Connecting Discovery and Delivery: The Need For More Evidence on Effective Smoking Cessation Strategies for People Living With HIV/AIDS

Smoking prevalence among the 1.1 million Americans living with HIV/AIDS is 2 to 3 times higher than the 19.8% rate among the general population. Since 1990, scientists have worked toward the discovery of health risks related to smoking in people living with HIV/AIDS; however, few studies have evaluated the delivery of smoking cessation interventions for this population. Increasing linkages between discovery science and delivery science may facilitate a faster transition to delivery of smoking cessation interventions for people living with HIV/AIDS.Health research often focuses on the discovery of risk factors associated with disease and death.¹ Although discovery of health risks is necessary to protect health, the delivery of interventions to improve health is equally important.^1–5 Information regarding how science moves from discovery to delivery points to substantial time lag and little cross-talk between discovery and delivery research.^1,6 This may be especially problematic in areas such as HIV/AIDS and smoking, where delay between discovery of smoking-related health outcomes in people living with HIV/AIDS and the delivery of interventions to reduce smoking among this population has serious consequences.Smoking prevalence in people living with HIV/AIDS is 2 to 3 times higher than is the 19.8% rate among the general population.^7–16 Discovery research has concluded that smokers with HIV/AIDS are more likely to be nonadherent to treatment, have a greater chance of being diagnosed with an AIDS-defining condition or dying, and report lower quality of life than do nonsmoking persons with HIV/AIDS.^13,17–21 Smokers living with HIV/AIDS have a higher risk of disease and opportunistic infection than do smokers who do not have HIV/AIDS.^9,22–34Delivery research indicates that population-specific smoking cessation interventions can be effective.^35–52 Although few studies have examined such strategies for persons living with HIV/AIDS,³⁵ a recent study found that 86% of smokers with HIV/AIDS would not benefit from standard cessation programs.⁵³ I used citation network analysis^54–56 to examine the characteristics of—and possible relationships between—discovery research relating health outcomes to smoking in persons living with HIV/AIDS and delivery research on interventions to reduce smoking among this population.     

Improving the health and mental health of people living with HIV/AIDS: 12-month assessment of a behavioral intervention in Thailand

Objectives. We examined findings from a randomized controlled intervention trial designed to improve the quality of life of people living with HIV in Thailand.Methods. A total of 507 people living with HIV were recruited from 4 district hospitals in northern and northeastern Thailand and were randomized to an intervention group (n = 260) or a standard care group (n = 247). Computer-assisted personal interviews were administered at baseline and at 6 and 12 months.Results. At baseline, the characteristics of participants in the intervention and standard care conditions were comparable. The mixed-effects models used to assess the impact of the intervention revealed significant improvements in general health (B = 2.51; P = .001) and mental health (B = 1.57; P = .02) among participants in the intervention condition over 12 months and declines among those in the standard care condition.Conclusions. Our results demonstrate that a behavioral intervention was successful in improving the quality of life of people living with HIV. Such interventions must be performed in a systematic, collaborative manner to ensure their cultural relevance, sustainability, and overall success.People living with HIV/AIDS in Thailand face multiple challenges, including coping with HIV-related disclosure and stigma and maintaining positive family relationships. HIV disclosure has been identified as a key stressor for people living with HIV in Thailand^1–3; when patients do not disclose their serostatus, their odds of becoming depressed increase 3-fold.⁴ Disclosure is also a key issue among Thai HIV support groups.⁵ Once individuals disclose their serostatus to their partners and family members, treatment becomes a challenge for the entire family.In addition to disclosure, it is necessary to address stigma as an HIV-related stressor. We have documented a high level of perceived stigma in Thailand and associations with other conditions, including a significant association between stigma and depression.⁶ People living with HIV in Thailand also face challenges with respect to maintaining general health routines,⁷ including medical visits, prophylactic treatment of symptoms (e.g., hepatitis C virus, pneumonia, tuberculosis),⁸ adherence to antiretroviral therapy (ART),⁹ knowledge of the course of their disease, and effective communication with doctors.By contrast, other factors have been shown to have a positive effect on management of HIV. For example, Thailand is a strongly family-oriented society, and typical Thai families are tightly knit. Therefore, family social support may help people living with HIV increase their adherence to ART and decrease their risk of depression.^9,10 Parents of children living with HIV need information about how their children may respond to their illness, how to parent children while dealing with their own illness, how to maintain positive family routines, and how to generate positive parental bonds with their children. Knowledge in such areas is hypothesized to improve patients’ quality of life and their children''s long-term adjustment.^11–13Past behavioral interventions in Thailand have framed HIV as an individual stressor for people living with the disease.^14,15 To address the multiple negative and positive factors faced by people living with HIV and their families in Thailand, we conducted a randomized controlled intervention trial in the northern and northeastern areas of the country. On the basis of the work of Rotheram-Borus et al.,^13,16–21 we identified common factors, processes, and principles shared across evidence-based interventions^22–24 and adapted them to address the specific needs of people living with HIV in Thailand. Here we describe findings based on data collected at baseline, 6 months, and 12 months to assess the efficacy of a cognitive-based intervention designed to improve the quality of life of people living with HIV.     

Effects of a Brief Case Management Intervention Linking People With HIV to Oral Health Care: Project SMILE

Objectives. Although people with HIV experience significant oral health problems, many consistently identify oral health as an unmet health care need. We conducted a randomized controlled trial to evaluate the impact of a dental case management intervention on dental care use.Methods. We evaluated the intervention according to self-reported dental care use at 6-, 12-, and 18-month follow-ups. Multivariable logistic models with generalized estimating equations were used to assess the effects of the intervention over time.Results. The odds of having a dental care visit were about twice as high in the intervention group as in the standard care group at 6 months (adjusted odds ratio [OR] = 2.52; 95% confidence interval [CI] = 1.58, 4.08) and 12 months (adjusted OR = 1.98; 95% CI = 1.17, 3.35), but the odds were comparable in the 2 groups by 18 months (adjusted OR = 1.07; 95% CI = 0.62, 1.86). Factors significantly associated with having a dental care visit included frequent physician visits and dental care referrals.Conclusions. We demonstrated that a dental case management intervention targeting people with HIV was efficacious but not sustainable over time. Barriers not addressed in the intervention must be considered to sustain its use over time.In the era of antiretroviral therapy, people with HIV are living longer and the treatment of associated medical and oral manifestations of the disease has shifted to a chronic disease model.1 Previous studies have shown that a person living with HIV/AIDS is more likely than a person without the disease to experience oral health problems.2–5 Furthermore, the oral health problems of individuals with HIV can be more severe and difficult to treat than those of the general population and may also contribute to the onset of opportunistic infections.5The oral health complications associated with HIV are well documented,2–6 and oral manifestations are increasingly being recognized as markers for monitoring treatment efficacy and predicting treatment failure.7 Oral manifestations, including Kaposi’s sarcoma, necrotizing ulcerative periodontitis, oral hairy leukoplakia, and candidiasis, may be present in up to 50% of people with HIV and 80% of people diagnosed with AIDS,5,6 and may predict low CD4 counts.8 In addition, individuals living with HIV/AIDS may experience difficulty in maintaining adequate salivary flow, which affects chewing, swallowing, and the ability to take medication.4 Chronic use of highly active antiretroviral therapy can also contribute to diminished salivary flow as well as an increased risk of oral candidiasis and oral hairy leukoplakia.9Throughout the 1990s, a series of study findings highlighted the unmet needs for dental care among people with HIV infection.10–14 This gap in oral health care services was corroborated by findings from the oral health component of the HIV Cost and Services Utilization Study,15 which demonstrated that unmet dental needs were twice as common as unmet medical needs among HIV-positive adults16,17 and led to a national call to action to improve access to oral health care.18 That study also showed that approximately half of people living with HIV had dental insurance, and those without dental insurance had greater unmet needs for dental services.17,19,20Recently published findings suggest that an unmet need still persists. One example is an initiative, funded by the Health Resources and Services Administration, that included 2469 people living with HIV who had not received dental care during the preceding year. Nearly half of these individuals (48%) reported an unmet dental need since their HIV diagnosis, 52% had not seen a dentist in more than 2 years, and 63% rated the health of their teeth and gums as fair or poor.21,22 An earlier investigation involving baseline data from the study presented here showed that oral health problems and symptoms were very prevalent among our study population, with 63% of participants having experienced an oral health impact very often or fairly often in the preceding 4 weeks.23Barriers to dental care use among individuals living with HIV include fear of dental care, HIV-specific stigma, fear of disclosing their HIV status to health care providers, perceived cost barriers, and poor adherence to medical guidance.20,22,24–31 Compounding patient access barriers, dental care providers may be reluctant to treat patients with HIV owing to fears of HIV transmission and associated stigma.32–36Previous research conducted in Florida revealed that more than one third of people with HIV do not discuss oral health with their primary care providers.37 Although clinical guidelines recommend that HIV care providers examine the oral cavity during initial and interim physical examinations of people living with HIV, this still may not be a regular clinical practice.37 To address underuse of oral health care services among individuals with HIV, we evaluated the efficacy of an intervention that linked individuals to dental care. The sample comprised a population of HIV-positive individuals in south Florida who had received HIV primary care but had not received oral health services in the preceding 12 months.     

Growing Older With HIV/AIDS: New Public Health Challenges

At present, the health care infrastructure is ill-equipped to handle the unique treatment and care needs of HIV-positive older adults.The long-term effects of antiretroviral use are still being discovered and have been associated with a number of comorbidities. Stigma presents challenges for those in need of services and health care, and can significantly affect mental health and treatment adherence.The training of elder service providers and health care providers in meeting the needs of HIV-positive older adults, including gay and transgender people, is needed as the population ages. HIV-related and antigay stigma should be challenged by social marketing campaigns. Continued research and key policy changes could greatly improve health outcomes for HIV-positive elderly persons by increasing access to treatment and support.THE ADVENT OF ANTIRETROVIral medications (ARVs) has enabled HIV-positive people to live increasingly longer lives. Those in the developed world who begin highly active antiretroviral treatment (HAART) at an initial CD4 count above 200 can expect to live well into their 70s.1Worldwide the leading cause of death among people living with HIV/AIDS is tuberculosis.2 In the United States tuberculosis is very rare. Less than one third of deaths among people with HIV/AIDS in the United States are now attributed to diseases traditionally associated with HIV infection, such as Kaposi’s sarcoma.3 Liver disease and cardiovascular disease, both associated with long-term use of ARVs, are leading causes of mortality among older people living with HIV.Longer life expectancy is already evident; by 2015 more than half of the HIV-positive population in the United States will be aged 50 years and older.4 Most older adults living with HIV/AIDS were infected in youth or middle age; only 1 in 9 new HIV infections in the United States occurs among people aged 50 years and older.5Aging with HIV/AIDS presents biomedical complexities only now beginning to reveal themselves. Higher rates of comorbidities are among the more severe biomedical issues facing older adults with HIV/AIDS.6 Widespread cognitive impairment among people on treatment of a long time could be caused by “chronic HIV-driven inflammation in an aging brain.”7^(p1) Answers to critical research questions regarding how HIV medications interact with medications to treat other conditions are still in the nascent stages. In this article, we examine what we know about growing older with HIV/AIDS, identify gaps in knowledge, and provide recommendations to enable public health professionals to better treat and care for the burgeoning population of HIV-positive older adults, and reduce infections among older adults.     

Perspectives on the Role of Patient-Centered Medical Homes in HIV Care

To strengthen the quality of HIV care and achieve improved clinical outcomes, payers, providers, and policymakers should encourage the use of patient-centered medical homes (PCMHs), building on the Ryan White CARE Act Program established in the 1990s.The rationale for a PCMH with HIV-specific expertise is rooted in clinical complexity, HIV’s social context, and ongoing gaps in HIV care. Existing Ryan White HIV/AIDS Program clinicians are prime candidates to serve HIV PCMHs, and HIV-experienced community-based organizations can play an important role.Increasingly, state Medicaid programs are adopting a PCMH care model to improve access and quality to care. Stakeholders should consider several important areas for future action and research with regard to development of the HIV PCMH.Combination antiretroviral therapy (ART) is critical to the management of HIV/AIDS because it improves survival of HIV-infected persons1,2 and reduces rates of both sexual and mother-to-child transmission of disease.3,4 Adherence to ART decreases the average mortality rate in people living with HIV (PLWH) by one half,2 reduces sexual transmission of HIV-1 in serodiscordant couples by 96%,4 and reduces the frequency of mother-to-child transmission to below 2%.3 Because of these clinical and preventive benefits, increasing access to ART and retention in care remains an important public health strategy.Unfortunately, the Centers for Disease Control and Prevention estimates that of the 1.1 million people living with HIV disease in the United States in 2012, only 37.0% were retained in HIV care.5 Only 25.0% of PLWH have achieved viral suppression (defined as a sustained viral load of ≤ 50 copies per mL).5,6 The Centers for Disease Control and Prevention considers ART with durable viral suppression key to a comprehensive HIV prevention strategy.7,8 Recent estimates show that increasing the HIV diagnosis rate (i.e., the percentage of individuals aware of their infection) to 90.0%, achieving 80.7% viral suppression in care, and obtaining full funding of behavioral interventions for PLWH could avert nearly 180 000 new infections by 2020.9Difficulties in accessing ART and achieving viral suppression stem from delayed diagnosis and other challenges to engagement and retention in care, such as substance use, unstable housing or homelessness, psychiatric disorders, language barriers, and incarceration.10,11 Regular adherence is crucial for long-term viral suppression, and missed doses or significant variation in dosage timing can lead to viral resistance that may portend treatment failure.12,13Serving PLWH through a patient-centered medical home (PCMH) may be a successful strategy for increasing the number of people who remain in care and achieve viral control. PCMH models, which have evolved over decades, focus on whole person care coordinated across all the elements of the health care system and the patient’s community.14 Both the National HIV/AIDS Strategy and the Patient Protection and Affordable Care Act include the PCMH as a valued strategy for accomplishing key goals of improving quality of care and cost containment.15–17The national rate of 25% viral suppression reflects a need for development and refinement of the PCMH specifically designed for PLWH, or the HIV PCMH. Stakeholders across the health care system—including providers and payers—should ensure that a growing proportion of PLWH enroll in a PCMH with specific HIV expertise that comprehensively meets their needs. An alternative policy direction would be to enroll PLWH into traditional PCMHs that address the full spectrum of primary care, although that alternative is suboptimal.     

Can Medicaid Reimbursement Help Give Female Condoms a Second Chance in the United States?

The female condom is the only other barrier contraception method besides the male condom, and it is the only “woman-initiated” device for prevention of sexually transmitted infections. Although studies demonstrate high acceptability and effectiveness for this device, overall use in the United States remains low.The female condom has been available through Medicaid in many states since 1994. We provide the first published summary of data on Medicaid reimbursement for the female condom. Our findings demonstrate low rates of claims for female condoms but high rates of reimbursement.In light of the 2009 approval of a new, cheaper female condom and the recent passage of comprehensive health care reform, we call for research examining how health care providers can best promote consumer use of Medicaid reimbursement to obtain this important infection-prevention device.The female condom is the only other barrier contraception method other than the male condom, and it is the only “woman-initiated” device for prevention of sexually transmitted infections (STIs), including HIV. Male and female condoms are currently the only technologies that may provide protection against both pregnancy and STIs. Studies have demonstrated that the female condom''s effectiveness in preventing pregnancy¹ and STIs² is comparable to that of the male condom. Studies have also shown that STI prevention counseling that addresses both male and female condoms results in more condom use than does counseling that addresses male condoms alone.³ Although the device is used predominantly by women, it is also increasingly used by men to have anal sex with men, despite lack of Food and Drug Administration (FDA) approval for such use.⁴ Acceptability and effectiveness studies consistently demonstrate that women at risk of STIs do use the device when it is available but that levels of use in the United States remain low.⁵ Several reports suggest there is a lack of leadership-level commitment to ensure improved distribution of the device in the public health care system.^5–7The female condom has been a reimbursable over-the-counter device for Medicaid recipients in many US states for more than a decade. Medicaid is the largest provider of reproductive health care among low-income people in the United States, and low-income women represent a disproportionately large proportion of those newly diagnosed with HIV infections.^8–10 A significant proportion of HIV-infected Medicaid beneficiaries are women, and more than 60% of women living with HIV in the United States receive Medicaid.^11–13 Because the evolving HIV epidemic in the United States increasingly affects women, minorities, persons infected through heterosexual contact, and the poor,¹⁰ access to the female condom through Medicaid may represent a critical STI prevention policy for poor women in the United States.Given the low profile of the female condom in the commercial sphere, we sought to document reimbursement for the female condom through Medicaid. We asked Medicaid representatives in each state about requests for female condoms and reimbursement for female condoms in response to those requests. Our goals were to provide a snapshot of female condom utilization through Medicaid and to inform a renewed dialogue about the device and its role in HIV prevention.     

Community Poverty and Trends in Racial/Ethnic Survival Disparities Among People Diagnosed With AIDS in Florida, 1993–2004

Objectives. We described the racial/ethnic disparities in survival among people diagnosed with AIDS in Florida from 1993 to 2004, as the availability of highly active antiretroviral therapy (HAART) became widespread. We determined whether these disparities decreased after controlling for measures of community-level socioeconomic status.Methods. We compared survival from all causes between non-Hispanic Blacks and non-Hispanic Whites vis-a-vis survival curves and Cox proportional hazards models controlling for demographic, clinical, and area-level poverty factors.Results. Racial/ethnic disparities in survival peaked for those diagnosed during the early implementation of HAART (1996–1998) with a Black-to-White hazard ratio (HR) of 1.72 (95% confidence interval [CI] = 1.62, 1.83) for males and 1.40 (95% CI = 1.24, 1.59) for females. These HRs declined significantly to 1.48 (95% CI = 1.35, 1.64) for males and nonsignificantly to 1.25 (95% CI = 1.05, 1.48) for females in the 2002 to 2004 diagnosis cohort. Disparities decreased significantly for males but not females when controlling for baseline demographic factors and CD4 count and percentage, and became nonsignificant in the 2002 to 2004 cohort after controlling for area poverty.Conclusions. Area poverty appears to play a role in racial/ethnic disparities even after controlling for demographic factors and CD4 count and percentage.The HIV/AIDS epidemic has disproportionately affected the non-Hispanic Black population in the United States. In 2008, an estimated 545 000 non-Hispanic Blacks were living with HIV/AIDS.1 The estimated prevalence of HIV infection for 2008 among non-Hispanic Blacks was 18.2 per 1000 population, more than 7 times higher than the estimated rate for non-Hispanic Whites (non-Hispanic Whites; 2.4 per 1000).1 Non-Hispanic Blacks as a group not only have a higher prevalence of HIV/AIDS, but once infected also have a lower survival rate. The 3-year survival rate in the United States for people diagnosed with AIDS between 2001 and 2005 was 80% among non-Hispanic Blacks compared with 84% for non-Hispanic Whites, 83% for Hispanics, and 88% for Asians,2 further contributing to the disparities in the HIV mortality rate of 16.8 per 100 000 among non-Hispanic Blacks compared with 1.6 per 100 000 among non-Hispanic Whites during 2007.3 Race/ethnicity is a fundamentally social as opposed to a biological construct,4,5 and survival disparities between non-Hispanic Blacks and non-Hispanic Whites have not generally been seen in settings with universal health care access such as in the Veterans Administration health care system,6 the military health care system,7 or a health maintenance organization.8 Therefore, potentially modifiable social explanations for the observed racial/ethnic disparities in survival should be examined.A most remarkable advance in medical treatment in the past century was the development of highly active antiretroviral therapy (HAART). It led to a significant improvement in survival from HIV/AIDS, 9–12 but racial/ethnic disparities in HIV/AIDS survival remain2, 13–16 and in New York City appeared to widen.17 Despite these well-recognized health disparities, there is a critical gap in the knowledge about why the disparity exists. Two population-based studies, both in San Francisco, California (a city that has provided free HIV care for those who cannot afford it), found that Black race was no longer associated with survival between 1996 and 2001 after controlling for neighborhood socioeconomic status (SES), and that this SES effect seemed to be related to HAART use.18,19 However, in a study using HIV surveillance data from 33 states, racial/ethnic disparities in 5-year survival after HIV diagnosis between 1996 and 2003 persisted after adjusting for county-level SES and other factors.20 The objective of this study was to describe the racial/ethnic disparities in AIDS survival in Florida among people diagnosed with AIDS between 1993 and 2004 (a period spanning the time before and during the widespread availability of HAART) and to determine if these disparities decrease after controlling for community-level SES.     

Medicaid Expansion Initiative in Massachusetts: Enrollment Among Substance-Abusing Homeless Adults

Objectives. We assessed whether homeless adults entering substance abuse treatment in Massachusetts were less likely than others to enroll in Medicaid after implementation of the MassHealth Medicaid expansion program in 1997.Methods. We used interrupted time-series analysis in data on substance abuse treatment admissions from the Treatment 0Episode Data Set (1992–2009) to evaluate Medicaid coverage rates in Massachusetts and to identify whether trends differed between homeless and housed participants. We also compared Massachusetts data with data from 17 other states and the District of Columbia combined.Results. The percentage of both homeless and housed people entering treatment with Medicaid increased approximately 21% after expansion (P = .01), with an average increase of 5.4% per year over 12 years (P = .01). The increase in coverage was specific to Massachusetts, providing evidence that the MassHealth policy was the cause of this increase.Conclusions. Findings provide evidence in favor of state participation in the Medicaid expansion in January 2014 under the Affordable Care Act and suggest that hard-to-reach vulnerable groups such as substance-abusing homeless adults are as likely as other population groups to benefit from this policy.Implemented in 1965, Medicaid was designed as publicly funded health insurance coverage for indigent US citizens and legal permanent residents. The program is jointly funded by the state and federal governments, and states are mandated to provide coverage for children younger than 6 years whose family incomes fall below 133%, children between ages 6 and 17 years whose family incomes fall below 100%, and pregnant women whose incomes fall below 133% of the federal poverty level, as defined by the US Department of Health and Human Services1; individuals who are aged, blind, or disabled and who are eligible for Supplemental Security Income; and low-income Medicare beneficiaries. This program has provided health insurance access to a significant number of previously uninsured low-income Americans and continues to be the only route to health care coverage for many people.Nationwide, Medicaid coverage has been found to be associated with several positive outcomes. Medicaid recipients have greater access to medical treatment than uninsured individuals and, therefore, fewer emergency department visits.2–6 Medicaid enrollees have better overall health and lower mortality rates over time than uninsured persons, likely because they have increased access to treatment.7–10 As a result, their medical care is significantly less costly to society, because health problems are more likely to be addressed before the onset of complications and adverse outcomes.11Although the implementation of the Medicaid program has been a largely successful attempt to provide medical insurance, a significant number of low-income adults remain uninsured, mainly because childless adults without qualifying disabilities are ineligible.12–14 In response to this disparity, some states have developed programs to broaden eligibility criteria through a Section 1115 waiver. Massachusetts was among the first states to implement such an initiative, establishing the MassHealth program in July 1997. Among other provisions, the program extended Medicaid eligibility to families and childless adults whose incomes fell below 200% and 133% of the federal poverty level, respectively. MassHealth was jointly funded by the federal and state governments, with Massachusetts paying for roughly 46% of the program.15,16Outcome evaluations of the MassHealth program demonstrated it to be remarkably successful, with significant declines in uninsured rates, particularly among childless adults who would otherwise be ineligible for Medicaid coverage.17,18 Research by Long et al. found that the MassHealth program resulted in a 33% decrease in the rate of uninsured Massachusetts residents.19 Furthermore, Quigley et al. reported that the MassHealth program covers nearly 1 in 6 Massachusetts residents.15 Consequently, it is estimated that only 6% of adults and 3% of children in Massachusetts remained uninsured after implementation of the program.Although evaluations of MassHealth have provided strong support for the program, some evidence suggests that certain marginalized populations are less affected by Medicaid expansion policies than others.16,20 Despite meeting the income eligibility criteria, many people living in poverty remain uninsured because they don''t know they are eligible, they don''t know how to obtain coverage, or they lack any form of identification.21,22 Homeless adults are disproportionately affected by lack of insurance and are reportedly difficult to enroll in public insurance programs.23,24 Although Massachusetts developed several approaches for targeting this hard-to-reach population, evidence suggests that the effort to enroll homeless adults and keep them enrolled faces many logistical barriers.16These challenges are even greater among homeless individuals with substance use disorders. These disorders are common among homeless persons, with prevalence estimates of 40% to 60%.25,26 These individuals generally have significantly greater health care needs, for treatment of, for example, psychiatric disorders, HIV and other sexually transmitted infections, hepatitis, liver disease, lung disease, and wound and skin infections.27–30 The premature mortality rate is significantly higher for homeless individuals than for the general population,27,31 and homeless people with substance use disorders are even more disproportionately affected.31,32 Finally, substance abuse is among the strongest predictors of returning to homelessness among formerly homeless individuals.33–36 Therefore, homeless adults'' lack of the Medicaid coverage necessary to obtain treatment is a significant public health concern.Assessing the impact of MassHealth is especially important in the context of national policy initiatives. Currently, many low-income childless adults qualify for Medicaid benefits because of a physical or mental health disability, but substance abuse is not among the conditions that confer eligibility, so many substance-abusing homeless adults who do not have children are ineligible for Medicaid coverage. However, a major provision of the Affordable Care Act is that all individuals with incomes that fall at or below 133% of the federal poverty level will be eligible for Medicaid effective January 2014, irrespective of parental or disability status. Although a Supreme Court ruling in June 2012 rejected a mandate for states to expand coverage,37 it is still expected that a significant portion of individuals with substance use disorders will benefit tremendously from the law''s expanded eligibility.To date, no large-scale quantitative evaluation has attempted to determine whether marginalized population groups, such as homeless substance-abusing adults, still have difficulty obtaining coverage under the Medicaid expansion.16,20–24 Data from state programs such as MassHealth are useful in assessing whether these groups will benefit from Medicaid expansion to the same extent as other population groups or may be in need of targeted interventions to improve their access. We examined administrative data on admissions to substance abuse treatment programs from 1992 to 2009 to assess the uptake of Medicaid coverage by substance-abusing homeless adults after the implementation of MassHealth in 1997. We assessed whether homeless adults entering substance use disorder treatment programs were less likely than housed adults to be covered by Medicaid. To rule out the potential impact of secular trends in national Medicaid coverage, we compared uptake of Medicaid coverage in adults entering substance abuse programs after 1997 in Massachusetts with rates in other states.     

Exploring Migratory Dynamics on HIV Transmission: The Case of Mexicans in New York City and Puebla,Mexico

Migration and population movement are increasingly viewed as important factors associated with HIV transmission risk. With growing awareness of the potential impact of migration on HIV transmission, several perspectives have emerged that posit differing dynamics of risk. We considered available data on the role of migration on HIV transmission among Mexican migrants in New York City and Puebla, Mexico. Specifically, we examined 3 distinct models of migratory dynamics of HIV transmission—namely, the structural model, the local contextual model, and the interplay model. In doing so, we reframed current public health perspectives on the role of migration on HIV transmission.The epidemiological literature related to Latinos and HIV in the United States highlights geographic disparities in disease burden.1 HIV/AIDS cases among Latinos are clustered geographically, such that Latinos experience increased vulnerability as a function of residence in high-risk physical and geographic areas.2 Recent trends in HIV infection demonstrate that Latino mobility and migratory patterns are potentially associated with increased HIV incidence.3 As a result, several key dynamics to account for the role of migration and HIV transmission have emerged in recent literature. However, to adequately address the current HIV epidemic among Latinos, greater consideration of each of these mechanisms and enhanced attention to the role of geography and migration is warranted.4 Recent findings increasingly draw attention to the role of population mixing and movement, geography, and other physical spaces as important factors for understanding Latino HIV disparities.5 We build upon this work by examining the available empirical literature on HIV and migration in relation to the social structures and contexts in which risk behavior takes place. Specifically, we explored 3 mechanisms for the impact of migration on HIV transmission through the case of Mexican migrants in New York City (NYC) and Puebla.As the epicenter of the HIV/AIDS epidemic in the United States, NYC is one such high-risk geographic area.6 New York City has an incidence rate 3 times the national average and the highest number of AIDS cases relative to any other metropolitan city.6 Latinos in the city are disproportionately affected by the disease and are twice as likely to be diagnosed with HIV/AIDS compared with non-Hispanic Whites.7 Furthermore, although Latinos account for approximately 25% of the population in NYC, they represent 33% of NYC persons living with HIV/AIDS (PLWHA).8,9 Among NYC Latinos, HIV occurs primarily among adults through high-risk sexual behavior and intravenous drug use.10 Specifically, Latino men who have sex with men (MSM) constitute the majority of cases (40%), followed by injection drug users (27%).10 These data suggest that in NYC, Latino MSM and intravenous drug users bear the burden of HIV disease. However, a significant proportion of Latina women in NYC infected with HIV are exposed through high-risk sexual activity (67%) and represents a steady proportion of new HIV diagnoses among women in recent years.11HIV/AIDS is of particular concern among Latinos as they are more likely to experience delays in access to care, which results in adverse health outcomes. For example, Latinos, particularly Mexicans with low levels of acculturation, are less likely to obtain an HIV test.12 Those who are diagnosed often experience rapid progression to AIDS, suggesting that many Latinos are diagnosed late in their infection.6 In 2011, for example, 31% of Latinos diagnosed with HIV in NYC were concurrently diagnosed with AIDS, compared with only 15% of Whites.11 Late diagnosis puts Latinos at greater health risks because they do not receive the benefits of early antiretroviral treatment.13 In addition to late diagnosis and delayed treatment, obstacles in access to HIV treatment for Latinos include lack of a designated routine health care provider and adequate health insurance.14Increasingly, the Latino population in NYC has undergone important demographic changes.15 Specifically, migratory changes have shifted the composition of the Latino population in NYC, introducing new Latino subgroups to a geographic area of heightened HIV risk. Traditionally, the Latino population in NYC has been classified as largely stemming from the Caribbean—specifically, Puerto Rico and the Dominican Republic. However, Mexicans, whose US migration patterns have traditionally been associated with the areas of the Southwest, are increasingly moving to NYC, a nontraditional receiving community.For example, the Mexican population in NYC in 2010 was more than 5 times what it was in 1990.16 In 1990, an estimated 56 700 Mexicans were living in NYC; by 2000, this number grew to 180 000, and later to 325 000 in 2010.16 Foreign-born males with less than a high-school education represent the bulk of the Mexican population growth and a significant portion of this population attains employment in NYC.15 By 2024, it is predicted that Mexicans will be the most populous Latino ethnic subgroup in the largest city of the United States.17 One notable feature of NYC’s Mexican community is that nearly half (45%) originates from the state of Puebla in east-central Mexico, although other sources suggest far higher proportions (more than 70%).18 Data from the American Community Survey demonstrate that Mexican-born persons are geographically clustered in specific target communities, predominantly the Bronx and Queens (Figure 1).19Open in a separate windowFIGURE 1—Foreign-born from Mexico by Public Use Microdata Areas in New York City: 2006–2008.Note. PUMA = Public Use Microdata Area.Source. US Census Bureau.20     

Off-Premise Alcohol Sales Policies, Drinking, and Sexual Risk Among People Living With HIV

Drinking among HIV-positive individuals increases risks of disease progression and possibly sexual transmission. We examined whether state alcohol sales policies are associated with drinking and sexual risk among people living with HIV. In a multivariate analysis combining national survey and state policy data, we found that HIV-positive residents of states allowing liquor sales in drug and grocery stores had 70% to 88% greater odds of drinking, daily drinking, and binge drinking than did HIV-positive residents of other states. High-risk sexual activity was more prevalent in states permitting longer sales hours (7% greater odds for each additional hour). Restrictive alcohol sales policies may reduce drinking and transmission risk in HIV-positive individuals.More than 1 million people in the United States are living with HIV,¹ and about 56 000 people are newly infected each year.² Approximately one half of those who have had positive test results for HIV drink alcohol; about 1 in 6 regularly binge drinks.³ Drinking in this population is associated with poor treatment adherence,^4,5 disease progression,^6–8 and spread of the virus through risky sexual activity.^9–12Thus, reducing drinking and problem drinking among HIV-positive individuals is an important public health goal. Alcohol sales policies may be 1 tool for accomplishing this. Research has linked geographic variations in off-premise alcohol sales practices (e.g., regulations regarding the sale of alcohol in stores) to drinking and drinking problems in the general population.¹³ Other types of alcohol regulation have been linked to sexual health.^14–16 Sales policies may influence drinking and sexual activity by making purchases inconvenient or affecting where and when people drink.^17–20 We investigated (1) whether findings linking off-premise sales policies to drinking extend to those living with HIV (who have unique demographic characteristics, drinking patterns, and life circumstances) and (2) whether off-premise sales policies predict sexual risk behavior in this group.     

Association of Race,Substance Abuse,and Health Insurance Coverage With Use of Highly Active Antiretroviral Therapy Among HIV-Infected Women, 2005

Objectives. We examined racial/ethnic disparities in highly active antiretroviral therapy (HAART) use and whether differences are moderated by substance use or insurance status, using data from the Women''s Interagency HIV Study (WIHS).Methods. Logistic regression examined HAART use in a longitudinal cohort of women for whom HAART was clinically indicated in 2005 (N = 1354).Results. Approximately 3 of every 10 eligible women reported not taking HAART. African American and Hispanic women were less likely than were White women to use HAART. After we adjusted for potential confounders, the higher likelihood of not using HAART persisted for African American but not for Hispanic women. Uninsured and privately insured women, regardless of race/ethnicity, were less likely than were Medicaid enrollees to use HAART. Although alcohol use was related to HAART nonuse, illicit drug use was not.Conclusions. These findings suggest that expanding and improving insurance coverage should increase access to antiretroviral therapy across racial/ethnic groups, but it is not likely to eliminate the disparity in use of HAART between African American and White women with HIV/AIDS.The epidemic of HIV/AIDS among women reflects a convergence of medical and social policy issues—including race, substance use, and sexual behavior—that are difficult to disentangle and address. Since the introduction of highly active antiretroviral therapy (HAART) as the standard of care in 1996, mortality rates from AIDS and its complications have declined dramatically.¹ However, the decline in AIDS deaths between 1993 and 2001 occurred at a much slower rate among African American men and women than among White men and women.² One possible explanation for the slower rate of decline is differences in access to quality medical care. In addition, there is growing evidence of lower use of HAART by women of color compared with other women.³Shapiro et al.⁴ analyzed data from the HIV Cost and Services Utilization Study, the only nationally representative study of US adults receiving care for HIV infection, and reported that African Americans were less likely than were Whites with similar CD4 counts to obtain combination drug therapy in 1998, 2 years after HAART became the standard of care for HIV infection. However, in a subsequent study that also analyzed HIV Cost and Services Utilization Study data, Cunningham et al.⁵ reported that racial/ethnic identity was not associated with receipt of HAART when they used a series of nested multivariate models that adjusted for factors that had been found to explain race-associated effects in earlier analyses. In their final analytic model, only insurance coverage and CD4 count were statistically significant predictors of HAART use.At least 2 studies^3,6 have provided evidence that HIV-infected African American women are less likely than HIV-infected White women to receive HAART, and several national studies have indicated that African Americans fare worse than Whites on a number of recognized standards of HIV care.^4,5,7 The same studies have also documented significant disparities in HAART use among illicit drug users. These studies assessed the independent effects of race, illicit substance abuse, and insurance coverage on use of medical care by people with HIV/AIDS.Studies of HIV-infected women have reported mixed findings regarding the roles of race/ethnicity and substance use in receipt of HAART when insurance status is taken into account. Analyzing data from the Women''s Interagency HIV Study (WIHS), Cohen et al.³ and Cook et al.⁶ reported that women who were either African American or illicit drug users were less likely to report using HAART than were their counterparts who were White or nondrug users, respectively. However, the studies'' findings differed on how Hispanic women fared relative to White women and on the effects of insurance coverage on receipt of HAART.Although these studies have substantially contributed to understanding factors associated with receipt of HAART, considerable gaps in knowledge still exist. We investigated the hypothesis that the combination of race/ethnicity and insurance status represents a greater risk than either factor alone for nonuse of HAART and that the association is more complex than the simple “main” effects used in previous research. We believe that continuing to track patterns of HIV care and clinically indicated HAART use, in particular, is important for gauging progress in reducing disparities in care and for informing HIV treatment policies and clinical practices.     

Connecting Race and Place: A County-Level Analysis of White,Black, and Hispanic HIV Prevalence,Poverty, and Level of Urbanization

Objectives. We evaluated the role of poverty in racial/ethnic disparities in HIV prevalence across levels of urbanization.Methods. Using national HIV surveillance data from the year 2009, we constructed negative binomial models, stratified by urbanization, with an outcome of race-specific, county-level HIV prevalence rates and covariates of race/ethnicity, poverty, and other publicly available data. We estimated model-based Black–White and Hispanic–White prevalence rate ratios (PRRs) across levels of urbanization and poverty.Results. We observed racial/ethnic disparities for all strata of urbanization across 1111 included counties. Poverty was associated with HIV prevalence only in major metropolitan counties. At the same level of urbanization, Black–White and Hispanic–White PRRs were not statistically different from 1.0 at high poverty rates (Black–White PRR = 1.0, 95% confidence interval [CI] = 0.4, 2.9; Hispanic–White PRR = 0.4, 95% CI = 0.1, 1.6). In nonurban counties, racial/ethnic disparities remained after we controlled for poverty.Conclusions. The association between HIV prevalence and poverty varies by level of urbanization. HIV prevention interventions should be tailored to this understanding. Reducing racial/ethnic disparities will require multifactorial interventions linking social factors with sexual networks and individual risks.Within the United States, disparities in diagnosed HIV prevalence among the 3 major racial/ethnic groups (White, Black, and Hispanic) are striking. At the end of 2009, 43% of people living with an HIV diagnosis were Black, 35% White, and 19% Hispanic.1 Concurrently, Blacks constituted only 12% of the population, non-Hispanic Whites 65%, and Hispanics 16%.2 In the 46 states with confidential name-based HIV reporting since at least January 2007, the estimated diagnosed HIV prevalence rate at the end of 2009 was 952 per 100 000 people among Blacks (near the threshold for a generalized epidemic),1 320 per 100 000 among Hispanics, and 144 per 100 000 among Whites; compared with Whites, therefore, Blacks and Hispanics were respectively 6.6 times and 2.2 times more likely to be living with an HIV diagnosis.A number of mechanisms, primarily structural and social factors, have been proposed to explain these stark racial/ethnic disparities in HIV prevalence.3,4 Structural factors, such as oppression and mistrust in government, may hinder receptivity to prevention outreach and increase HIV prevalence.3 Social constructs (e.g., homophobia and HIV stigma) may discourage open discussion of risk behaviors and limit HIV testing and treatment. Additionally, limited access to health care resources has been identified as a key driver of racial/ethnic health disparities.5 Finally, Black men are more likely than White men to be both incarcerated and infected with HIV while incarcerated.6,7 All of these factors are, in turn, associated with poverty.8 However, specific relationships among these multiple factors and racial/ethnic HIV prevalence disparities, and variation of these relationships across levels of urbanization, are not well understood.Previous analyses of national surveillance and survey data in the United States have focused on associations between HIV prevalence rates, poverty, and race exclusively in urban areas, finding no disparities in poverty-adjusted HIV prevalence rates among heterosexuals in urban settings.9,10 Furthermore, among heterosexuals living in US urban areas with high AIDS prevalence, HIV prevalence rates among those living at or below the poverty line were 2.2 times as high as rates among those living above the poverty line.10 A more recent analysis of US surveillance data confirmed the complex associations between demographics, social determinants of health, and AIDS diagnosis rates.8However, variation in these factors across the urban–rural continuum may limit generalizability of these findings to nonurban settings, where similar research is lacking. In 2009, the proportions of Black and Hispanic Americans living in poverty were roughly twice that of White Americans.11 For all races/ethnicities, the proportion living in poverty is greater in rural areas than in urban areas.12 Additionally, rural areas, with lower HIV prevalence, are more likely to be medically underserved, with reduced access to HIV care and treatment.13In the context of these complex sociodemographic associations, previously observed associations in the United States between poverty and racial/ethnic disparities in HIV may differ outside of urban areas. Therefore, using publicly available county-level data, we first describe the association between poverty and HIV prevalence by race/ethnicity across levels of urbanization. We subsequently examine racial/ethnic disparities in HIV prevalence across levels of urbanization, after controlling for poverty. We hypothesized that, in all strata of urbanization, poverty-adjusted Black–White and Hispanic–White HIV prevalence rate ratios (PRRs) would statistically differ from 1.0.     

Risks of Recreational Exposure to Waterborne Pathogens Among Persons With HIV/AIDS in Baltimore, Maryland

Objectives. We assessed the prevalence of recreational activities in the waterways of Baltimore, MD, and the risk of exposure to Cryptosporidium among persons with HIV/AIDS.Methods. We studied patients at the Johns Hopkins Moore Outpatient AIDS Clinic. We conducted oral interviews with a convenience sample of 157 HIV/AIDS patients to ascertain the sites used for recreational water contact within Baltimore waters and assess risk behaviors.Results. Approximately 48% of respondents reported participating in recreational water activities (fishing, crabbing, boating, and swimming). Men and women were almost equally likely to engage in recreational water activities (53.3% versus 51.3%). Approximately 67% (105 of 157) ate their own catch or that of friends or family members, and a majority (61%, or 46 of 75) of respondents who reported recreational water contact reported consumption of their own catch.Conclusions. Baltimoreans with HIV/AIDS are engaging in recreational water activities in urban waters that may expose them to waterborne pathogens and recreational water illnesses. Susceptible persons, such as patients with HIV/AIDS, should be cautioned regarding potential microbial risks from recreational water contact with surface waters.Persons with HIV/AIDS are at high risk for increased morbidity and mortality associated with a range of opportunistic infections, some of which are caused by Cryptosporidium. Cryptosporidium species are of particular public health and medical importance because they are prevalent in surface waters of the United States,^1–7 are efficiently transmitted via water,⁸ and can be consumed in foods contaminated by fecal matter.^9–11 Exposures to Cryptosporidium are common in the US population,¹² and past studies have demonstrated that Cryptosporidium infections significantly contribute to illness and mortality in persons with HIV/AIDS.^13–15 In the 1980s, Cryptosporidium was identified as a major opportunistic pathogen.^16–21 Infection continues to be frequently diagnosed in persons with HIV/AIDS.^22–27 Before the advent of highly active antiretroviral therapy, Cryptosporidium was a relatively common opportunistic infection even in developed countries.^28,29Cryptosporidiosis manifests as an acute gastroenteritis, accompanied by cramps, anorexia, vomiting, abdominal pains, fever, and chills²⁹ and by histological presentation of gastrointestinal mucosal injury.^30,31 Persons with AIDS who become infected with this parasite are at increased risk of developing chronic and often life-threatening diarrhea, biliary tract diseases, pancreatitis, colitis, and chronic asymptomatic infection and recurrence. These developments are especially likely in those who are severely immunosuppressed (CD4 counts < 150 cells/mL).^29,32–35 Infection is diagnosed by the presence of oocysts in unpreserved or preserved stools.³⁶ Histological and ultrastructural examination of biopsy material for different Cryptosporidium life stages, detection of Cryptosporidium DNA and antigens, and identification of species through molecular techniques can also aid in diagnosis.^36–38Cryptosporidium species are enteric protozoan organisms and are prevalent in US watersheds, especially in urban waters.^1,6,39 These parasites have natural hosts in domestic and wild animals such as cattle (especially newborn calves), horses, fish, and birds.^5,40–42 These parasites cause cryptosporidiosis by infecting and damaging the cells of the small intestine and other organs.^13,41 For persons with HIV/AIDS, increased risk for infection by Cryptosporidium has been related to sexual practices such as engaging in sexual intercourse within the past 2 years, having multiple partners during that time, and engaging in anal intercourse.⁴³ Use of spas and saunas has also been identified as a risk factor.⁴³In the United States, Cryptosporidium is the most commonly identified pathogen in cases of recreationally acquired gastroenteritis⁴⁴; the majority of those affected are children. Increased risk of cryptosporidiosis in persons with HIV/AIDS has been associated with swimming.^45,46 US residents make an estimated 360 million annual visits to recreational water venues such as swimming pools, spas, and lakes; swimming is the second most popular physical activity in the country and the most popular among children.⁴⁷Recreational swimming, even in highly chlorinated water, carries a high risk of exposure to enteric pathogens, including Cryptosporidium, Norovirus, Shigella, Escherichia coli, and Giardia.⁴⁸ Cryptosporidiosis and some other enteric illnesses are seasonal, with spikes in occurrence in the summer months from contact with recreational water venues.⁴⁹ Extreme precipitation⁵⁰ and high ambient temperatures⁵¹ can also affect patterns of disease outbreaks. Because not all infections with Cryptosporidium lead to apparent illness or symptoms, infected persons may unknowingly transmit these pathogens to others, such as household members and other recreationists.^12,52 Cryptosporidiosis from swimming, wading, and splashing is prevalent in the United States.^44,46,53,54Risks from the presence of pathogens in waterways include (1) waterborne gastroenteritis and other recreational water illnesses in anglers and other recreationists^44,55–59; (2) transmission of pathogens to humans from caught seafood acting as fomites, or surface carriers⁶⁰; (3) food-borne gastroenteritis from consumption of raw or improperly cooked fish and shellfish^61,62; and (4) hand-to-mouth transmission of pathogens while eating, drinking, or smoking during activities such as fishing and crabbing.⁷Recreational water activities in the Baltimore, Maryland, area take place in Jones Falls and Baltimore Harbor. These and other waterways are used for angling, crabbing, swimming, kayaking, and boating (including paddle boating).^7,63 In addition, Baltimore-area residents often catch and consume fish and crabs from the Baltimore Harbor and local waterways, many of which are already highly contaminated by persistent chemicals such as mercury and polychlorinated biphenyls.⁶⁴ These activities are known to increase risks of exposure to waterborne pathogens through direct contact with contaminated waters or through contact with or handling and consumption of caught seafood (fish, crabs, oysters).^7,65,66To investigate the potential contribution of recreational water contact to Cryptosporidium exposures among persons with HIV/AIDS, we carried out a cross-sectional study at the Johns Hopkins Moore Outpatient AIDS Clinic. The Baltimore metropolitan area has a high prevalence rate of HIV/AIDS among both men and women,⁶⁷ and its population makes intensive recreational use of a contaminated watershed. In addition, laboratory experiments have indicated that crabs can become superficially contaminated by Cryptosporidium and transfer the pathogen to hands.⁶⁸ Local anglers are at risk from Cryptosporidium on wild-caught fish.⁷Our objective was to address the risks of exposure to Cryptosporidium for an urban subpopulation, persons with HIV/AIDS, as a result of recreational contact with Baltimore waterways. We also assessed the patterns and locations of recreational water activities in Baltimore waters.     

Integrated behavioral intervention to improve HIV/AIDS treatment adherence and reduce HIV transmission

Objectives. We conducted a randomized clinical trial to test an integrated behavioral intervention designed to enhance using HIV treatment as prevention by improving medication adherence, reducing risks for other sexually transmitted infections, and minimizing risk compensation beliefs.Methods. Individuals living with HIV/AIDS (n = 436) participated in a randomized clinical trial testing an intensive behavioral intervention aimed at reducing HIV transmission risks compared with an attention control condition. We used unannounced pill counts to monitor antiretroviral therapy adherence and computerized interviews to measure risk behaviors.Results. The integrated transmission risk reduction intervention demonstrated increased antiretroviral therapy adherence and less unprotected intercourse with nonseroconcordant partners at 3- and 6-month follow-ups as well as fewer new sexually transmitted infections diagnosed over the 9-month follow-up period (adjusted odds ratio = 3.0; P < .05; 95% confidence interval = 1.01, 9.04). The integrated intervention also reduced behavioral risk compensation beliefs.Conclusions. A theory-based integrated behavioral intervention can improve HIV treatment adherence and reduce HIV transmission risks. HIV treatment as prevention should be bundled with behavioral interventions to maximize effectiveness.Antiretroviral therapy (ART) improves the health and increases the longevity of people infected with HIV.¹ Growing evidence indicates that ART can also reduce HIV infectiousness, raising the possibility of using HIV treatment as prevention.^2–3 Mathematical models suggest that HIV testing with immediate treatment may have a substantial preventative effect in high HIV prevalence populations.^4–6 The potential preventative benefits of treating HIV infection are shifting prevention policies. Most notably, the Swiss Federal AIDS Commission has stated that repeated undetectable HIV RNA (viral load) tests can render individuals noninfectious.^7–9 Although biologically and epidemiologically plausible,^10,11 using HIV treatment as prevention will fail when medication adherence is poor and when there are co-occurring sexually transmitted infections (STIs).Most ART regimens demonstrate suppressive effects in the genital tract that are similar to those in blood plasma,¹² and the genital tract suffers similar detrimental ramifications of ART nonadherence.¹³ The most forgiving ART regimens require at least 85% adherence to suppress HIV replication, avoid treatment-resistant variants of the virus, and reduce infectiousness.^14–16 Evidence also shows that individuals who experience difficulty adhering to ART engage in higher-risk sexual behaviors.¹⁷ Even under optimal adherence, persons with undetectable peripheral blood viral loads will be highly infectious in their genital secretions when they have co-occurring STIs.¹⁸Co-occurring STIs are prevalent among people living with HIV/AIDS^19,20 and cause HIV shedding in genital fluids.²¹ Individuals who are coinfected with HIV and other STIs are therefore far more infectious than their blood plasma viral load indicates. The poor concordance between blood plasma and semen HIV RNA is at least in part the result of inflammatory processes caused by co-occurring STIs.²² The interplay between treatment, viral load, and sexual transmission is further complicated by risk compensation; individuals who believe they are less infectious take fewer precautions against infecting partners.^23–26To succeed, the use of HIV treatment as prevention, or so-called test and treat strategies, will require a comprehensive approach that encompasses adherence support, sexual risk reduction, and the amelioration of risk compensation.²⁷ HIV transmission risk reduction interventions for people infected with HIV have thus far focused exclusively on reducing unprotected sex with non-HIV–positive partners.²⁸ Similarly, ART adherence interventions have not directly addressed HIV transmission risks. One example of an intervention that addressed treatment adherence and transmission risk reduction was the Healthy Living Project.^29–30 In a multisite trial, the Healthy Living Project targeted mental health, treatment adherence, and risk behaviors in separate intervention modules delivered several weeks apart. The investigators of the Healthy Living Project examined the 3 modules independently in separate analyses. The Healthy Living Project medication module demonstrated significant increased treatment adherence,²⁸ and the prevention module resulted in significant reductions in HIV transmission risk behaviors.²⁹ Unfortunately, the Healthy Living Project did not test the synergistic effects of the adherence and risk reduction modules. We are not aware of any unified behavioral intervention that has attempted to simultaneously reduce HIV infectiousness by improving treatment adherence and reducing HIV exposures. We sought to fill this gap by testing an integrated adherence and risk-reduction intervention designed for use in conjunction with HIV treatment as prevention.The aim of this clinical trial was to test the effects of a theory-based integrated behavioral intervention for reducing HIV transmission risks in individuals living with HIV/AIDS. Our primary hypothesis was that an integrated intervention approach would improve treatment adherence and reduce risk behaviors relative to a matched-contact control intervention. The secondary hypothesis was that the integrated intervention would reduce risk compensation beliefs concerning undetectable HIV RNA.     

Rethinking HIV/AID Disclosure Among Women Within the Context of Motherhood in South Africa

This qualitative study explored whether motherhood plays a role in influencing decisions to conceal or reveal knowledge of seropositive status among women living with HIV/AIDS in 2 South African communities: Gugulethu and Mitchell''s Plain. Using the PEN-3 cultural model, we explored how HIV-positive women disclose their status to their mothers and how HIV-positive mothers make decisions about disclosure of their seropositive status. Our findings revealed 3 themes: the positive consequences of disclosing to mothers, how being a mother influences disclosure (existential role of motherhood), and the cost of disclosing to mothers (negative consequences). The findings highlight the importance of motherhood in shaping decisions to reveal or conceal knowledge of seropositive status. Implications for interventions on HIV/AIDS prevention, care, and support are discussed.The literature on the experiences and factors that influence disclosure of HIV seropositive status among women in many developed countries is quite extensive.^1–9 However, in sub-Saharan African countries like South Africa where the prevalence of HIV remains high,¹⁰ there is scant evidence on the disclosure experiences of women. Inevitably, the available evidence fails to explore the broader contextual factors that influence women''s decisions to conceal or reveal their seropositive status. For example, Makin et al.¹¹ explored individual factors that influence disclosure among pregnant women in South Africa, but it remains unclear whether collective contexts such as mother–daughter relationships or aspects of motherhood (i.e., the desire to nurture and protect children, and so on) play a critical role in influencing women''s decisions to disclose. A better understanding of factors such as the concept of motherhood is essential to understanding how women disclose and cope with living with their seropositive status. Moreover, such insights could help advance and focus public health intervention efforts to reduce HIV- and AIDS-related stigma and discrimination, prevent new HIV infections, promote effective care, and support strategies for mothers and women living with HIV and AIDS.The discourse on notions of motherhood in sub-Saharan Africa in general and in South Africa in particular has long been a subject of interest to many researchers over the decades. Previous studies have described motherhood as a form of collective identity, the analysis of which is useful in understanding not only the critical role the mother plays in a child''s welfare but also the roles and expectations of being mothers.^12–15 Two aspects of motherhood are examined in this study. First, what is most unstated about motherhood is that it is a lifelong commitment—one remains a child to one''s mother regardless of one''s age.^13,16 Mothers play a crucial role not only as birth givers but also as life givers, as one needs one''s mother at every turn in life.¹³ Second, as Magwaza noted, “mothering is not only about children but also the mothers who are involved in the actual practice.”^17(p14) Because child care is often the sole responsibility of mothers, there is a generally held view that all mothers are expected to provide emotional care and support for their children. However, in some cases it is not uncommon to have “contradictions between what societies expect of mothers and what mothers themselves do”^17(p14) (as in the case of mothers abusing their children).Kruger noted that the discourse on motherhood is much more complex than simply describing “mothering practices as either fulfilling/successful or difficult/problematic.”^18(p196) Instead, it is important to note that the act of mothering may entail different meanings to different women and that these meanings are often influenced by the historical, sociocultural, and economic contexts of the women who are doing the mothering.¹⁸ In the context of HIV and AIDS disclosure, it is imperative to understand these different meanings of motherhood (particularly as women living with HIV and AIDS try to decide whether to reveal or conceal their seropositive status) as well as issues related to emotional care, support, stigma, and discrimination.In South Africa, the discourse on motherhood cannot be separated from the history of institutional discrimination that occurred within South Africa, particularly during apartheid. The apartheid era was a critical period in South Africa that led to forced removals and dislocations of families and communities and also weakened families’ capacities to care for their family members.^17,19 Apartheid, alongside various interrelated racial, ethnic, historical, political, and socioeconomic circumstances, also influenced the nature and characteristics of mothering practices in South Africa.^17,19–21Although it is important to take ethnic differences (such as being African, Indian, or Colored) into account when contextualizing motherhood in South Africa, there is minimal evidence on how mothering practices differ across ethnicities. The existing literature highlights similarities in mothering practices between ethnicities as related to nurturing and providing care for family members. For example, Magwaza¹⁷ noted that among African mothers, informal adoptions were on the rise. Much of the task of providing basic needs such as education, food, and clothing to relatives were carried out by these mothers, “who did not consider themselves as mothers to their biological children only.”^17(p7) Field has argued that Colored mothers are viewed “not only as the maternal head of the family, but also the moral authority of the family,”^21(p64) noting that even in male-headed households, these mothers often assume the central role of disciplining, teaching, and nurturing the children. Colored mothers are expected to teach their children ideals related to preserving the dignity of their households.The significance of mothers as nurturers as well as symbols of moral authority and dignity²¹ within families has particular relevance in the context of the HIV and AIDS epidemic in South Africa, as young women now account for about 90% of new HIV infections.^22,23 Given the burden of HIV and AIDS alongside the legacy of apartheid, it is possible that the combination of these factors may affect traditional and societal expectations of mothering practices in South Africa, particularly in the context of disclosing seropositive status.We expand the current literature on disclosure of HIV/AIDS status among women in South Africa by exploring whether motherhood plays a role in influencing decisions to conceal or reveal knowledge of seropositive status. In particular, we explored how HIV-positive women disclose their status to their mothers and how HIV-positive mothers make decisions about disclosure of their seropositive status. Because motherhood in general occupies an important focus around which individual and collective identities are structured,¹³ we suggest that it can provide an anchor on which people living with HIV and AIDS can gain emotional care, support, and acceptance as well as buffer the negative factors associated with HIV and AIDS infection, such as stigma and discrimination. We also argue that the critical but often obscure position of mothers can serve as a useful guide for exploring the factors that influence decisions on disclosure of seropositive status. Given that issues surrounding HIV and AIDS disclosure are central to notions of identity, expectations, and belongingness, we explored the context of motherhood within disclosure of HIV and AIDS status using the PEN-3 cultural model developed by Airhihenbuwa.^12,24,25     

Childbearing Intentions of HIV-Positive Women of Reproductive Age in Soweto,South Africa: The Influence of Expanding Access to HAART in an HIV Hyperendemic Setting

Objectives. We investigated whether the intention to have children varied according to HIV status and use of highly active antiretroviral therapy (HAART) among women in Soweto, South Africa.Methods. We used survey data from 674 women aged 18 to 44 years recruited from the Perinatal HIV Research Unit in Soweto (May through December 2007); 217 were HIV-positive HAART users (median duration of use = 31 months; interquartile range = 28, 33), 215 were HIV-positive and HAART–naive, and 242 were HIV negative. Logistic regression models examined associations between HIV status, HAART use, and intention to have children.Results. Overall, 44% of women reported intent to have children, with significant variation by HIV status: 31% of HAART users, 29% of HAART-naive women, and 68% of HIV-negative women (P < .001). In adjusted models, HIV-positive women were nearly 60% less likely to report childbearing intentions compared with HIV-negative women (for HAART users, adjusted odds ratio [AOR] = 0.40; 95% confidence interval [CI] = 0.23, 0.69; for HAART-naive women, AOR = 0.35; 95% CI = 0.21, 0.60), with minimal differences according to use or duration of HAART.Conclusions. Integrated HIV, HAART, and reproductive health services must be provided to support the rights of all women to safely achieve their fertility goals.In sub-Saharan Africa, women of childbearing age comprise 61% of people living with HIV, accounting for over 12 million women.¹ In many regions, HIV incidence is increasing most dramatically among young women aged 18 to 30 years,^1,2 which coincides with their peak reproductive years.³ Globally, a plethora of evidence indicates that many women living with HIV continue to desire children,^4–8 become pregnant,^5,6,9 and give birth^5,6,10 after knowing their HIV-positive status.Childbearing decision making can be complex regardless of HIV seropositivity¹¹; among HIV-infected women, however, reproduction introduces additional personal, public health, and clinical care issues.¹² The vast majority of conceptions occur without the use of reproductive technologies such as sperm washing and artificial insemination.¹³ Thus, the unprotected sexual activity required for conception carries a risk of HIV transmission to uninfected sexual partners.¹⁴ Reproduction among HIV-positive women also carries a risk of vertical transmission during pregnancy and labor and through breastfeeding.^15,16 Moreover, HIV-positive women have a lower life expectancy than HIV-negative women,¹⁷ increasing the risk of maternal orphanhood.¹⁸ In light of these concerns, early reproductive guidelines for people living with HIV were dissuasive,¹⁹ and HIV-positive women who express a desire to have children continue to encounter the disapproval of the community and of health care workers.^4,20Nonetheless, although the potential health risks may have dampened the fertility intentions of some HIV-positive women, stigma associated with childlessness in many societies²¹ and the strong personal desires for biological parenthood⁴ remain potent drivers of childbearing intentions, despite an HIV-positive status. Indeed, in some cultural contexts, remaining childless can be a violation of societal norms more stigmatizing than the HIV infection itself.^4,22Expanding access to highly active antiretroviral therapy (HAART) is changing the landscape of childbearing decision making for people living with HIV.²³ HAART increases life expectancy,^24–26 decreases morbidity,^25,27 and dramatically reduces the risks of vertical²⁸ and horizontal^29,30 transmission. In this era of expanding access to HAART, the significant reduction in health risks and barriers to reproduction among people living with HIV has coincided with increased calls for a rights- and evidenced-based approach to reproduction.^31,32 Since childbearing intentions are among the strongest predictors of eventual childbearing,³³ creating effective and responsive sexual and reproductive health services for HIV-positive women in the context of expanding access to HAART requires a clear understanding of expressed childbearing intentions.Existing evidence concerning the influence of expanding access to HAART on childbearing intentions is largely incomplete. Although recent regional studies have shown that HAART use is associated with higher childbearing intentions, these studies neglected to consider the duration of HAART use^6,7 and tended only to compare the childbearing intentions of HIV-positive women without conducting a comparison with HIV-negative women from the same community.^6–8 Moreover, the lack of an HIV-negative control group precludes the opportunity to assess whether HAART users begin to resemble HIV-negative women in their childbearing intentions, particularly as HIV is increasingly recognized as a manageable chronic disease.Given the high HIV prevalence among women of reproductive age in Soweto, South Africa,¹ we aimed to assess the prevalence of childbearing intentions and to determine whether they varied according to HIV status and HAART use among women. We hypothesized that HIV-positive women would have lower childbearing intentions than would HIV-negative women. In addition, we hypothesized that HIV-positive women receiving HAART would have higher childbearing intentions than would HIV-positive HAART-naive women, with increasing duration of HAART treatment associated with incrementally higher childbearing intentions. Overall, we hypothesized that HAART use would narrow the measurable differences in childbearing intentions between HIV-positive and HIV-negative women.²³