Biomedical subjects

Steven D Pinkerton

Publications and source records attributed to Steven D Pinkerton.

At least 19 recordsLinked to original sources

PubMed2007

Can increasing awareness of HIV seropositivity reduce infections by 50% in the United States?

BACKGROUND: In 2003, US Centers for Disease Control and Prevention (CDC) announced an HIV prevention initiative that emphasized increasing the proportion of persons living with HIV who are aware of their positive serostatus. Previously, CDC set a national HIV prevention goal of reducing new infections by 50% by 2005, with increasing serostatus awareness a central goal. The objectives of this article are to examine the national epidemiologic consequences of increasing serostatus awareness and the important question of how far increasing awareness could lead toward achieving CDC's goal of a 50% reduction in incident infections. METHODS: Scenario analysis methods were used to project incident HIV infections over 1- and 10-year time horizons at varying levels of HIV seropositivity awareness. Because HIV transmission rates are several times higher for those who are unaware of their HIV seropositivity than for those who are aware, we modeled the effects of increasing awareness via HIV counseling and testing and moving people from the higher to the lower transmission category. RESULTS: Increasing awareness of HIV seropositivity via HIV counseling and testing in the United States from a baseline 75% to 95% has the potential of reducing new infections by as much as 32% in a single year. Achieving the national goal of 50% reduction seems out of reach, however. CONCLUSIONS: Reduction of new infections by 50% in the United States requires a combination of prevention services to reduce further the already low HIV transmission rate from persons aware of their HIV seropositivity and HIV risk reduction interventions for at-risk persons. Counseling and testing alone seems insufficient to meet the 50% incidence reduction goal.

AIDS Serodiagnosis↗

PubMed2006

Severely mentally ill women's HIV risk: the influence of social support, substance use, and contextual risk factors.

In structured interviews with 96 women with severe mental illness, nearly two-thirds had not used condoms during sexual intercourse in the past 3 months, more than two-thirds had sex with multiple partners, and almost one-third had been treated for a sexually transmitted infection (STI) in the past year. Women who reported fewer sexual risk context factors, such as having sex with someone the participant did not know or transactional sex, had fewer sexual partners. Larger social support networks were associated with less frequent sex after drug use. In turn, women who less often had sex after using drugs had unprotected intercourse less frequently.

Adult↗

PubMed2006

Reducing HIV transmission risk by increasing serostatus disclosure: a mathematical modeling analysis.

Persons living with HIV infection are encouraged to disclose their HIV-positive serostatus to prospective sex partners to decrease the likelihood of unsafe sex and HIV transmission. However, the effectiveness of serostatus disclosure as a preventive measure is not known. We developed a mathematical framework for assessing the HIV transmission risk reduction effectiveness of serostatus disclosure, examined how increasing the disclosure rate affects the transmission risk reduction effectiveness of disclosure, and explored the interaction between condom use and disclosure effectiveness. Under base-case assumptions, serostatus disclosure reduced the risk of HIV transmission by between 17.9% and 40.6% relative to no disclosure. Increasing the disclosure rate from the base-case value of 51.9-75.7% produced a 26.2-59.2% reduction in risk. The findings of this modeling study strongly support intervention efforts to increase both serostatus disclosure and condom use by persons living with HIV.

Condoms↗

PubMed2006

Conflicting messages: how criminal HIV disclosure laws undermine public health efforts to control the spread of HIV.

Twenty-three U.S. states currently have laws that make it a crime for persons who have HIV to engage in various sexual behaviors without, in most cases, disclosing their HIV-positive status to prospective sex partners. As structural interventions aimed at reducing new HIV infections, the laws ideally should complement the HIV prevention efforts of public health professionals. Unfortunately, they do not. This article demonstrates how HIV disclosure laws disregard or discount the effectiveness of universal precautions and safer sex, criminalize activities that are central to harm reduction efforts, and offer, as an implicit alternative to risk reduction and safer sex, a disclosure-based HIV transmission prevention strategy that undermines public health efforts. The article also describes how criminal HIV disclosure laws may work against the efforts of public health leaders to reduce stigmatizing attitudes toward persons living with HIV.

Criminal Law↗

PubMed2006

Sexual risk and HIV acquisition among men who have sex with men travelers to Key West, Florida: a mathematical modeling analysis.

The present study investigated the sexual risk behaviors of men who have sex with men (MSM) traveling to a popular gay tourist destination in the United States. In 2004, a brief survey was administered to 247 MSM tourists recruited from gay-oriented venues in Key West, Florida. Data collected included demographics, HIV status, length of stay, substance use, and sexual risk behaviors. A probabilistic model of HIV transmission was used to translate participants' reports of their sexual behaviors while in Key West into estimates of their risk of acquiring HIV. Twenty-two percent of participants reported anal sex with multiple partners over a relatively brief period (M = 4.1 days), and approximately one third reported having sex with a partner met during the vacation period. Modeling analyses suggested that sexual activity among vacationing MSM would account for approximately 201 new HIV infections among MSM visitors to Key West each year. Although previous studies have documented sexual risk behavior in travelers, quantitative estimates of the impact of these behaviors on the spread of HIV are lacking. Findings suggest that the risk-taking behavior of MSM on vacation may play an important role in the dissemination of HIV and other sexually transmitted diseases (STDs). Future research should assess additional factors (e.g., use of highly active antiretroviral therapy) that may affect HIV transmission in MSM travelers. In addition, efforts are needed to develop effective risk-reduction interventions for this population.

Adult↗

PubMed2006

Substance use, medications for sexual facilitation, and sexual risk behavior among traveling men who have sex with men.

OBJECTIVES: The objective of the study was to examine correlates of sexual risk behavior among men who have sex with men (MSM) traveling for leisure. STUDY DESIGN: MSM (N = 304) visiting popular tourist areas completed a brief survey assessing sexual behavior and substances used while on vacation, including the use of erectile dysfunction medications (e.g., Viagra). RESULTS: Forty-seven percent of the respondents were sexually active during their vacation, with a mean of 1.33 unprotected anal sex acts during their brief stay (mean = 3.6 days). More than half of the sexually active men reported sex with a partner of unknown HIV status. Individuals reporting substance use or taking erectile dysfunction medications reported higher rates of sexual risk behaviors. CONCLUSION: Many MSM travelers report behaviors that may put their health at risk, including substance use and unprotected sexual activity. Interventions designed to reduce risk behaviors among MSM tourists are needed.

Adult↗

PubMed2006

HIV risk behavior in male and female Russian sexually transmitted disease clinic patients.

Russia is experiencing one of the fastest growing HIV epidemics in the world. Russian sexually transmitted disease (STD) clinic patients are at elevated risk for infection with HIV and other STDs due to unsafe sexual behaviors. Future risk reduction intervention efforts for this group must be grounded in a solid understanding of the factors associated with risky behaviors. We collected information about the sexual behaviors, substance use, protective strategies, and HIV-related attitudes of 400 high-risk men and women presenting at an STD clinic in a major Russian metropolis. Alcohol use in conjunction with sexual activity was common in this sample (85%). One-third of study participants had more than 1 partner in the past 3 months, and about half (48%) of the sample had previously been diagnosed with an STD. However, despite this evidence of high-risk behavior, most participants (67%) reported using condoms less than half the time. High-risk behavior was associated with substance use and lower perceived severity of AIDS. Self-protective strategies differed by gender: men reported higher condom use rates whereas women reported efforts to limit their number of sexual partners. This study has important implications for the development of culturally tailored interventions to help stem the spread of HIV in Russia.

Adolescent↗

PubMed2005

Predicting HIV transmission risk among HIV-infected men who have sex with men: findings from the healthy living project.

OBJECTIVE: To examine the predictors of transmission risk among HIV-infected men who have sex with men (MSM) in 4 US cities. METHOD: Individual computer-assisted interviews assessing psychologic measures and sexual behavior with the 5 most recent male and female partners were conducted with a diverse sample of 1910 HIV-infected MSM recruited from community and clinic settings in San Francisco, New York, Los Angeles, and Milwaukee. Transmission-risk events were defined as unprotected vaginal or anal sex with a partner who was HIV negative or of unknown status. RESULTS: A small but not insignificant proportion of MSM (12.7%) reported at least 1 transmission-risk event in the previous 3 months, with 57% of those events taking place with casual as opposed to steady partners. Multivariate predictors of transmission risk with casual partners were stimulant (eg, crystal methamphetamine) and other drug use, having low coping self-efficacy, and not having disclosed one's HIV serostatus to all partners. Stimulant use and failing to disclosing one's serostatus to all partners were associated with risk in primary relationships. CONCLUSIONS: Responding to HIV transmission risk in MSM requires different strategies for primary and casual partners.

HIV Infections↗

PubMed2005

Evidence of a brief surge in safer sex practices after HIV testing among a sample of high-risk men and women.

OBJECTIVES: We investigated the association between recent HIV testing and safer sex among clients of a publicly funded sexually transmitted disease (STD) clinic. METHODS: Of 401 men and women who were anonymously assessed on sexual risk, HIV testing, STD history, motivations for behavior change, and exposure to HIV prevention education, we studied 292 sexually active respondents who reported previous testing for HIV. Outcome measures included condom use at last intercourse and frequent (at least "most of the time") condom use during the past 3 months. Logistic regression was used to examine the association between each outcome and length of time since HIV testing, controlling for other putative predictors of condom use. RESULTS: The sample consisted mainly of African-American (79%) heterosexual (95%) men and women, almost half (44%) of whom were less than 26 years old. Regression analyses indicated that recent HIV testing was significantly associated with safer sex. Prevalence of condom use at last intercourse was highest among respondents who received an HIV test <3 months before the survey, whereas frequent condom use during the past 3 months peaked among clients who had been tested 3 to 5 months before assessment. CONCLUSIONS: The occurrence of a brief "surge" in safer sex among recent HIV counseling and testing clients, regardless of serostatus, suggests that these individuals may be particularly amenable to additional interventions designed to achieve longer term reductions in risky behaviors.

Adult↗

PubMed2005

Cost-effectiveness of a community-level HIV risk reduction intervention for women living in low-income housing developments.

We conducted a cost-effectiveness analysis of a multi-site community-level HIV prevention trial that enrolled women living in 18 low-income housing developments in 5 U.S. cities. A mathematical model of HIV transmission was used to estimate the number of HIV infections averted and quality-adjusted life years (QALYs) saved by the community-level intervention, based on data obtained from community-wide sexual behavior surveys at baseline and 12-month follow-up. Results indicated that the intervention prevented approximately 1 infection per 3500 women reached by the intervention, at a total cost of 174,845 dollars. The cost per QALY saved by the intervention was 37,433 dollars and the cost per HIV infection averted was 732,072 dollars. The community-level intervention was moderately cost-effective in comparison with other HIV prevention programs for at-risk women. Synergistic approaches to HIV prevention that combine community-level sexual norm change interventions with more intensive risk reduction programs for high-risk women are needed. EDITORS' STRATEGIC IMPLICATIONS: The authors present a promising and efficient community-level HIV prevention approach, with effects beyond the limited scope of individual or small group interventions. This paper represents an example of how an analysis of cost-effectiveness can provide policymakers with information needed for difficult decisions about prevention resource allocations.

Adult↗

PubMed2004

Cost-effectiveness of HIV postexposure prophylaxis following sexual or injection drug exposure in 96 metropolitan areas in the United States.

OBJECTIVES: To evaluate the cost-effectiveness of HIV postexposure prophylaxis (PEP) following sexual or injection-related exposures in 96 metropolitan statistical areas in the United States (MSA). DESIGN: Empirical, model-based cost-effectiveness analysis. METHODS: Epidemiological and population size estimates from the literature were combined with information about the distribution of exposure types, PEP completion rate, proportion of source partners known to be HIV infected, and PEP program costs obtained from a feasibility study of PEP in San Francisco to estimate the cost-effectiveness of hypothetical PEP programs in each of the 96 MSA. The effectiveness of combination antiretroviral therapy following sexual or drug use-related exposures, which is presently not known, was assumed equal to the effectiveness of zidovudine monotherapy in the occupational setting. The main outcome measure was the cost-utility ratio, defined as the cost per quality-adjusted life year (QALY) saved by the PEP intervention. RESULTS: The cost-utility ratios for the 96 MSA ranged from 4137 dollars to 39,101 dollars per QALY saved; only two of the ratios exceeded 30,000 dollars per QALY saved. Combined across the 96 MSA, the hypothetical PEP programs would reach nearly 20,000 clients at a total cost of approximately 22 million dollars. The overall cost-utility ratio across MSA was 12,567 dollars per QALY saved. The majority of the HIV infections prevented by PEP were among men and women who reported receptive anal intercourse exposure. CONCLUSIONS: PEP following sexual or drug use-related exposures could be a cost-effective complement to existing HIV-prevention efforts in most MSA across the United States.

Chemoprevention↗

PubMed2004

Distance communication transfer of HIV prevention interventions to service providers.

Most acquired immunodeficiency syndrome (AIDS) service providers are in countries with little access to scientific developments relevant to their programs. It is critical to transfer advances from the scientific arena to service providers on a global scale. Human immunodeficiency virus (HIV) prevention organizations in 78 countries were randomized to receive either a control condition or a technology transfer condition with an interactive distance learning computer training curriculum and individualized distance consultation. Of 42 nongovernmental organizations in the technology transfer condition, 29 adopted the science-based program in their communities or trained other agencies to also use it. Advanced communication technologies can create a cost-effective infrastructure to disseminate new intervention models to service providers worldwide.

Communication↗

PubMed2004

HIV transmission risk behavior among men and women living with HIV in 4 cities in the United States.

Determining rates of HIV transmission risk behavior among HIV-positive individuals is a public health priority, especially as infected persons live longer because of improved medical treatments. Few studies have assessed the potential for transmission to the partners of HIV-positive persons who engage in high-risk activities. A total of 3723 HIV-infected persons (1918 men who have sex with men [MSM], 978 women, and 827 heterosexual men) were interviewed in clinics and community-based agencies in Los Angeles, Milwaukee, New York City, and San Francisco from June 2000 to January 2002 regarding sexual and drug use behaviors that confer risk for transmitting HIV. Less than one quarter of women and heterosexual men had 2 or more sexual partners, whereas 59% of MSM reported having multiple partners. Most unprotected vaginal and anal sexual activity took place in the context of relationships with other HIV-positive individuals. Approximately 19% of women, 15.6% of MSM, and 13.1% of heterosexual men engaged in unprotected vaginal or anal intercourse with partners who were HIV-negative or whose serostatus was unknown. The majority of sexually active participants disclosed their serostatus to all partners with whom they engaged in unprotected intercourse. An estimated 30.4 new infections (79.7% as a result of sexual interactions with MSM) would be expected among the sex partners of study participants during the 3-month reporting period. Eighteen percent of 304 participants who injected drugs in the past 3 months reported lending their used injection equipment to others. In addition to the more traditional approaches of HIV test counseling and of focusing on persons not infected, intensive prevention programs for persons with HIV infection are needed to stem the future spread of the virus.

Adult↗

PubMed2004

Cost-effectiveness of postexposure prophylaxis after sexual or injection-drug exposure to human immunodeficiency virus.

BACKGROUND: The cost-effectiveness of interventions that provide human immunodeficiency virus (HIV) postexposure prophylaxis (PEP) to individuals after sexual or injection-drug use exposures depends on the distribution of exposure routes, prevalence of infection among source partners, adherence to PEP regimens, medical care costs, and prevailing epidemiologic contexts, among other factors. OBJECTIVE: To determine the cost-effectiveness of a comprehensive program to prevent HIV infection after sexual or injection-drug use exposure for 401 persons seeking PEP in an urban community. METHODS: We conducted a retrospective cost analysis to evaluate the cost of the PEP intervention, then combined this information with model-based effectiveness estimates to determine the PEP program's "cost-utility ratio," which is the ratio of net program costs to the total number of quality-adjusted life-years (QALYs) saved by the program. RESULTS: The average cost of the PEP regimen was $1222, and the total cost of the program was $450 970. The PEP program prevented an estimated 1.26 HIV infections, saved 11.74 QALYs, and averted $281 323 in future HIV-related medical care costs. The overall cost-utility ratio was $14 449 per QALY saved. When analysis was restricted to men reporting receptive anal intercourse, the savings in averted HIV-related medical care costs exceeded the cost of the program. The results were generally robust to changes in key parameter values but were sensitive to assumptions about the HIV transmission probability for receptive anal intercourse. CONCLUSIONS: For this study population, HIV PEP was cost-effective by conventional standards and cost-saving for persons seeking PEP after male-male receptive anal intercourse.

Anti-HIV Agents↗

PubMed2004

A comparison of HIV/AIDS knowledge and attitudes of STD clinic clients in St. Petersburg, Russia and Milwaukee, Wi, USA.

Over the last decade, Russia has experienced alarming increases in rates of HIV and other sexually transmitted diseases (STDs). Most empirically validated HIV-prevention studies have been conducted in the United States or other developed nations and it is unclear the extent to which these techniques may be useful in the different conditions found in Eastern Europe. The present study compared HIV/AIDS knowledge, attitudes toward condoms, perceived vulnerability to HIV, and attitudes towards HIV testing in samples of 400 Russian and 401 American STD clinic patients. Participants in both samples exhibited knowledge deficits. Overall, Russians had less accurate HIV transmission knowledge, fewer sources of HIV-relevant information, and lower perceived vulnerability to HIV/AIDS. In both countries, a desire to be tested for HIV was related to perceived vulnerability to the disease. American participants were more likely to indicate that they planned to be tested (or re-tested) for HIV in the future (88%) relative to Russian participants (40%). Americans also were more likely to have been tested in the past. Results suggest that interventions designed to work with STD clinic patients are urgently needed but that appropriate intervention strategies may differ from one country to the other, reflecting the more advanced state of the HIV epidemic in the United States vs. the emerging epidemic in Russia.

Acquired Immunodeficiency Syndrome↗

PubMed2004

Estimates of the annual number and cost of new HIV infections among women attributable to trichomoniasis in the United States.

BACKGROUND: Clinical evidence suggests that trichomoniasis facilitates the sexual transmission and acquisition of HIV. GOAL: The goal of this study was to estimate the annual number and cost of new HIV infections among women in the United States attributable to trichomoniasis. STUDY: We used a mathematical model of HIV transmission to estimate the probability that a woman with trichomoniasis would acquire HIV as a result of her trichomoniasis-mediated increased susceptibility to HIV infection or as a result of increased HIV infectiousness in a trichomoniasis-infected male partner. RESULTS: Our results indicate that each year in the United States, an estimated 746 new HIV cases among women can be attributed to the facilitative effects of trichomoniasis on HIV transmission. The lifetime cost of treating these trichomoniasis-attributable HIV infections is approximately $167 million. CONCLUSIONS: Efforts to prevent trichomoniasis could help prevent HIV transmission and could reduce the economic burden associated with trichomoniasis-attributable HIV cases that occur each year. Because trichomoniasis is so common, however, a substantial number of cases would need to be detected and treated to have a discernible impact on HIV. Future research is needed to examine the cost-effectiveness of trichomoniasis prevention as a tool for HIV prevention.

Disease Susceptibility↗

PubMed2004

Toward rational criminal HIV exposure laws.

This article examines criminal HIV exposure statues that address undisclosed exposure through consensual sexual activity. Twenty-seven U.S. states have adopted some form of HIV exposure statute. Thirteen of these statutes specifically address exposure through sexual activity, while another eleven statutes could be applied to exposure through sexual activity, while another eleven statutes could be applied to exposure through consensual sexual interactions. Although the penalties for breach of these laws are often severe, the risk of actual harm posed by the many of the behaviors prescribed is minimal and in some cases virtually nonexistent. After an overview of the various types of U.S. criminal HIV exposure statutes and discussion of the risk of HIV transmission through the various sexual activities addressed in the laws, the authors highlight the tenuous relationship between proscribed activities and actual risk of virus transmission. The authors address this limitation in the law by offering a framework for the evaluation and construction of HIV exposure statutes that considers not only the intent of the HIV-positive actor but also the risk that his or her conduct poses to others.

Communicable Disease Control↗

PubMed2003

Economic implications of failure to reduce incident HIV infections by 50% by 2005 in the United States.

BACKGROUND: The Centers for Disease Control and Prevention have set a national goal of reducing new HIV infections by 50% by 2005 in the United States. There are no available published estimates of the economic consequences of failure to meet this national goal, however. OBJECTIVES: The purpose of this article is to calculate the potential net economic implications of a failure to meet the national HIV prevention goal of reducing new HIV infections by 50% by 2005. METHODS: Standard methods of cost-effectiveness analysis were used to determine 1) the excess number of HIV infections incurred if the goal is not met and 2) the excess net medical costs (without the cost of an expanded HIV prevention program in the United States) incurred if the goal is not achieved. RESULTS: Base case results indicate that if the goal is not met, 130,000 excess HIV infections will occur between the present and 2010 and that the excess net medical costs incurred will total over $18 billion during the same time frame. Sensitivity analyses indicate that although changes in some parameter values do alter the quantitative results, none alter the basic qualitative finding that even dramatically expanded HIV prevention efforts that reduce new HIV infections by 50% are actually cost saving to society. CONCLUSIONS: The human and fiscal stakes of meeting the CDC's national HIV prevention goal of reducing new infections by 50% by 2005 are sufficiently large to make the achievement of this goal an urgent public health priority.

Centers for Disease Control and Prevention, U.S.↗