. The objective of this study was to test the effectiveness of a community-based advanced practice nurse (APN) intervention (PATH, Preventing AIDS Through Health) to promote adherence to HIV and psychiatric treatment regimens.

Methods: Community-dwelling HIV-positive participants with co-occurring serious mental illnesses (N=238) were recruited from community HIV provider agencies from 2004 to 2008 to participate in the randomized controlled trial. Participants in the intervention group (N=128) were assigned an APN who provided community-based care management at a minimum of one visit per week and coordinated clients' medical and mental health care for one year. Viral load and CD4 cell count were evaluated at baseline and 12 months.

Results: Longitudinal models for continuous log viral load showed that compared with the control group, the intervention group exhibited a significantly greater reduction in log viral load at 12 months (d=-.361 log 10 copies per milliliter, p<.001). Differences in CD4 counts from baseline to 12 months were not statistically significant.

Conclusions: This project demonstrated the effectiveness of community-based APNs in delivering a tailored intervention to improve outcomes of individuals with HIV and co-occurring serious mental illnesses. Persons with these co-occurring conditions can be successfully treated; with appropriate supportive services, their viral loads can be reduced.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5072175PMC
http://dx.doi.org/10.1176/ps.62.11.pss6211_1318DOI Listing
November 2011

Randomized Clinical Trial of the Effectiveness of a Home-Based Advanced Practice Psychiatric Nurse Intervention: Outcomes for Individuals with Serious Mental Illness and HIV.

Nurs Res Pract 2011 17;2011:840248. Epub 2011 May 17.

Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, 418 Curie Boulevard, Philadelphia, PA 19204-4217, USA.

Individuals with serious mental illness have greater risk for contracting HIV, multiple morbidities, and die 25 years younger than the general population. This high need and high cost subgroup face unique barriers to accessing required health care in the current health care system. The effectiveness of an advanced practice nurse model of care management was assessed in a four-year random controlled trial. Results are reported in this paper. In a four-year random controlled trial, a total of 238 community-dwelling individuals with HIV and serious mental illness (SMI) were randomly assigned to an intervention group (n=128) or to a control group (n=110). Over 12 months, the intervention group received care management from advanced practice psychiatric nurse, and the control group received usual care. The intervention group showed significant improvement in depression (P=.012) and the physical component of health-related quality of life (P=.03) from baseline to 12 months. The advanced practice psychiatric nurse intervention is a model of care that holds promise for a higher quality of care and outcomes for this vulnerable population.
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http://dx.doi.org/10.1155/2011/840248DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3169337PMC
November 2011
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