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BACKGROUND: Pharmacists have demonstrated the ability to improve patient adherence to antiretroviral therapy (ART). OBJECTIVE: To determine the clinical and economic effects of a pharmacist-administered ART adherence clinic for patients living with human immunodeficiency virus (HIV). METHODS: This pilot study with a pretest-posttest design examined the effect of a pharmacy adherence clinic on patient HIV viral load and CD4 count over a 6-month period. Patients with documented adherence problems were referred to the clinic. The pharmacist counseled patients at baseline and met with patients 1-2 weeks, 6 weeks, 3 months, and 6 months after starting ART. A societal perspective net cost analysis of the pharmacy adherence clinic was conducted to assess the economic efficiency of the intervention. RESULTS: Twenty-eight patients were enrolled in the study, and 16 patients reached completion. Median HIV RNA significantly decreased from 48,000 copies/mL (interquartile range [IQR] = 16,750-139,000) to undetectable (< 20 copies/mL) at 6 months for all study participants who completed the full intervention (P = 0.001). In the 3 months following the intervention, we estimated that it prevented approximately 0.13 secondary HIV infections among the sexual partners of the 16 participants who completed the intervention. The total cost of the intervention was $16,811 ($1,051 per patient), which was less than the future savings in averted HIV-related medical care expenditures ($49,702). CONCLUSIONS: A pharmacy adherence clinic that focused on early and sustained ART adherence interventions helped patients with documented medication adherence problems achieve an undetectable HIV RNA. The intervention was highly cost saving, with a return of nearly $3 in future medical care savings per dollar spent on the intervention. DISCLOSURES: This work was supported in part by a research grant to Dilworth, Mercier, and Borrego from the American Society of Health-System Pharmacists Foundation. Klein and Pinkerton were supported in part by grants T32-MH19985 and P30-MH52776, respectively, from the National Institute of Mental Health. No funding bodies had any role in the study design, data collection, analysis, decision to publish, or preparation of the manuscript. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Health Resources and Services Administration. The authors have no conflicts of interest to disclose. Study concept and design were contributed primarily by Dilworth, Mercier, and Borrego, along with the other authors. Dilworth took the lead in data collection, along with Pinkerton, Klein, Mercier, and Jakeman. Data interpretation was performed by Dilworth and Pinkerton, along with the other authors. The manuscript was written by Dilworth, Klein, and Jakeman, with assistance from the other authors, and revised by Dilworth, Jakeman, and Klein, with assistance from the other authors. The results from this study were presented in part at the 2015 United States Conference on AIDS in Washington, DC, on September 10-13, 2015.
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Instituciones de Atención Ambulatoria/economía , Fármacos Anti-VIH/economía , Fármacos Anti-VIH/uso terapéutico , Costos de los Medicamentos , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/economía , Cumplimiento de la Medicación , Servicios Farmacéuticos/economía , Farmacéuticos/economía , Rol Profesional , Adulto , Instituciones de Atención Ambulatoria/organización & administración , Recuento de Linfocito CD4 , Ahorro de Costo , Análisis Costo-Beneficio , Consejo/economía , Femenino , Infecciones por VIH/diagnóstico , Infecciones por VIH/psicología , Gastos en Salud , Humanos , Liderazgo , Masculino , Persona de Mediana Edad , Educación del Paciente como Asunto/economía , Servicios Farmacéuticos/organización & administración , Farmacéuticos/organización & administración , Proyectos Piloto , Factores de Tiempo , Resultado del Tratamiento , Carga Viral , Adulto JovenRESUMEN
The majority of research on risky sexual behavior in African American women has examined global associations between individual-level predictors and behavior. However, this method obscures the potentially significant impact of the specific relationship or relationship partner on risky sexual behavior. To address this gap, we conducted partnership-level analysis of risky sexual behavior among 718 African American women recruited from HIV counseling, testing, and referral sites in four states. Using mixed model regressions, we tested relationships between condomless vaginal intercourse with men and variables drawn from the Theory of Planned Behavior, Theory of Gender and Power, and previous research specifically on sexual risks among African American women. Significant associations with risky sexual behavior indicate the need for continued emphasis on condom attitudes, condom negotiation behaviors, and overcoming partner resistance to condoms within both main and non-main partnerships when implementing interventions designed to address HIV and sexually transmitted infection risks among African American women.
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Negro o Afroamericano/psicología , Infecciones por VIH/etnología , Infecciones por VIH/transmisión , Parejas Sexuales/psicología , Sexo Inseguro/etnología , Sexo Inseguro/psicología , Serodiagnóstico del SIDA , Adolescente , Adulto , Anciano , Condones/estadística & datos numéricos , Femenino , Infecciones por VIH/prevención & control , Humanos , Intención , Persona de Mediana Edad , Negociación/psicología , Teoría Psicológica , Análisis de Regresión , Adulto JovenRESUMEN
Continued debate about the relative value of fidelity versus adaptation, and lack of clarity about the meaning of fidelity, raise concerns about how frontline service providers resolve similar issues in their daily practice. We use SISTA ('Sisters Informing Sisters on Topics about acquired immune deficiency syndrome'), an evidence-based human immunodeficiency virus (HIV) prevention intervention for African American women, to understand how facilitators and program directors interpret and enact implementation fidelity with the need for adaptation in real-world program delivery. We conducted 22 in-depth, semi-structured interviews with service providers from four agencies implementing SISTA. Facilitators valued their skills as group leaders and ability to emotionally engage participants as more critical to program effectiveness than delivering the intervention with strict fidelity. Consequently, they saw program manuals as guides rather than static texts that should never be changed and, moreover, viewed the prescriptive nature of manuals as undermining their efforts to fully engage with participants. Our findings suggest that greater consideration should be given to understanding the role of facilitators in program effectiveness over and above the question of whether they implement the program with fidelity. Moreover, training curricula should provide facilitators with transferable skills through general facilitator training rather than only program-specific or manual-specific training.
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Negro o Afroamericano , Infecciones por VIH/prevención & control , Educación en Salud/organización & administración , Conocimientos, Actitudes y Práctica en Salud , Práctica Clínica Basada en la Evidencia , Femenino , Educación en Salud/normas , Humanos , Entrevistas como Asunto , Masculino , Evaluación de Programas y Proyectos de SaludRESUMEN
Evaluation has become expected within the nonprofit sector, including HIV prevention service delivery through community-based organizations (CBOs). While staff and directors at CBOs may acknowledge the potential contribution of evaluation data to the improvement of agency services, the results of evaluation are often used to demonstrate fiscal prudence, efficiency, and accountability to funders and the public, rather than to produce information for the organization's benefit. We conducted 22 in-depth, semistructured interviews with service providers from four agencies implementing the same evidence-based HIV prevention intervention. We use the lens of "audit culture" to understand how the evaluation and accountability mandates of evidence-based program implementation within HIV prevention service provision affect provider-client relations, staff members' daily work, and organizational focus in natural settings, or contexts without continuous support and implementation monitoring. We conclude with recommendations for improving the use and methods of evaluation within HIV prevention service delivery.
RESUMEN
OBJECTIVE: To describe community pharmacists' perceptions on their current role in direct patient care services, an expanded role for pharmacists in providing patient care services, and changes needed to optimally use pharmacists' expertise to provide high-quality direct patient care services to people living with human immunodeficiency virus (HIV) infections. DESIGN: Cross-sectional study. SETTING: Four Midwestern cities in the United States in August through October 2009. PARTICIPANTS: 28 community-based pharmacists practicing in 17 pharmacies. INTERVENTIONS: Interviews. MAIN OUTCOME MEASURES: Opinions of participants about roles of specialty and nonspecialty pharmacists in caring for patients living with HIV infections. RESULTS: Pharmacists noted that although challenges in our health care system characterized by inaccessible health professionals presented opportunities for a greater pharmacist role, there were missed opportunities for greater level of patient care services in many community-based nonspecialty settings. Many pharmacists in semispecialty and nonspecialty pharmacies expressed a desire for an expanded role in patient care congruent with their pharmacy education and training. CONCLUSION: Structural-level policy changes needed to transform community-based pharmacy settings to patient-centered medical homes include recognizing pharmacists as important players in the multidisciplinary health care team, extending the health information exchange highway to include pharmacist-generated electronic therapeutic records, and realigning financial incentives. Comprehensive policy initiatives are needed to optimize the use of highly trained pharmacists in enhancing the quality of health care to an ever-growing number of Americans with chronic conditions who access care in community-based pharmacy settings.
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Fármacos Anti-VIH/uso terapéutico , Servicios Comunitarios de Farmacia , Atención a la Salud , Infecciones por VIH/tratamiento farmacológico , Grupo de Atención al Paciente , Farmacéuticos , Rol Profesional , Fármacos Anti-VIH/efectos adversos , Actitud del Personal de Salud , Servicios Comunitarios de Farmacia/normas , Estudios Transversales , Atención a la Salud/normas , Infecciones por VIH/diagnóstico , Encuestas de Atención de la Salud , Conocimientos, Actitudes y Práctica en Salud , Humanos , Perfil Laboral , Administración del Tratamiento Farmacológico , Medio Oeste de Estados Unidos , Grupo de Atención al Paciente/normas , Seguridad del Paciente , Percepción , Farmacéuticos/psicología , Farmacéuticos/normas , Relaciones Profesional-Paciente , Garantía de la Calidad de Atención de Salud , EspecializaciónRESUMEN
The study was undertaken to assess the potential effectiveness of combined HIV prevention on the very high seroprevalence epidemic among persons who inject drugs (PWID) in Tallinn, Estonia, a transitional country. Data from community-based cross-sectional (respondent-driven sampling) surveys of PWID in 2005, 2007, 2009, and 2011 were used together with mathematical modeling of injection-associated HIV acquisition to estimate changes in injection-related HIV incidence during these periods. Utilization of one, two, or three of the interventions available in the community (needle and syringes exchange program, antiretroviral treatment [ART], HIV testing, opioid substitution treatment) was reported by 42.5%, 30.5%, and 11.5% of HIV+ and 34.7%, 36.4%, and 5.7% of HIV- PWIDs, respectively, in 2011. The modeling results suggest that the combination of needle/syringe programs and provision of ART to PWID in Tallinn substantially reduced the incidence of HIV infection in this population, from an estimated 20.7/100 person-years in 2005 to 7.5/100 person-years in 2011. In conclusion, combined prevention targeting HIV acquisition and transmission-related risks among PWID in Tallinn has paralleled the downturn of the HIV epidemic in this population.
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Infecciones por VIH/prevención & control , Servicios Preventivos de Salud/organización & administración , Abuso de Sustancias por Vía Intravenosa , Fármacos Anti-VIH/uso terapéutico , Estonia/epidemiología , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/epidemiología , Humanos , Programas de Intercambio de AgujasRESUMEN
To examine whether increasing investment in needle/syringe exchange programs (NSPs) in the US would be cost-effective for HIV prevention, we modeled HIV incidence in hypothetical cases with higher NSP syringe supply than current levels, and estimated number of infections averted, cost per infection averted, treatment costs saved, and financial return on investment. We modified Pinkerton's model, which was an adaptation of Kaplan's simplified needle circulation theory model, to compare different syringe supply levels, account for syringes from non-NSP sources, and reflect reduction in syringe sharing and contamination. With an annual $10 to $50 million funding increase, 194-816 HIV infections would be averted (cost per infection averted $51,601-$61,302). Contrasted with HIV treatment cost savings alone, the rate of financial return on investment would be 7.58-6.38. Main and sensitivity analyses strongly suggest that it would be cost-saving for the US to invest in syringe exchange expansion.
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Programas de Intercambio de Agujas/economía , Ahorro de Costo/economía , Ahorro de Costo/métodos , Análisis Costo-Beneficio , Femenino , Infecciones por VIH/economía , Infecciones por VIH/epidemiología , Infecciones por VIH/prevención & control , Costos de la Atención en Salud/estadística & datos numéricos , Humanos , Masculino , Modelos Económicos , Programas de Intercambio de Agujas/métodos , Abuso de Sustancias por Vía Intravenosa/economía , Abuso de Sustancias por Vía Intravenosa/epidemiología , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: To examine pharmacists' self-reported competence in providing care to persons living with HIV (PLWH) and their HIV-related training and experience needs. METHODS: We interviewed 28 community-based pharmacists providing care to PLWH in 4 Midwestern cities. RESULTS: Less than half (46%) of the pharmacists considered themselves competent to provide PLWH care, and less than a third (29%) worked with PLWH during their pharmacy residency. Specialty pharmacists need training on opportunistic infections and HIV-related comorbidities, nonspecialty pharmacists need general training in HIV treatment and patient communications skills, and all pharmacists require a mechanism to keep updated in the latest HIV treatment recommendations. CONCLUSION: In the current era of patient-centered care, a pharmacist that is well rounded-not just in dispensing antiretroviral medications but highly knowledgeable in different aspects of ART and HIV-specific patient care-can make a valuable contribution to the health care team. Pharmacy school curricula and continuing professional education need to be aligned to meet the knowledge and competency needs of community pharmacists who are strategically positioned to provide care to PLWH.
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Servicios Comunitarios de Farmacia/organización & administración , Infecciones por VIH/terapia , Farmacéuticos/estadística & datos numéricos , Competencia Profesional , Fármacos Anti-VIH/uso terapéutico , Comunicación , Servicios Comunitarios de Farmacia/normas , Curriculum , Educación en Farmacia , Educación Continua en Farmacia/normas , Femenino , Conocimientos, Actitudes y Práctica en Salud , Humanos , Masculino , Grupo de Atención al Paciente/organización & administración , Atención Dirigida al Paciente/organización & administración , Farmacéuticos/normas , Rol Profesional , EspecializaciónRESUMEN
Each year, the US AIDS drug assistance program (ADAP) provides access to prescription drugs-including antiretrovirals-to more than 110,000 persons living with HIV (PLWH) who lack adequate medical insurance. PLWH on effective antiretroviral therapy live longer lives, with enhanced quality of life, and are less likely to transmit HIV to others. There are thus significant benefits associated with the ADAP program. But there also are substantial costs. A mathematical model was used to assess the cost-effectiveness of the US ADAP program. Findings indicate that by providing antiretrovirals to underinsured persons, the ADAP program prevented 3,191 secondary infections and saved 24,922 quality-adjusted life years in 2008. The net cost per quality-adjusted life year saved was $11,955, which suggests that the ADAP program is cost-effective by conventional standards.
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Síndrome de Inmunodeficiencia Adquirida/tratamiento farmacológico , Síndrome de Inmunodeficiencia Adquirida/economía , Fármacos Anti-VIH/economía , Fármacos Anti-VIH/uso terapéutico , Asistencia Médica/organización & administración , Síndrome de Inmunodeficiencia Adquirida/prevención & control , Terapia Antirretroviral Altamente Activa , Análisis Costo-Beneficio , Femenino , Accesibilidad a los Servicios de Salud/economía , Humanos , Masculino , Modelos Teóricos , Años de Vida Ajustados por Calidad de Vida , Estados UnidosRESUMEN
We are not aware of published cost-effectiveness studies addressing community transitional programs for HIV-infected jail detainees. To address this gap, data from 9 sites of EnhanceLink, a project that enrolled HIV-infected releasees from jails across the US, were examined. Figures on the number of clients served, cost of linkage services, number of linkages and 6-month sustained linkages to community HIV care, and number of clients achieving viral suppression were assessed for subjects released in the first quarter of 2010 (n = 543). The cost analysis included all costs that participating service agencies incurred. A cost-effectiveness analysis was conducted to estimate the new HIV cases averted by EnhanceLink and the cost per quality-adjusted life year saved by the program. The mean cost per linked client was $4,219; the mean cost per 6-month sustained linkage was $4,670; and the mean cost per client achieving viral suppression was $8,432. Compared to standard care, the cost per additional quality-adjusted life year saved was $72,285, suggesting that the EnhanceLink interventions were cost-effective from the societal perspective.
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Fármacos Anti-VIH/economía , Servicios de Salud Comunitaria/economía , Infecciones por VIH/economía , Infecciones por VIH/prevención & control , Adolescente , Adulto , Fármacos Anti-VIH/uso terapéutico , Análisis Costo-Beneficio , Femenino , Infecciones por VIH/epidemiología , Costos de la Atención en Salud/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Procesos y Resultados en Atención de Salud , Prisiones , Evaluación de Programas y Proyectos de Salud , Años de Vida Ajustados por Calidad de Vida , Apoyo Social , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVES: We explored associations between awareness of New Jersey's HIV exposure law and the HIV-related attitudes, beliefs, and sexual and seropositive status disclosure behaviors of HIV-positive persons. METHODS: A statewide convenience sample (n = 479) completed anonymous written surveys during 2010. We recruited participants through networks of community-based organizations in the state's 9 health sectors. The survey assessed participants' awareness of New Jersey's HIV exposure law, their sexual and serostatus disclosure behavior in the past year, and their HIV-related attitudes and beliefs. We compared responses of participants who were and were not aware of the law through univariate analyses. RESULTS: Fifty-one percent of participants knew about the HIV exposure law. This awareness was not associated with increased sexual abstinence, condom use with most recent partner, or seropositive status disclosure. Contrary to hypotheses, persons who were unaware of the law experienced greater stigma and were less comfortable with positive serostatus disclosure. CONCLUSIONS: Criminializing nondisclosure of HIV serostatus does not reduce sexual risk behavior. Although the laws do not appear to increase stigma, they are also not likely to reduce HIV transmission.
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Actitud Frente a la Salud , Derecho Penal , Infecciones por VIH/psicología , Seropositividad para VIH/psicología , Autorrevelación , Conducta Sexual/psicología , Adolescente , Adulto , Derecho Penal/legislación & jurisprudencia , Femenino , Conocimientos, Actitudes y Práctica en Salud , Humanos , Masculino , Persona de Mediana Edad , New Jersey , Conducta Sexual/estadística & datos numéricos , Parejas Sexuales , Adulto JovenAsunto(s)
Antirretrovirales/administración & dosificación , Terapia Antirretroviral Altamente Activa , Servicios Comunitarios de Farmacia , Infecciones por VIH/tratamiento farmacológico , Cooperación del Paciente , Atención a la Salud/métodos , Humanos , Cuidados a Largo Plazo/métodos , Farmacéuticos , Servicios Postales/métodosRESUMEN
Michigan's Medicaid program implemented four cost containment policies--preferred drug lists, joint and multistate purchasing arrangements, and maximum allowable cost--during 2002-04. The goal was to control growth of drug spending for beneficiaries who were enrolled in both Medicaid and Medicare and taking antihypertensive or antihyperlipidemic prescription drugs. We analyzed the impact of each policy while holding the effect of all other policies constant. Preferred drug lists increased both preferred and generic drugs' market share and reduced daily cost--the cost per day for each prescription provided to a beneficiary. In contrast, the maximum allowable cost policy increased daily cost and was the only policy that did not generate cost savings. The joint and multistate arrangements did not affect daily cost. Despite these policy trade-offs, the cumulative effect was a 10 percent decrease in daily cost and a total cost savings of $46,195 per year. Our findings suggest that policy makers need to evaluate the impact of multiple policies aimed at restraining drug spending, and further evaluate the policy trade-offs, to ensure that scarce public dollars achieve the greatest return for money spent.
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Control de Costos/métodos , Costos de los Medicamentos , Medicaid/economía , Política Organizacional , Anciano , Femenino , Humanos , Revisión de Utilización de Seguros , Masculino , Michigan , Persona de Mediana Edad , Estados UnidosRESUMEN
UNLABELLED: Minimal hepatic encephalopathy (MHE) in cirrhosis is associated with impaired driving skills and increased risk of motor vehicle accidents (MVAs). Detection and treatment of MHE has the potential to reduce costs and morbidity associated with MVAs. We conducted a cost-effectiveness analysis to assess the benefits of different strategies of MHE diagnosis and treatment for reducing MVA-related societal costs. The analyses compared five MHE management strategies: (1) presumptive treatment of all cirrhosis patients; (2) diagnosis by neuropsychological exam (NPE) with treatment; (3) diagnosis by standard psychometric tests (SPTs) with treatment; (4) diagnosis by rapid screening using inhibitory control test (ICT) with treatment; and (5) no MHE diagnosis or treatment (status quo). Treatments considered were lactulose or rifaximin, which were assumed to reduce the MVA rate to the level of similarly aged noncirrhosis patients with benefit adjusted for treatment compliance. A Markov model followed a simulated cohort of 1,000 cirrhosis patients without overt hepatic encephalopathy (OHE), from entry into treatment, through MHE development, and later OHE, when they exited the modeled cohort. Follow-up was for 5 years and included biannual MHE testing. The societal cost of a single MVA was estimated at $42,100. All four strategies with lactulose were cost-saving compared with the status quo. Diagnosis with ICT and lactulose was the most cost-effective approach (cost/MVA prevented: $24,454 ICT; $25,470 SPT; $30,469 presumptive treatment and $33,742 NPE). Net program savings over 5 years ranged from $1.7 to 3.6 million depending on the strategy. Rifaximin therapy was not cost-saving at current prices but would become so at a monthly cost of <$353. CONCLUSION: Detection of MHE, especially using the ICT, and subsequent treatment with lactulose could substantially reduce societal costs by preventing MVAs.
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Accidentes de Tránsito/economía , Accidentes de Tránsito/prevención & control , Fármacos Gastrointestinales/economía , Fármacos Gastrointestinales/uso terapéutico , Encefalopatía Hepática/diagnóstico , Encefalopatía Hepática/tratamiento farmacológico , Índice de Severidad de la Enfermedad , Anciano , Estudios de Cohortes , Análisis Costo-Beneficio , Estudios de Seguimiento , Encefalopatía Hepática/etiología , Humanos , Lactulosa/economía , Lactulosa/uso terapéutico , Cirrosis Hepática/complicaciones , Cadenas de Markov , Persona de Mediana Edad , Pruebas Neuropsicológicas , Psicometría , Rifamicinas/economía , Rifamicinas/uso terapéutico , Rifaximina , Estados UnidosRESUMEN
The objectives of the project were (1) to determine the extent to which HIV-positive persons living in Michigan were aware of and understood Michigan's criminal HIV exposure law, (2) to examine whether awareness of the law was associated with seropositive status disclosure to prospective sex partners, and, (3) to examine whether awareness of the law was associated with potential negative effects of the law on persons living with HIV (PLWH) including heightened HIV-related stigma, perceived societal hostility toward PLWH, and perceived need to conceal one's HIV infection. The study design was cross-sectional. A statewide sample of 384 PLWH in Michigan completed anonymous pen and paper surveys in 1 of 25 data collection sessions. A majority of participants were aware of Michigan's HIV exposure law. Awareness of the law was not associated with increased seropositive status disclosure to all prospective sex partners, decreased HIV transmission risk behavior, or increased perceived responsibility for HIV transmission prevention. However, awareness of the law was significantly associated with disclosure to a greater proportion of sex partners prior to respondents' first sexual interaction with that partner. Awareness of the law was not associated with increased HIV-related stigma, perceived societal hostility toward PLWH, or decreased comfort with seropositive status disclosure. Evidence of an effect of Michigan's HIV exposure law on seropositive status disclosure was mixed. Further research is needed to examine the various forms of HIV exposure laws among diverse groups of persons living with or at increased risk of acquiring HIV.
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Derecho Penal , Infecciones por VIH/prevención & control , Seropositividad para VIH/transmisión , Conocimientos, Actitudes y Práctica en Salud , Autorrevelación , Parejas Sexuales , Adulto , Anciano , Estudios Transversales , Femenino , Humanos , Masculino , Michigan , Persona de Mediana Edad , Conducta Sexual , Estigma Social , Adulto JovenRESUMEN
Several mathematical modeling studies based on the concept of "HIV transmission rates" have recently appeared in the literature. The transmission rate for a particular group of HIV-infected persons is defined as the mean number of secondary infections per member of the group per unit time. This article reviews the fundamental principles and mathematics of transmission rate models; explicates the relationship between these models, Bernoullian models of HIV transmission, and mathematical models based on the concept of the "reproductive rate of infection"; describes an extension of existing transmission rate models to better incorporate the positive impact of HIV treatment; and discusses the limitations of the transmission rate modeling approach. Results from the extended transmission rate model indicate that approximately 51.6% of new sexually-transmitted infections in the US are due to the transmission risk behaviors of infected persons who are unaware of their infection, including 10.9% due to persons in the acute phase of HIV infection. Findings from this study suggest that significant reductions in HIV incidence likely will require a combination of increased antibody testing, enhanced early detection of acute HIV infection, appropriate medical care and antiretroviral medicine adherence counseling, and behavioral risk reduction interventions.
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Coinfección/transmisión , Seropositividad para VIH/transmisión , Coinfección/epidemiología , Consejo/métodos , Femenino , Seropositividad para VIH/epidemiología , Humanos , Incidencia , Masculino , Modelos Teóricos , Conducta de Reducción del Riesgo , Asunción de RiesgosRESUMEN
A mathematical model of HIV/sexually transmitted infections (STI) transmission was used to examine how linearity or nonlinearity in the relationship between the number of unprotected sex acts (or the number of sex partners) and the risk of acquiring HIV or a highly infectious STI (such as gonorrhea or chlamydia) affects the utility of sexual behavior change measures as indicators of the effectiveness of HIV/STI risk-reduction interventions. Findings indicate that the risk of acquiring HIV through vaginal intercourse is essentially a linear function of the number of unprotected sex acts and is nearly independent of the number of sex partners. Consequently, the number of unprotected sex acts is an excellent marker for the risk of acquiring HIV through vaginal intercourse, whereas the number of sex partners is largely uninformative. In general, the number of unprotected sex acts is not an adequate marker for the risk of acquiring a highly infectious STI due to the highly nonlinear per act transmission dynamics of these STIs. The number of sex partners is a reasonable indicator of STI risk only under highly circumscribed conditions. A theoretical explanation for this pattern of results is provided. The contrasting extent to which HIV and highly infectious STIs deviate from the linearity assumption that underlies sexual behavior outcome measures has important implications for the use of these measures to assess the effectiveness of HIV/STI risk-reduction interventions.
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Transmisión de Enfermedad Infecciosa , Infecciones por VIH/transmisión , Conducta Sexual , Infecciones por VIH/prevención & control , Humanos , Modelos Lineales , Evaluación de Programas y Proyectos de Salud , Conducta de Reducción del Riesgo , Enfermedades de Transmisión Sexual/prevención & control , Enfermedades de Transmisión Sexual/transmisiónRESUMEN
BACKGROUND: The most efficient sexual behavior for HIV transmission is unprotected receptive anal intercourse. However, it is unclear what role heterosexual unprotected anal sex is playing in the world's worst HIV epidemics of southern Africa. The objective is to examine the prevalence of heterosexual unprotected anal intercourse among men and women who drink at informal alcohol serving establishments (shebeens) in South Africa. METHODS: Cross-sectional surveys were collected from a convenience sample of 5037 patrons of 10 shebeens in a peri-urban township of Cape Town, South Africa. Analyses concentrated on establishing the rates of unprotected anal intercourse practiced by men and women as well as the factors associated with practicing anal intercourse. RESULTS: We found that 15% of men and 11% of women reported anal intercourse in the previous month, with 8% of men and 7% of women practicing any unprotected anal intercourse. Multiple logistic regression showed that younger age, having primary and casual sex partners, and meeting sex partners at shebeens were independently associated with engaging in anal intercourse. Mathematical modeling showed that individual risks are significantly impacted by anal intercourse but probably not to the degree needed to drive a generalized HIV epidemic. CONCLUSIONS: Anal intercourse likely plays a significant role in HIV infections among a small minority of South Africans who patronize alcohol serving establishments. Heterosexual anal intercourse, the most risky sexual behavior for HIV transmission, should not be ignored in HIV prevention for South African heterosexuals. However, this relatively infrequent behavior should not become the focus of prevention efforts.
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Consumo de Bebidas Alcohólicas , Infecciones por VIH/epidemiología , VIH , Heterosexualidad , Conducta Sexual/estadística & datos numéricos , Adolescente , Adulto , Estudios Transversales , Femenino , Humanos , Modelos Logísticos , Masculino , Factores de Riesgo , Asunción de Riesgos , Parejas Sexuales , Sudáfrica/epidemiología , Adulto JovenRESUMEN
Mathematical modelling analyses of drug injection-related HIV risk reduction interventions can provide policy makers, researchers, and others with important information that would be difficult to obtain through other means. The validity of the results of mathematical modelling analyses that rely on secondary data sources critically depends on the model(s) employed in the analyses and the parameter values used to populate the models. A recent article in the International Journal of Drug Policy by Andresen and Boyd (2010: 70-76) utilised four different mathematical models of injection-related HIV transmission to estimate the number of HIV infections prevented by Vancouver Canada's Insite supervised injection facility (SIF). The present article reviews and critiques the mathematical models utilised in the Andresen and Boyd article, then describes an alternative-and potentially more accurate-method for estimating the impact of the Insite SIF. This model indicates that the SIF prevents approximately 5-6 infections per year, with a plausible range of 4-8 prevented infections. These estimates are far smaller than suggested by Andresen and Boyd (19-57 prevented infections).