Late HIV Diagnosis and Determinants of Progression to AIDS or Death after HIV Diagnosis among Injection Drug Users, 33 US States, 1996–2004

BACKGROUND: The timeliness of HIV diagnosis and the initiation of antiretroviral treatment are major determinants of survival for HIV-infected people. Injection drug users (IDUs) are less likely than persons in other transmission categories to seek early HIV counseling, testing, and treatment. Our objective was to estimate the proportion of IDUs with a late HIV diagnosis (AIDS diagnosis within 12 months of HIV diagnosis) and determine the factors associated with disease progression after HIV diagnosis. METHODOLOGY/PRINCIPAL FINDINGS: Using data from 33 states with confidential name-based HIV reporting, we determined the proportion of IDUs aged >or=13 years who received a late HIV diagnosis during 1996-2004. We used standardized Kaplan-Meier survival methods to determine differences in time of progression from HIV to AIDS and death, by race/ethnicity, sex, age group, CD4(+) T-cell count, metropolitan residence, and diagnosis year. We compared the survival of IDUs with the survival of persons in other transmission categories. During 1996-2004, 42.2% (11,635) of 27,572 IDUs were diagnosed late. For IDUs, the risk for progression from HIV to AIDS 3 years after HIV diagnosis was greater for nonwhites, males and older persons. Three-year survival after HIV diagnosis was lower for IDU males (87.3%, 95% confidence interval (CI), 87.1-87.4) compared with males exposed through male-to-male sexual contact (91.6%, 95% CI, 91.6-91.7) and males exposed through high-risk heterosexual contact (HRHC) (91.9%, 95% CI, 91.8-91.9). Survival was also lower for IDU females (89.5%, 95% CI, 89.4-89.6) compared to HRHC females (93.3%, 95% CI, 93.3-93.4). CONCLUSIONS/SIGNIFICANCE: A substantial proportion of IDUs living with HIV received their HIV diagnosis late. To improve survival of IDUs, HIV prevention efforts must ensure early access to HIV testing and care, as well as encourage adherence to antiretroviral treatment to slow disease progression

Limited Awareness and Low Immediate Uptake of Pre-Exposure Prophylaxis among Men Who Have Sex with Men Using an Internet Social Networking Site

Background: In 2010, the iPrEx trial demonstrated that oral antiretroviral pre-exposure prophylaxis (PrEP) reduced the risk of HIV acquisition among high-risk men who have sex with men (MSM). The impact of iPrEx on PrEP knowledge and actual use among at-risk MSM is unknown. Online surveys were conducted to assess PrEP awareness, interest and experience among at-risk MSM before and after iPrEx, and to determine demographic and behavioral factors associated with these measures. Methods and Findings: Cross-sectional, national, internet-based surveys were administered to U.S. based members of the most popular American MSM social networking site 2 months before (n = 398) and 1 month after (n = 4 558) publication of iPrEx results. Comparisons were made between these samples with regards to PrEP knowledge, interest, and experience. Data were collected on demographics, sexual risk, and experience with post-exposure prophylaxis (PEP). Regression analyses were performed to identify factors associated with PrEP awareness, interest, and experience post-iPrEx. Most participants were white, educated, and indicated high-risk sexual behaviors. Awareness of PrEP was limited pre- and post-iPrEx (13% vs. 19%), whereas interest levels after being provided with a description of PrEP remained high (76% vs. 79%). PrEP use remained uncommon (0.7% vs. 0.9%). PrEP use was associated with PEP awareness (OR 7.46; CI 1.52–36.6) and PEP experience (OR 34.2; CI 13.3–88.4). PrEP interest was associated with older age (OR 1.01; CI 1.00–1.02), unprotected anal intercourse with ≥1 male partner in the prior 3 months (OR 1.40; CI 1.10–1.77), and perceiving oneself at increased risk for HIV acquisition (OR 1.20; CI 1.13–1.27). Conclusions: Among MSM engaged in online networking, awareness of PrEP was limited 1 month after the iPrEx data were released. Utilization was low, although some MSM who reported high-risk behaviors were interested in using PrEP. Studies are needed to understand barriers to PrEP utilization by at-risk MSM

A Qualitative Examination of the Indirect Effects of Modified Directly Observed Therapy on Health Behaviors Other Than Adherence

Modified directly observed therapy (mDOT), in which a portion of doses in a medication regimen are ingested under supervision, has had some demonstrated success in improving the high levels of adherence necessary to achieve maximum benefit from antiretroviral medications. Consistent with the Information-Motivation-Behavioral skills (IMB) model, mDOT's success is likely due to its direct impact on patients' knowledge, motivation, and behaviors related to adherence. However, mDOT's potential impact on patients' information, motivation, and behaviors related to health activities other than adherence to antiretroviral medications has not been explored. Data from participants enrolled in Project MOTIV8, a randomized controlled trial to test the efficacy of novel behavioral adherence interventions, were analyzed to explore the potential impact of mDOT on health behaviors other than adherence. Participants were recruited from local HIV clinics from 2004–2008. Thirty-four percent of those approached, agreed to participate in the study. Data from all participants randomized to the mDOT intervention arm thus far (n = 50, mean age 39.7 standard deviation [SD] = 9.0, 78% male 64% African American, and 86% infected via sexual transmission) were included. Overall, participants reported a high level of satisfaction with the mDOT intervention. Qualitative data revealed that mDOT had a positive impact on participants' adherence to nonantiretroviral medications as well as their involvement and communication with health care providers. In addition, participants reported that the daily mDOT visits had indirect effects on their daily functioning, including improvements in their daily living activities (e.g., earlier awakenings, getting dressed, and cleaning their homes) and an increased level of community involvement

Exploring strategies for PrEP adherence and dosing preferences in the context of sexualized recreational drug use among MSM: a qualitative study.

The use of recreational drugs while having sex is associated with increased HIV incidence among men who have sex with men (MSM). Taking a daily antiretroviral pill, or pre-exposure prophylaxis (PrEP) is a biomedical intervention to prevent HIV. However, the efficacy of PrEP is closely tied with high levels of adherence. While PrEP has the potential to reduce HIV acquisition, the use of recreational drugs may impede adherence. We explored perceptions of PrEP utilization and regimen preferences among 40 HIV-negative, MSM who reported concurrent recreational drug use and condomless anal sex with a man. Semi-structured qualitative interviews were conducted and the data were analyzed using a qualitative descriptive approach. Participants perceived that it would be challenging to take PrEP while high on crystal meth, crack, powder cocaine, ecstasy and/or GHB. However, men identified strategies for using PrEP when they were not high on these drugs, including taking the pill when they started their day and integrating PrEP into an established routine, such as when taking other medications or preparing for sex. PrEP regimen preferences seemed to be shaped by the frequency in which participants used drugs and their ability to plan for sex. Taking PrEP everyday was appealing for those who regularly engaged in sexualized recreational drug use. Accounts depict these sexual interactions as frequent but unpredictable. A daily regimen would allow them to be prepared for sex without having to plan. An event-driven regimen was acceptable to men who occasionally used recreational drugs in the context of sex. For this group, sex usually occurred was generally prearranged. Patterns of sex and recreational drug use figured largely into participants' framings of how they would use PrEP. These behaviors will likely play a role in the uptake of and adherence to PrEP among this population