Fu, Amy Nunn, Curt G. In the United States, the human immunodeficiency virus HIV epidemic among heterosexual men disproportionately affects individuals involved with the criminal justice system, injection drug and other substance users, and racial and ethnic minorities. These overlapping populations confront similar social and structural disparities that contribute to HIV risk and limit access to HIV testing, treatment, and care.
In this review, we discuss barriers to linkage to comprehensive HIV care for specific subpopulations of heterosexual men and examine approaches for enhancing linkage to care for this diverse population.
HIV-infected men are also more likely to receive a diagnosis late in the course of infection
Heterosexual men 3 ] and have lower CD4 cell counts when care is initiated [ 4 ]. Significant racial and ethnic disparities in HIV infection persist. Racial and ethnic minorities are
Heterosexual men disproportionately represented among late diagnoses and are significantly more likely to experience delayed linkage to care [ 5—11 ].
Modes of HIV transmission among men have changed during the last decade [ 12 ]. Increasing rates of heterosexual HIV transmission underscore the potential for a more generalized heterosexual HIV epidemic, and studies in Washington, DC, and Baltimore, Maryland, have identified this trajectory in marginalized urban communities [ 1213 ].
In describing these disparities and risks, clinicians and researchers need to be particularly cautious about protecting sensitive health information, such as drug use and sexual risk-taking behaviors. Other studies have used technology such as audio computer-assisted self-interviews to improve rates of reporting of sensitive behaviors and to reduce socially desirable responding [ 23—26 ].
In this review, we discuss barriers to linking specific subpopulations of heterosexual men to comprehensive HIV care and examine approaches for enhancing the linkage to care for this diverse population. During the past 2 decades, there has been a significant decline in IDU-related HIV infections [ 27—29 ], probably in part because of increases in HIV prevention programs
Heterosexual men to IDUs, including syringe exchange programs [ 3031 ].
Despite these declines, IDU-related HIV transmission continues to affect racial and ethnic minorities at disproportionate rates, particularly African American men [ 32 ]. Among African Americans in high-risk communities in Houston, Texas, Risser et al found that individuals reporting both IDU and heterosexual anal intercourse had 6. These findings demonstrate the need
Heterosexual men coordinated efforts between researchers, policymakers, and outreach and community-based organizations to address late HIV diagnoses among IDUs and to target interventions to the needs of specific IDU subpopulations.
Booth et al found that crack cocaine smokers and crack cocaine—smoking IDUs were more likely to report
Heterosexual men multiple sexual partners and exchanging sex for drugs or money than those who only injected [ 36 ]. McCoy et al found that, compared with neighborhood controls, crack cocaine smokers were 2.
Alcohol use has also been shown to be an important mediator of high-risk sexual behavior among men [ 3839 ], with additional studies finding strong associations between alcohol use and HIV incidence [ 4041 ]. Methamphetamine use is yet another emerging risk factor for HIV infection among heterosexual men [ 4243 ]. Understanding risk factors among men who have sex with men and women MSMW and adapting "Heterosexual men" prevention interventions should be
Heterosexual men, given the potential of MSMW to bridge the epidemics between sexes. Hook up two modems one phone line
In a sample of mostly low-income, unemployed, minority MSMW, Gorbach et al found that sexual and drug use networks were highly interconnected [ 46 ].
Another characteristic of the changing HIV
Heterosexual men among heterosexual males in the United States is the increasing number of HIV-infected persons who are foreign born [ 47 ].
This includes legal and illegal immigrants as well as refugees and asylum seekers. The regulatory change in that removed HIV infection from the list of communicable diseases of public health significance among foreign immigrants may affect the proportion of foreign-born HIV-infected persons in the United States in the coming
Heterosexual men [ 48 ]. Before this change, HIV-infected immigrants were inadmissible to the country without a government waiver.
Heterosexual risk is the predominant mode of HIV transmission among many foreign-born populations [ 4950 ]; however, relatively little is known about the epidemiology of HIV infection in these populations and the extent to which these individuals engage in HIV care after arrival in the United States. Large numbers of HIV-infected individuals pass through correctional facilities each year. Access and adherence to antiretroviral treatment can often be most difficult in the period immediately after release from incarceration.
Recently released individuals are at elevated risk
Heterosexual men relapse to drug use and sexual and drug-related risk behaviors [ 52—58 ] and have difficulty securing stable housing and employment [ 59—61 ]. These stressors during community reentry may disrupt engagement in care and lead to worsened virologic outcomes as well as increase the risk of secondary HIV transmission [ 62—64 ]. Newly released "Heterosexual men" American and Latino inmates in Heterosexual men have difficulty accessing antiretroviral treatment ART in the community [ 65 ].
The majority of correctional facilities provide some type of discharge
Heterosexual men for HIV-positive inmates T. Kuck, unpublished data,and studies have found that inmates who receive such "Heterosexual men" are more likely to engage in HIV treatment and care in the community [ 6166 ]. Because recently released Heterosexual men inmates confront a multitude of challenges during community reentry, initiating and remaining engaged in community-based care often requires intensive and sustained assistance that addresses barriers such as substance dependence, mental illness, unstable housing, unemployment, and lack of health insurance.
Intensive case management can be successful in engaging recently released HIV-infected prisoners into medical care and providing linkage to social services [ 63 ].
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Newly released HIV-infected individuals are also more likely to fill a prescription for ART within 10, 30, or 60 days of release if they receive assistance from a community caseworker in completing the AIDS Drug Assistance Program application [ 65 ]. Kuck, unpublished data, Organized discharge planning and intensive case management are critical to facilitating successful linkage to and retention in care within this population and
Heterosexual men be implemented Heterosexual men a wide scale.
Substance use frequently undermines the medical management of HIV among HIV-infected substance users
Heterosexual men 68 ], who are also more likely to experience high levels of socioeconomic instability and have limited health care access and utilization [ 68—70 ].
In a systematic review of 41 studies examining the relationship between substance use and adherence to ART, Malta et al found that active substance use was widely associated with poor ART adherence [ 71 ]. In turn, these associations may create reluctance among physicians to initiate combination ART in active substance users [ 72 ].
Involvement with the criminal justice system further complicates the provision of HIV care for substance users. Furthermore, because of the limited provision of substance-dependence treatment such as opiate replacement therapy ORT in correctional facilities [ 74 ], substance-dependent individuals undergoing treatment with buprenorphine or methadone in the community may not be able to continue treatment while incarcerated [ 75 ].
As a result, they may undergo withdrawal and be less inclined to reinitiate treatment after release [ 75 ], which may increase their risk of relapse to drug use and significantly affect their ability to engage in
Heterosexual men treatment and care. Recently, studies in several cities have demonstrated the feasibility and effectiveness of linking prisoners to ORT during incarceration and after release [ 76—84 ]. Despite the challenges to engaging and retaining this population in care, a number of different treatment interventions targeted to Heterosexual men substance users have achieved favorable clinical outcomes.
Smith-Rohrberg et al conducted a randomized, controlled trial of directly administered ART for IDUs and found improved virologic and immunologic outcomes as well as improved adherence [ 85 ]. Integrating substance
Heterosexual men and HIV treatment is an approach to engaging substance users in care that directly addresses substance use and its associated complications. The efficacy of integrating ORT and HIV treatment has been increasingly examined and models that integrate treatment with buprenorphine-naloxone into HIV primary care have recently been successfully piloted [ 6886—89 ].
Medication-assisted treatment is also available for individuals dependent on cocaine, methamphetamine, or alcohol, although more work is needed to explore the potential for integrating these therapies with ART and HIV care [ 90 ]. Case management and colocation of services can also enhance linkage to care for substance users [ 91 ], although interventions using case management alone may be less effective than direct linkage to substance-dependence treatment in this population [ 92 ].
In their study, Smith-Rohrberg "Heterosexual men" al assessed the impact of colocated medical, case management, and referral to substance abuse services among drug users
Heterosexual men directly administered ART and found that greater utilization of onsite medical and case management services was independently associated with improved virologic outcomes [ 85 ].
The impact of case management on engagement and retention in care has also been demonstrated among substance-using homeless populations [ 9394 ]. Broadhead et al confirmed the feasibility of using peer health advocates to engage HIV-infected drug users in care and described this social support structure as a more accessible alternative in the context of limited access to integrated substance-dependence treatment and HIV care.
In a modeling analysis using data from the national HIV Research Network to describe HIV survival disparities among specific racial and ethnic groups, Losina et al found that late initiation and early discontinuation of ART were most pronounced among Hispanic subjects, with an additional 3. In a retrospective cohort study, Ulett et al found 2. Racial and ethnic minorities experience
Heterosexual men marginalization from the health care system and are more likely than their white counterparts to receive lower quality medical care [ 791098— ].
Distrust of the health care system can pose an additional barrier to engaging HIV-infected African American and Latino persons in treatment and care [ — ]. The complex interplay between social, cultural, and economic
Heterosexual men to care among African American and Latino populations is not fully understood.
However, socially and culturally sensitive linkage interventions have been developed in a manner consistent with the adaptation of culturally sensitive and client-centered HIV prevention interventions .
Peer and outreach-based interventions that address structural barriers to care have demonstrated
Heterosexual men in linking marginalized racial and ethnic minorities to treatment. The California Bridge Project used peer-based staff in outreach to locate out-of-treatment HIV-infected individuals [ ]. Nearly a third of the predominantly African American and Latino clients who reported no history of HIV treatment were linked to care.
African American and
Heterosexual men clients had 2.
An average of Rajabiun et al conducted qualitative interviews with predominantly underserved African American and Latino HIV-positive individuals at 7 sites of the Health Resources and Services Administration—funded Outreach Initiative to identify components of outreach programs that contributed to engagement and retention in HIV care by these populations [ ].
Outreach staff improved access to care through locating physicians and clinics, linking clients to health insurance, accompanying them to medical appointments, and facilitating communication with providers.
Forty-five percent of participants achieved undetectable viral loads by 12 months [ ]. Randomized, controlled trials are needed to assess the effect of outreach-based interventions on initiating and retaining disadvantaged minority populations in care [ ].
The feasibility of integrating outreach interventions with substance-dependence treatment should also be explored [ 70, ]. Interventions that incorporate case management have also been successful in enhancing linkage to care among racial and ethnic minorities. The Antiretroviral Treatment Access Study ARTAS was a brief strengths-based case management intervention implemented in health departments and
Heterosexual men organizations that "Heterosexual men" client identification of strengths and abilities and the development of a personalized plan to acquire needed resources.
Hispanic subjects were more likely to be engaged in HIV care than other racial and ethnic groups odds ratio,
Heterosexual men. Gardner et al conducted a randomized controlled trial of ARTAS in 4 states, comparing the efficacy of passive referral to a case management intervention in linking persons recently diagnosed to care. The intervention had a Heterosexual men impact on Hispanic participants relative risk, 2. Colocation of medical care Heterosexual men other support services has also been shown to be an important factor in engaging marginalized racial and ethnic minorities in care.
Individuals who participated in the ARTAS intervention at a site colocated with HIV medical care providers were more likely to be linked to care [ ]. In a program designed to facilitate HIV health care utilization among mostly minority populations in Bronx, New York, through colocation of case management, support groups, mental health, and harm reduction services, Cunningham et al
Heterosexual men that case management and HIV support group visits were associated with 1.
In summary, factors such as substance use, poverty, unemployment, lack of educational opportunities, and marginalization from the health
Heterosexual men system constitute multilevel barriers to care for vulnerable subpopulations of HIV-infected heterosexual
Heterosexual men. Consequently, interventions that address social and structural barriers to care through case management, colocation of services, and outreach have been shown to enhance linkage to care across these subpopulations.
Despite the broad efficacy of these interventions, those involved with the criminal justice system, substance users, and disadvantaged racial and ethnic minorities face distinct challenges to accessing care that also require more targeted strategies. Correctional facilities have the capacity to improve the health of HIV-infected individuals beyond incarceration, where they are arguably most vulnerable, by providing organized and coordinated discharge planning and linkage to intensive case management after release.
Although substance-dependent populations
Heterosexual men especially challenging to link to and retain in care, the emergence of integrated substance use and HIV treatment offers new possibilities to engage this population. The efficacy of peer- and outreach-based interventions in linking racial and Heterosexual men minorities to care demonstrates the importance of socially and culturally sensitive interventions that foster trust in providers and provide means of overcoming structural Heterosexual men to care.
Future work is urgently needed to scale up successful models of linkage to care and to adapt these models to local contexts. This will require additional resources, but, most importantly, it will require collaboration across agencies and institutions
Heterosexual men the innovative use of existing resources and capacities. Integration of services is an important example of improving efficiency in delivering comprehensive HIV care.
The challenge and complexity of linking HIV-infected heterosexual men to care require renewed efforts to adapt interventions to the needs of diverse subpopulations.
As has been reported previously,...
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Removable PrEP implant produces high drug levels in rabbits; further studies planned 15 November Viral load in semen rapidly rebounds to infectious levels during HIV treatment breaks 14 November Behind the scenes at European Testing Week. A long life with HIV.
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