Spillover effects of HIV testing policies: changes in HIV testing guidelines and HCV testing practices in drug treatment programs in the United States

Background: To examine the extent to which state adoption of the Centers for Disease Control and Prevention (CDC) 2006 revisions to adult and adolescent HIV testing guidelines is associated with availability of other important prevention and medical services. We hypothesized that in states where the pretest counseling requirement for HIV testing was dropped from state legislation, substance use disorder treatment programs would have higher availability of HCV testing services than in states that had maintained this requirement. Methods: We analyzed a nationally representative sample of 383 opioid treatment programs from the 2005 and 2011 National Drug Abuse Treatment System Survey (NDATSS). Data were collected from program directors and clinical supervisors through telephone surveys. Multivariate logistic regression models were used to measure associations between state adoption of CDC recommended guidelines for HIV pretest counseling and availability of HCV testing services. Results: The effects of HIV testing legislative changes on HCV testing practices varied by type of opioid treatment program. In states that had removed the requirement for HIV pretest counseling, buprenorphine-only programs were more likely to offer HCV testing to their patients. The positive spillover effect of HIV pretest counseling policies, however, did not extend to methadone programs and did not translate into increased availability of on-site HCV testing in either program type. Conclusions: Our findings highlight potential positive spillover effects of HIV testing policies on HCV testing practices. They also suggest that maximizing the benefits of HIV policies may require other initiatives, including resources and programmatic efforts that support systematic integration with other services and effective implementation

Primary Care Use among HIV Positive Inpatients at an Inner City Public Hospital: The Impact of Crack Cocaine Use

We studied factors associated with HIV care utilization in symptomatic HIV-positive crack-using and non-using patients at a public hospital in Miami, Florida. A bedside survey conducted with 89 HIV-positive crack-users and 93 HIV-positive non-users examined health care knowledge, perceived health status, drug use, and HIV care patterns. A multi-nominal model was utilized to calculate the adjusted odds ratio (AOR) of three levels of care: currently receiving care (having seen an HIV provider in the past 4 months), having dropped out of care (having seen an HIV provider at least once but not in the past 4 months), and never having seen an HIV provider. Crack use and homelessness were associated with having dropped out of care. Better knowledge of HIV, living with HIV for a longer time, and being employed were associated with currently being in care. Attention to socioeconomic factors and substance abuse rehabilitation is needed to improve treatment outcomes

Sexual Risk, Substance Use and Undiagnosed Seropositivity among Men Who Have Sex with Men and Women in Miami, Florida

This paper utilizes the National HIV Behavioral Surveillance data in Miami for the men who have sex with men cycle (NHBS-MSM2) in 2008. We analyzed sexual risk, substance use and undiagnosed seropositivity in a diverse sample of men who have sex with men and women (MSMW) and compared them with MSM. Of 152 MSMW, 15.1% tested HIV positive with 73.9% previously undiagnosed. Almost half (44.1%) of the MSMW reported unprotected sex with male and female partners in the past year. More MSMW than MSM had undiagnosed HIV infection, exchanged sex for money or drugs, used crack and cocaine, been high during sex, and had not received HIV treatment if HIV positive. Undiagnosed HIV infection among MSMW was associated with Black race, older age, non-alcohol use and Ecstasy use. Our findings indicate that MSMW represent a unique population at risk of acquiring and transmitting HIV in Miami

Trends in the HIV Epidemic among Men Who Have Sex with Men in Miami-Dade County, Florida, 2004-2014

Miami, Florida has a large population of Hispanic and black men who have sex with men (MSM), a population more likely to become HIV infected than white MSM. We present here HIV behavioral trends in this population that reflect the effects of public health prevention in Miami over a 10-year period. Using National HIV Behavioral Surveillance (NHBS) data of MSM in Miami-Dade County, Florida, in 2004-05, 2008, 2011 and 2014, chi-square trend analyses were used to assess the epidemiologic trends related to HIV infection rates, HIV testing rates, undiagnosed HIV infection, use antiretroviral therapy (ART) and access to HIV care. Of 258, 527, 511, and 536 MSM, HIV rates have remained steady between 22.5% (95% CI 17.4-27.6) in 2004-05 to a high of 25.9% (95% CI 22.2-29.6) in MSM4 in 2014, with no significant trend. There was an increase in HIV testing in the past six months between 2004 (48.4%;95% CI 41.8-55.0) and 2014 (55.8;95% CI 51.3-60.3), p \u3c .001; and a decrease in unrecognized HIV infection from 48.3% (95% CI 35.4- 61.2) in 2004 to 31.4% (95% CI 23.7-39.1) in 2014, p = .004, over the same period. Being currently on ART and knowledge of pre-exposure prophylaxis (PrEP) also increased significantly during this 10-year period. HIV surveillance is providing valuable information, notably, as HIV testing rates have gone up unrecognized infections have decreased. Continued use of the NHBS system should provide insights into the epidemic and assist in reaching public health goals for the control of HIV infections

The HIV/AIDS Epidemic in Miami: Perspectives of Stakeholders and Frontline Providers

Background: Miami, Florida persists as an epicenter of HIV/AIDS nationally and has been more delayed than other areas with high HIV burden in implementing public health measures that mitigate transmission risk. These issues among other social and structural-level determinants have complicated progress in addressing HIV/AIDS in Miami. Purpose: The stagnated progress in improving HIV outcomes in Miami necessitated a more comprehensive understanding of the experiences and insights of stakeholders within the system. We used a stakeholder analysis approach to understand the complexity of driving factors and key challenges facing this HIV epidemic. Methods: A stakeholder analysis was conducted through 11 focus groups (64 participants) with front line workers working in non-profit, community-based agencies in Miami. The interview guide was designed to elicit a broad discussion on the social and intermediary determinants of HIV/AIDS, as well as the context surrounding barriers to treatment. Data were analyzed using qualitative software for thematic analysis. Results: Participants highlighted particular populations vulnerable to HIV/AIDS and insufficiently engaged in treatment, including immigrants and people who use drugs. Stigma surrounding HIV/AIDS as well as sexual orientation, mental health, and drug use was a noted persisting barrier. Participants expressed needs for more targeted outreach and education for both prevention and treatment. Numerous systemic gaps were identified as barriers to treatment engagement and retention. Other comorbidities and socioeconomic challenges, including criminal justice histories, housing instability and low educational attainment, also hamper HIV/AIDS management. Discussion: Through these discussions with stakeholders representing a diversity of voices, findings can inform comprehensive and coordinated strategies for curbing the HIV/AIDS epidemic in Miami. The development of prevention and treatment interventions should consider cultural contexts of health behaviors, multi-level stigma related to HIV/AIDS and other comorbid and socioeconomic challenges, and increased implementation of harm reduction programs such as PrEP delivery and syringe exchange programs

Heroin Use and Sex: Some Patterns in Miami-Dade County, Florida

Much of the literature on heroin and opioid addiction holds that regular, long-term users of heroin and other opioids lose interest in sex as their drug using careers lengthen. Analysis of self-reports collected from IDUs in two cross- sectional surveys on patterns of risk behavior in Miami-Dade County, Florida, reveals that large proportions of IDUs report using heroin before or during sex across a wide range of self-injection experience, from as little as twelve months to over 40 years. One half or more of respondents to both surveys reported using heroin in their recent sexual experiences, with similar proportions reported by both males and females. The same IDUs, however, tend not to report using prescription painkillers before or during sex. This finding indicates that co-occurring risk behavior related to both sexual behavior and heroin use may be more prevalent among long-term IDUs than previous literature has suggested

Mechanisms for the Negative Effects of Internalized HIV-Related Stigma on Antiretroviral Therapy Adherence in Women: The Mediating Roles of Social Isolation and Depression

Internalization of HIV-related stigma may inhibit a person's ability to manage HIV disease through adherence to treatment regimens. Studies, mainly with white men, have suggested an association between internalized stigma and suboptimal adherence to antiretroviral therapy (ART). However, there is a scarcity of research with women of different racial/ethnic backgrounds and on mediating mechanisms in the association between internalized stigma and ART adherence

Health Insurance Type and Control of Hypertension Among US Women Living With and Without HIV Infection in the Women’s Interagency HIV Study

BACKGROUND: Health care access is an important determinant of health. We assessed the effect of health insurance status and type on blood pressure control among US women living with (WLWH) and without HIV. METHODS: We used longitudinal cohort data from the Women's Interagency HIV Study (WIHS). WIHS participants were included at their first study visit since 2001 with incident uncontrolled blood pressure (BP) (i.e., BP ≥140/90 and at which BP at the prior visit was controlled (i.e., <135/85). We assessed time to regained BP control using inverse Kaplan-Meier curves and Cox proportional hazard models. Confounding and selection bias were accounted for using inverse probability-of-exposure-and-censoring weights. RESULTS: Most of the 1,130 WLWH and 422 HIV-uninfected WIHS participants who had an elevated systolic or diastolic measurement were insured via Medicaid, were African-American, and had a yearly income ≤$12,000. Among participants living with HIV, comparing the uninsured to those with Medicaid yielded an 18-month BP control risk difference of 0.16 (95% CI: 0.10, 0.23). This translates into a number-needed-to-treat (or insure) of 6; to reduce the caseload of WLWH with uncontrolled BP by one case, five individuals without insurance would need to be insured via Medicaid. Blood pressure control was similar among WLWH with private insurance and Medicaid. There were no differences observed by health insurance status on 18-month risk of BP control among the HIV-uninfected participants. CONCLUSIONS: These results underscore the importance of health insurance for hypertension control-especially for people living with HIV

Problem opioid use and HIV primary care engagement among hospitalized people who use drugs and/or alcohol

Background There is growing public health concern around the potential impact of the opioid crisis on efforts to eradicate HIV. This secondary analysis seeks to determine if those who report opioids as their primary problem drug compared to those who report other drugs and/or alcohol differ in engagement in HIV primary care among a sample of hospitalized people with HIV (PWH) who use drugs and/or alcohol, a traditionally marginalized and difficult to engage population key to ending the HIV epidemic. Setting and participants A total of 801 participants (67% male; 75% Black, non-Hispanic; mean age 44.2) with uncontrolled HIV and reported drug and/or alcohol use were recruited from 11 hospitals around the U.S. in cities with high HIV prevalence from 2012 to 2014 for a multisite clinical trial to improve HIV viral suppression. Methods A generalized linear model compared those who reported opioids as their primary problem drug to those who reported other problem drugs and/or alcohol on their previous engagement in HIV primary care, controlling for age, sex, race, education, income, any previous drug and/or alcohol treatment, length of time since diagnosis, and study site. Results A total of 95 (11.9%) participants reported opioids as their primary problem drug. In adjusted models, those who reported opioids were significantly less likely to have ever engaged in HIV primary care than those who reported no problem drug use (adjusted risk ratio, ARR = 0.84, 95% Confidence Interval, CI 0.73, 0.98), stimulants (ARR = 0.84, 95% CI 0.74, 0.95), and polydrug use but no alcohol (ARR = 0.79, 95% CI 0.68, 0.93). While not statistically significant, the trend in the estimates of the remaining drug and/or alcohol categories (alcohol, cannabis, polydrug use with alcohol, and [but excluding the estimate for] other), point to a similar phenomena—those who identify opioids as their primary problem drug are engaging in HIV primary care less. Conclusions These findings suggest that for hospitalized PWH who use drugs and/or alcohol, tailored and expanded efforts are especially needed to link those who report problem opioid use to HIV primary care. Trial registration This study was funded by National Institutes of Health (NIH) grant: U10-DA01372011 (Project HOPE—Hospital Visit as Opportunity for Prevention and Engagement for HIV-Infected Drug Users; Metsch); which is also a registered clinical trial under the Clinical Trials Network (CTN-0049). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH

Impact of Health Insurance, ADAP, and Income on HIV Viral Suppression Among US Women in the Womenʼs Interagency HIV Study, 2006–2009

Implementation of the Affordable Care Act motivates assessment of health insurance and supplementary programs, such as the AIDS Drug Assistance Program (ADAP) on health outcomes of HIV-infected people in the United States. We assessed the effects of health insurance, ADAP, and income on HIV viral load suppression