Background Although HIV infections are documented among all race and sexual risk groups, black men who have sex with men (BMSM) are the most affected by HIV in the US. Currently, there is considerable emphasis on the implementation and use of biomedical HIV prevention to slow the HIV epidemic among this group; however, use of biomedical prevention requires engagement in routine medical care – a necessity that has not been met. Methods In order to better understand this shortcoming, we surveyed 544 BMSM (in 2012) to assess how health care related stigma, global medical mistrust, and personal trust in health care provider relate to engaging in medical care. We used generalized linear modeling and mediation analyses to assess data (completed in 2013). Results Twenty nine percent of participants reported experiencing race/sexual orientation stigma from heath care providers and 48% reported feelings of mistrust towards medical establishments. In generalized linear modeling we found that, among HIV negative BMSM, those who experienced greater stigma and global medical mistrust had longer gaps in time since last medical exam. Furthermore, global medical mistrust mediated the relationship between stigma and engagement in care. Among HIV positive BMSM, experiencing stigma from health care providers was also associated with longer gaps in time since last HIV care appointment. Conclusions Interventions that support the development of greater awareness around the sexual health needs of BMSM are desperately needed. Failure to address psychosocial deterrents will stymie progress made in biomedical prevention and, ultimately, cripple our ability to implement these technologies.

IntroductionFood insecurity is a well-established predictor of poor health outcomes. Antiretroviral therapies (ARTs) that should be taken with food to increase bioavailability may further challenge food insecure patients. This study examined factors associated with antiretroviral adherence and HIV viral suppression among people living with HIV who are food insecure and prescribed medications that require food.MethodsA community sample of 313 men and 105 women who experienced food insecurity in the previous month and were currently taking ART completed computerized interviews, urine screening for drug use, prospective biweekly unannounced pill count adherence assessments, and obtained their HIV viral load and CD4 cell counts from medical records.ResultsIndividuals taking ART regimens that should be taken with food were significantly more likely to be unemployed, were living longer with an HIV diagnosis, had lower CD4 cell counts, poorer HIV suppression, and endorsed more beliefs that taking medications was necessary for their health. Multivariable regression models controlling for potential confounding factors showed that receiving ART that requires food was significantly related to poorer ART adherence and unsuppressed HIV in this food insecure sample.ConclusionPeople living with HIV who are food insecure likely experience multiple facets of poverty that challenge their medication adherence, but food insecurity is the only such factor that is directly related to the pharmacokinetics of some antiretroviral medications. Achieving optimal treatment outcomes for HIV infection will require routine assessment of access to food when determining patient-tailored ART regimens.Electronic supplementary materialThe online version of this article (doi:10.1007/s40121-015-0057-y) contains supplementary material, which is available to authorized users.

Purpose: For Black women who have sex with women (BWSW), obtaining routine healthcare can be obstructed by a number of psychosocial barriers, including experiences of stigma, related to both sexual orientation and race, and medical mistrust, both race-based and global. Previous research demonstrates that sexual orientation and race-based stigma, as well as global and race-based medical mistrust, each have a negative impact on health outcomes and engagement in care (EIC) independently. This study addresses gaps in the literature by examining the impact of these psychosocial barriers and their interactions among BWSW, an understudied population. Methods: Participants (256 BWSW) were surveyed at a Black Gay Pride festival. Separate generalized linear models assessed the independent and multiplicative effects of participants' self-reported sexual orientation stigma, race-based stigma, race-based medical mistrust, and global medical mistrust related to their engagement in routine physical exams and blood pressure screenings. Results: Prevalence rates of both stigma measures were low, but prevalence rates of global and race-based medical mistrust were high. The results show that experiencing sexual orientation stigma or having race-based medical mistrust predicts significantly lower EIC. Furthermore, the frequencies of obtaining recent physical examinations and blood pressure screenings were significantly related to three-and two-way interactions between stigma and medical mistrust, respectively. Conclusion: There is an urgent need to address the intersectionality of these psychosocial barriers in an effort to increase BWSW's EIC.Keywords: barriers to care, lesbian, race/ethnicity/culture, women who have sex with women (WSW)

HIV infection is concentrated in populations living in poverty. We examined the overlapping and independent effects of multiple poverty indicators on HIV-related health status. Because substance use can create competing survival needs when resources are limited, we also sought to objectively measure expenditures on food relative to alcohol and tobacco products. To achieve these aims, 459 men and 212 women living with HIV infection in Atlanta, GA completed measures of socio-demographic and heath characteristics as well as multiple indicators of poverty including housing stability, transportation, food insecurity, and substance use. Participants were given a $30 grocery gift card for their participation and we collected receipts which were coded for alcohol (beer, wine, liquors) and tobacco purchases. Results showed that participants with unsuppressed HIV replication were significantly more likely to experience multiple indicators of poverty. In addition, one in four participants purchased alcohol or tobacco products with their gift cards, with as much as one-fourth of money spent on these products. A multivariable logistic regression model showed that food insecurity was independently associated with unsuppressed HIV, and purchasing alcohol or tobacco products did not moderate this association. Results confirm previous research to show the primacy of food insecurity in relation to HIV-related health outcomes. Competing survival needs, including addictive substances, should be addressed in programs that aim to alleviate poverty to enhance the health and well-being of people with HIV infection.

The Internet is a primary source for health-related information, and Internet search activity is associated with infectious disease outbreaks. The authors hypothesized that Internet search activity for vaccine-related information would predict vaccination coverage. They examined Internet search activity for H1N1 and human papilloma virus (HPV) disease and vaccine information in relation to H1N1 and HPV vaccine uptake. Google Insight for Search was used to assess the volume of Internet search queries for H1N1- and vaccine-related terms in the United States in 2009, the year of the H1N1 pandemic. Vaccine coverage data were also obtained from the Centers for Disease Control and Prevention at the state level for H1N1 vaccinations in 2009. These same measures were collected at the state level for HPV- and vaccine-related search terms in 2010 as well as HPV vaccine uptake in that year. Analyses showed that the search terms H1N1 and vaccine were correlated with H1N1 vaccine uptake; ordinal regression found the H1N1 search term was independently associated with H1N1 vaccine coverage. Similarly, the correlation between vaccine search volume and HPV coverage was significant; ordinal regression showed the search term vaccine independently predicted HPV vaccination coverage. This is among the first studies to show that Internet search activity is associated with vaccination coverage. The Internet should be exploited as an opportunity to dispel vaccine misinformation by providing accurate information to support vaccine decision making.

Background Food insecurity is a known barrier to medication adherence among people living with HIV. Antiretroviral therapies (ART) that require food for maximum benefit likely pose added challenges to patients who do not have reliable access to food. This study examines the health implications of prescribing ART that requires food to patients who are food insecure. Method A community sample of 538 men and 221 women currently taking ART to treat their HIV infection completed computerized interviews, biweekly-unannounced pill count adherence assessments, and obtained their CD4 cell count and HIV RNA from medical records. Results Sixty-three percent of participants experienced at least one indicator of food insecurity during the previous month, of which 274 (57%) were prescribed an ART regimen that requires food. Among participants who were food insecure, individuals taking ART requiring food indicated significantly greater HIV symptoms, lower CD4 cell counts, and poorer HIV suppression. For participants who were food secure, those taking ART that requires food were significantly less adherent than those whose ART regimen does not require food. Conclusions People living with HIV who experience food insecurity are significantly more likely to be prescribed ART regimens that require food and experience poorer treatment outcomes. Determination of optimal ART regimens should take patient access to food into account and treatment guidelines should highlight the importance of food access in selecting ART regimens.

Beliefs about medication necessity and concerns predict treatment adherence in people with a wide-array of medical conditions, including HIV infection. However, medication beliefs have not been examined in people dually treated with psychotropic medications and antiretroviral therapy. In the current study, we used a prospective design to investigate the factors associated with adherence to psychotropic medications and antiretrovirals among 123 dually treated persons living with HIV. We used unannounced phone-based pill counts to monitor adherence to psychiatric and antiretroviral medications over a 6-week period. Hierarchical regression models included demographic, health and psychosocial characteristics as predictors of adherence followed by medication necessity and concerns beliefs. Results showed that medication necessity beliefs predicted both antiretroviral and psychiatric medication adherence over and above established predictors of adherence. Medication concerns also predicted psychotropic adherence, but not antiretroviral adherence. These models accounted for 31% and 22% of the variance in antiretroviral and psychotropic adherence, respectively. Findings suggest that the necessity-concerns medication beliefs framework has utility in understanding adherence to multiple medications and addressing these beliefs should be integrated into adherence interventions.

IntroductionAntiretroviral therapy (ART) improves the health of people living with HIV and has the potential to reduce HIV infectiousness, thereby preventing HIV transmission. However, the success of ART for HIV prevention hinges on sustained ART adherence and avoiding sexually transmitted infections (STI).ObjectivesTo determine the sexual behaviours and HIV transmission risks of individuals with suppressed and unsuppressed HIV replication (i.e., viral load).MethodsAssessed HIV sexual transmission risks among individuals with clinically determined suppressed and unsuppressed HIV. Participants were 760 men and 280 women living with HIV in Atlanta, GA, USA, who completed behavioural assessments, 28-daily prospective sexual behaviour diaries, one-month prospective unannounced pill counts for ART adherence, urine screening for illicit drug use and medical record chart abstraction for HIV viral load.ResultsIndividuals with unsuppressed HIV demonstrated a constellation of behavioural risks for transmitting HIV to uninfected sex partners that included symptoms of STI and substance use. In addition, 15% of participants with suppressed HIV had recent STI symptoms/diagnoses, indicating significant risks for sexual infectiousness despite their HIV suppression in blood plasma. Overall, 38% of participants were at risk for elevated sexual infectiousness and just as many engaged in unprotected sexual intercourse with non-HIV-infected partners.ConclusionsImplementation strategies for using HIV treatments as HIV prevention requires enhanced behavioural interventions that extend beyond ART to address substance use and sexual health that will otherwise undermine the potential preventive impact of early ART.