JAIDS Journal of Acquired Immune Deficiency Syndromes:
Epidemiology and Social Science
Meta-Analysis of High-Risk Sexual Behavior in Persons Aware and Unaware They are Infected With HIV in the United States: Implications for HIV Prevention Programs
Marks, Gary; Crepaz, Nicole PhD; Senterfitt, J Walton PhD; Janssen, Robert S MD
From the Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention (CDC), Atlanta, GA.
Received for publication June 9, 2004; accepted November 4, 2004.
Reprints: Gary Marks, Division of HIV/AIDS Prevention, CDC, 1600 Clifton Road, Mailstop E-45, Atlanta, GA 30333 (e-mail: email@example.com).
Objectives: To compare the prevalence of high-risk sexual behaviors in HIV+ persons aware of their serostatus with that in HIV+ persons unaware of their status in the United States and to discuss implications for HIV prevention programs.
Methods: A meta-analysis was conducted on 11 independent findings. Six findings compared HIV+ aware persons with independent groups of HIV+ unaware persons (between-group comparisons), and 5 findings compared seroconverting individuals before and after being notified of their HIV+ status (within-subject comparisons). Outcomes were self-reported unprotected anal or vaginal intercourse (UAV) during specified recall periods.
Results: The analysis integrating all 11 findings indicated that the prevalence of UAV with any partner was an average of 53% (95% confidence interval [CI]: 45%-60%) lower in HIV+ persons aware of their status relative to HIV+ persons unaware of their status. There was a 68% reduction (95% CI: 59%-76%) after adjusting the data of the primary studies to focus on UAV with partners who were not already HIV+. The reductions were larger in between-group comparisons than in within-subject comparisons. Findings for men and women were highly similar.
Conclusions: The prevalence of high-risk sexual behavior is reduced substantially after people become aware they are HIV+. Increased emphasis on HIV testing and counseling is needed to reduce exposure to HIV from persons unaware they are infected. Ongoing prevention services are needed for persons who know they are HIV+ and continue to engage in high-risk behavior.
Sexually transmitted HIV infection may stem from 2 groups of people: HIV+ persons unaware they are infected and HIV+ persons aware of their infection status. The Centers for Disease Control and Prevention (CDC) estimates that 850,000 to 900,000 persons are living with HIV in the United States and that approximately 650,000 are aware of their status and 250,000 are not.1,2 Little is known about the relative difference between these 2 groups in exposing uninfected sex partners to HIV. A better understanding of this relative difference can help to guide public health strategies and allocation of resources to fight the HIV/AIDS epidemic in the United States.
To reduce the risk of HIV transmission, the CDC recommends a variety of interventions in medical care and community settings for those who are aware of their status. Linkage to medical care and antiretroviral therapy, which may reduce viral load and transmission risk,3-6 and ongoing behavioral interventions are important approaches for those who know they are living with HIV. To reach those who are unaware of their infection, the CDC recommends making HIV counseling and testing more accessible and acceptable for people at high risk for HIV infection.7 Of course, both strategic pathways are important, and prevention efforts can be informed by even roughly estimating the differences in sexual risk behaviors between awareness groups. We performed a meta-analysis of findings that compared the prevalence of unprotected anal and vaginal intercourse (UAV) between persons who were aware and unaware of their HIV infection.
Literature Search and Study Selection
Electronic databases, including MEDLINE, PubMed, PsycINFO, AIDSLINE, and SocioFile from January 1987 through January 2004, were searched to identify relevant published articles and conference abstracts. We crossed multiple search terms (ie, keywords and medical subject headings) reflecting 2 categories: (1) HIV status (HIV, AIDS, antibody, positive, counseling, testing, and aware) and (2) sexual behavior or sexually transmitted diseases (sexual behavior, sex, unsafe, unprotected, condom, anal, vaginal, intercourse, risk, high risk, exposure, transmission, sexually transmitted disease, STD, sexually transmitted infection, STI, gonorrhea, and syphilis). Additional material was identified from reference lists of pertinent articles. Studies were included in the meta-analysis if they met all the following criteria:
1. Data from the United States
2. Compared a group of HIV+ aware persons with an independent group of HIV+ unaware persons (ie, between-group comparison) or measured seroconverting individuals before and after notification of HIV+ status (ie, within-subject comparison)
3. Measured any of the following sexual behaviors during a specified recall period:
a. Unprotected insertive or receptive anal intercourse or unprotected vaginal intercourse
b. Consistency of condom use during sexual intercourse
c. Other sexual risk measures that combined components of the previous categories
4. Data were reported or available to calculate the prevalence of UAV (ie, 1 or more instances during the recall period)
A total of 620 abstracts were screened. Although many studies identified in the search examined the prevalence of sexual behavior or the effects of HIV testing and counseling, few of the screened sources provided the specific types of comparisons (criterion 2) needed for this meta-analysis. Four studies8-11 published in peer-reviewed journals and 4 multisite data sets met inclusion criteria. The 4 data sets were (1) the Multicenter AIDS Cohort Study (MACS),12 (2) the HIV Epidemiology Research Study (HERS),13 (3) the Supplement to HIV/AIDS Surveillance (SHAS phase 1, 1995-2000),14 and (4) SHAS phase 2 (2000-2003).15 The 2 SHAS data sets were independent (no dual participation). We obtained the data necessary for our meta-analysis directly from the investigators. The Women's Interagency HIV Study (WIHS) was also eligible for inclusion but not used because it had too few seroconversions for a meaningful analysis.
Using a standardized spreadsheet, information on the following variables was abstracted: author(s), location and/or setting of data collection, study period, sample characteristics (eg, gender), sample size, type of comparison (between-group vs. within-subject), data collection methods (self-administered vs. interviewer-administered questionnaire), sexual behavior measured, recall period, and findings.
The data abstraction was guided by the following rules:
1. If a study had independent samples of participants (eg, men, women) and reported data on each sample, we calculated an effect size (ES) for each independent sample.8,14,15
2. To ensure independence of data in the meta-analysis, only 1 sexual behavior measure per study was used in calculating the overall ES. If separate data were available for unprotected insertive and receptive anal intercourse, we included only insertive activity because it has a higher risk of transmitting HIV when performed by an HIV+ person.16 One study8 used a composite index (UAV or oral sex).
Calculation of Effect Size
Effect sizes were estimated with a prevalence ratio (PR). For between-group comparisons, the HIV+ aware groups' prevalence of UAV was divided by the HIV+ unaware groups' prevalence of UAV, resulting in the PR. For within-subject comparisons, PR was calculated by dividing the prevalence of UAV at the postnotification period by the prevalence at the prenotification period. For each type of comparison, 1−PR was then calculated to reflect the percentage reduction in the prevalence of UAV in aware groups relative to unaware groups (or prenotification vs. postnotification period).
Standard meta-analytic methods were used.17,18 A random-effects model for aggregating individual ESs was used because it provides a more conservative estimate (than a fixed-effects model) of the variance and generates more accurate inferences about a population of studies beyond those included in the review.19 We first used the natural logarithm to obtain the log PR (lnPR) and calculated its corresponding weight (ie, inverse variance) for each independent sample. For within-subject comparisons, the variance of lnPR was adjusted for nonindependence of pre- and postnotification sexual behavior before aggregation (Appendix). To calculate the overall ES, we multiplied each lnPR by its weight, summed the weighted lnPR across samples, and then divided by the sum of the weights. In presenting the results, the aggregated lnPR was converted back to the PR by exponential function. 1−PR was then derived, along with a 95% confidence interval (CI).
Sensitivity analyses examined the effect of outliers by comparing the aggregated ES with estimates obtained after iterations using k−1 findings (k = number of independent samples). In other words, we removed a finding and calculated the aggregated ES. We then replaced that finding, removed another, and repeated the process. Stratified analyses were also conducted to examine whether ESs differed by type of comparison (between-group vs. within-subject) and gender of participants (men vs. women).
Adjustment for HIV Serostatus of Sex Partners
The meta-analysis was conducted with and without applying an adjustment factor to primary studies that assessed self-reported sexual behavior with any partner.8-10,12,14 Data on the prevalence of UAV with any partner may bias the meta-analysis, because some people who know they are HIV+ only have unprotected sex with partners perceived to be HIV+.20-22 The adjustment factor focused the analysis on behavior with partners at risk for infection.
The adjustment was applied to the prevalence data of HIV+ aware participants (or prevalence during the postnotification period) before conducting the meta-analysis. The adjustment was not applied to the HIV+ unaware group (or prenotification period) under the reasonable assumption that unawareness leaves risky behavior patterns unaltered and that persons who are unaware of their infection are not likely to be having unprotected sex only with HIV+ partners. Accordingly, we assume that some of their sexual activity is with persons at risk for infection.
The empirically derived adjustment factor was calculated with data from 6 US studies conducted from 1995 to 2001 (J. L. Richardson, S. Stoyanoff, J. Milam, et al, unpublished data, 1999)22-26 different from those in the meta-analysis. The participants in the “adjustment studies” were all aware of their HIV+ status and were recruited at a variety of locations (eg, HIV clinics, AIDS service organizations, bars, clubs). The adjustment studies contained data on self-reported UAV with any partners and with partners reported to be HIV+. The behavioral window varied (eg, past 3 months, last 2 sexual encounters). Half of the studies used self-administered surveys, and the other half used face-to-face interviews.
For each adjustment study, we first calculated the percentage of participants who engaged in UAV with any partner (factor “A”). Next, participants who engaged in those risk behaviors only with partners reported to be HIV+ were removed from the numerator. The percentage was then recalculated using all participants in the denominator to estimate the prevalence of UAV with partners at risk for infection (factor “B”). Dividing this “at-risk prevalence” (B) by the “any partner prevalence” (A) and then subtracting from 1 (ie, 1−B/A) yields the percentage reduction in the prevalence of UAV with at-risk partners relative to any partner. Calculations were performed for 3 groups to identify appropriate adjustment indices for the samples in the meta-analysis: men who have sex with men (MSM; 5 samples), men in general (4 samples that pooled MSM and heterosexual men), and women (3 samples).
The adjustment index was calculated as the unweighted average of the reductions across studies within each group. The unweighted average minimizes the influence of sample size and methodologic factors that may affect behavioral assessment. The unweighted average reduction was 43% (range: 27.3%-52.5%) for MSM, 47.5% (range: 42.0%-51.8%) for men in general, and 45.1% (range: 38.9%-56.0%) for women. These indices were applied only to studies that assessed UAV with any partner. For example, HIV+ aware MSM's prevalence of UAV with any partner was reduced 43% to derive an estimated prevalence of UAV with at-risk partners. The adjustment factor was not applied to studies that assessed behavior with at-risk partners (study by Colfax et al,11 SHAS phase 2 data set), nor was it applied to “casual partners” (HERS data set), because many of those casual partners were probably at risk. Sensitivity analyses examined whether there were any changes in the meta-analytic results when the adjustment index was calculated as a weighted average (ie, applying an inverse variance weight to each adjustment study before averaging).
Eleven independent findings from 1988 through 2003 were included in the meta-analysis. Six were between-group comparisons, and 5 were within-subject comparisons. Table 1 presents the characteristics of the studies and the unadjusted findings. Every study showed that the prevalence of UAV was lower in the HIV+ aware group (or postnotification period) compared with the HIV+ unaware group (or prenotification period).
Two sets of results of the random-effects models are presented in Table 2: findings based on the unadjusted data and findings based on data adjusted to focus on at-risk sex partners. The combined ES for all 11 findings in the unadjusted model indicates that the prevalence of UAV was an average of 53% (95% CI: 45%-60%) lower in HIV+ aware persons relative to HIV+ unaware persons. The reduction was 68% (95% CI: 59%-76%) in the adjusted model (k = 11). Each of these reductions differed significantly from 0 (Z > 25, P < 0.001). In both models, the reduction was significantly larger in the between-group findings (k = 6) compared with the within-subject findings (k = 5) (unadjusted model: χ(1)2 = 38.71, P < 0.0001; adjusted model: χ(1)2 = 8.32, P < 0.01). The ESs of the men and women did not differ significantly in either model (unadjusted: χ(1)2 = 0.18, P > 0.50; adjusted: χ(1)2 = 2.47, P > 0.10).
Sensitivity analyses indicated that no individual finding appreciably affected the overall (k = 11) or between-group (k = 6) ES in the two models. The ESs were affected less than ±3% (eg, absolute change from 68% to 70% reduction in the prevalence of UAV) with any single finding removed. For the unadjusted and adjusted models, the within-group ES (k = 5) changed no more than ±5% and the men's ES (k = 7) changed no more than ±4%. There was slightly more instability in the women's aggregated findings. The ES changed no more than ±4% in the women's unadjusted model but changed up to 8% in the adjusted model. For example, the ES was reduced nearly 8% in the adjusted model when the SHAS phase 1 finding was removed and was increased 4% in the adjusted model when the SHAS phase 2 finding was removed. These individual findings (especially the SHAS phase 1 finding) were heavily weighted in the aggregated analysis because of large sample sizes. In summary, the overall models (k = 11) showed a high level of stability. The stability decreased only slightly when analyses were performed separately for between-group and within-subject comparisons. The stability of the men's data exceeded the stability of the women's data in the adjusted model.
Finally, we examined the effect of using a weighted (as opposed to an unweighted) average of the adjustment studies that focused the analysis on at-risk sex partners. The meta-analytic findings were virtually identical when using these 2 methods (absolute difference of 1% in the estimated ESs).
Our meta-analysis shows that the prevalence of high-risk sexual behavior is markedly lower in HIV+ persons aware of their seropositive status than in HIV+ persons unaware of their status. The findings of studies conducted in the United States from 1988 through 2003 were highly consistent despite methodologic differences among the investigations. A highly similar picture emerges from studies that examined STD acquisition rates between HIV-infected aware and unaware persons.27-30 These studies were not included in the meta-analysis because of the qualitatively different nature of the outcome variable and the fact that the partner serostatus adjustment could not validly be applied to those studies. Of persons presenting at an STD clinic in New Orleans (1989-1991) with a first-time diagnosis of gonorrhea, new gonorrhea diagnoses were 50% lower during 2 to 3 years of follow-up in persons aware relative to unaware that they were HIV+.27 In an STD clinic in Miami in 1988 through 1989, the percentage with a newly diagnosed STD declined 11% in the 6 months after they learned they had HIV infection compared with the 6 months before their HIV+ diagnosis.28 STD studies conducted in other countries show even stronger findings. Of HIV+ persons presenting at a genitourinary clinic in London in 1994, the prevalence of diagnosed STDs was 73% lower in the year after HIV diagnosis than in the year before.29 Finally, of HIV+ women presenting at prenatal and pediatric clinics in Rwanda (1988-1989), the prevalence of clinically diagnosed gonorrhea was 54% lower in the year after than the year before HIV diagnosis.30
In our analysis, the between-group and within-subject comparisons demonstrated significant reductions in self-reported UAV, although the reduction was higher in the between-group design. One explanation is that a group of HIV+ aware persons may differ from a group of HIV+ unaware persons on other variables associated with unsafe sex, potentially accentuating the difference between the groups. For example, on average, people who are unaware they are infected with HIV are likely to be younger than people who are aware they are HIV+.31 The prevalence of unsafe sex has been found to be higher among younger than older MSM. 31,32
Another issue concerns whether behavior change in HIV+ aware persons is maintained over time. Additional analysis of the SHAS phase 2 data set showed that the prevalence of UAV in the most recent encounter with an at-risk partner was remarkably similar among subgroups of HIV+ aware men who differed in length of time they knew they were HIV+ (range: 1-24 months [17%], 25-48 months [16%], 49-72 months [17%], 73-96 months [14%], and >96 months [13%]). The prevalence was 39% in HIV+ unaware men. A highly similar pattern was seen in HIV+ aware women in SHAS phase 2 and in men and women in SHAS phase 1. One other study not included in the meta-analysis because it assessed sexual behavior of HIV+ aware persons but not HIV+ unaware persons did not confirm this pattern. The prevalence of UAV was higher in persons aware of their infection for 5 or more years compared with those diagnosed more recently.33 These mixed results make it difficult to reach conclusions at this time about the stability of behavior change after being diagnosed HIV+. This issue merits attention in future research.
Our meta-analytic findings must be viewed within the context of the methodologic limitations of the primary studies. First, the studies used self-reported sexual behavior. Self-reports are open to socially desirable responding, and some HIV+ aware persons may underreport unprotected sex with at-risk partners.34 US studies of HIV serodiscordant homosexual35 and heterosexual36 couples demonstrate high levels of agreement (approximately 90%) between couple members in self-reports of condom use, however. We were not able to gauge the level of partner agreement in the studies analyzed here. Second, we were not able to examine the number of sex partners placed at risk by HIV+ aware and HIV+ unaware persons, because those data were not available in the literature. The difference between these groups in the prevalence of UAV may not necessarily reflect the magnitude of difference in the number of sex partners placed at risk. Our analysis, however, provides a starting point for a more refined model when additional data become available. Third, the difference in the prevalence of UAV between HIV+ aware and HIV+ unaware persons may not reflect differences in HIV transmission rates between groups. Actual transmission depends on a host of biologic factors. For example, transmission risk is increased when an individual who is the source of exposure is in the primary HIV infection stage,37 has a high viral load,3,4 or has an STD.38,39 These factors would elevate transmission risk more from HIV+ unaware than HIV+ aware persons, because unaware persons as a group are more likely to be in the primary infection stage, to a have higher viral load because they are not in medical care, and to have an STD.27-30
Our findings reinforce the need for a multidimensional approach to HIV prevention.7 Resources and efforts are needed to make HIV testing opportunities more accessible (eg, rapid tests) and to reduce barriers to testing so that infected persons learn their status. Public health campaigns targeting young MSM, especially young MSM of color, are urgently needed, because many of these men are unaware they are infected.40 Promising but underused methods for reaching such persons include offering HIV testing routinely in all health care settings in high HIV prevalence areas7; offering testing at venues that attract high-risk persons; adding HIV testing capacity to all effective educational outreach and risk reduction interventions41; and gaining the cooperation of current HIV+ aware persons to reach members of their sexual and social networks for HIV testing, counseling, and care if needed.42
Clearly, HIV counseling and testing alone are not enough to control the HIV epidemic. Behavioral interventions for people aware they are infected and for those at high risk for HIV are needed. Those interventions may reduce sexual risk behavior by as much as 30% to 40%.43-45 For those aware that they are HIV+, the challenge is to find settings and approaches for delivering prevention programs to this population over time. The HIV clinic is an ideal setting for offering prevention messages and counseling to HIV+ persons and for integrating prevention with routine medical care.46 Such counseling from HIV providers has been shown to be efficacious in reducing unprotected intercourse in HIV+ patients.44 Other promising interventions have been delivered by HIV+ peers in community settings.47 Assisting HIV+ people to establish social networks that encourage risk reduction and provide social support for seeking medical care and adhering to treatment regimens has also shown promise in demonstration projects.48 Together, these approaches may contribute to more rapid control of the HIV epidemic in the United States and elsewhere.
The authors thank Paul Denning, Michael Campsmith, and Glenn Nakamura for providing data from the SHAS; the Executive Committee of the HERS for permission to use HERS data; Merle Hamburger for assistance in constructing the HERS seroconversion data set; the Executive Committee of the MACS for permission to use MACS data; Mary Elizabeth Gore and Lisa Jacobson for assistance in constructing the MACS variables used in the analysis; Ramses Sadek for statistical consultation; and Ida Onorato for helpful comments on several substantive issues.
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APPENDIX: ADJUSTMENT FOR NONINDEPENDENCE OF RESPONSE IN THE WITHIN-SUBJECT STUDIES
We had access to individual level data from a within-subject study of MSM (MACS) and a within-subject study of women (HERS) and calculated the covariance terms for those investigations. The other within-subject studies did not provide individual level data to calculate the before and after correlations, so we imputed values based on the MACS (r = 0.49) and HERS (r = 0.20). The MACS value was used for the subgroup of men in the studies by Cleary et al8 and Colfax et al.11 The HERS value was used for the subgroup of women in the study by Cleary et al.8
We performed a sensitivity analysis to examine how much the aggregated PRs and CIs changed when these correlation values were increased or decreased by 0.20 correlation units of the original imputed values (ie, the MACS value was changed by ±0.20, the HERS value was changed by ±0.20). This ±0.20 represents a reasonable boundary for capturing the correlation between before and after behavior in the population. The aggregated PR changed half of 1% or less in each direction, and the width of the CIs increased or decreased only 4 units (percentage points) from the original. Thus, the imputation did not unduly affect the results. Cited Here...
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Public Health Reports
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International Journal of Std & AIDSThought processes associated with reluctance in gay men to be tested for HIVInternational Journal of Std & AIDS
AIDS and BehaviorReducing HIV transmission risk by increasing serostatus disclosure: A mathematical modeling analysisAIDS and Behavior
AIDS Patient Care and StdsOutcomes of blood and oral fluid rapid HIV testing: A literature review, 2000-2006AIDS Patient Care and Stds
Costs of HIV care: Evolution and update
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Why don't physicians test for HIV? A review of the US literature
Sexual HealthUsing mathematical modelling to help explain the differential increase in HIV incidence in New South Wales, Victoria and Queensland: importance of other sexually transmissible infectionsSexual Health
Jama-Journal of the American Medical Association
Estimation of HIV incidence in the United States
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Asian Pacific Journal of Cancer Prevention
Human Immunodeficiency Virus Infection in Women Undergoing Treatment for Cervical Neoplasia: Prevalence and the Feasibility of Routine Screening
Asian Pacific Journal of Cancer Prevention, 9(1):
ThoraxHIV prevalence and testing practices among tuberculosis cases in London: a missed opportunity for HIV diagnosis?Thorax
Journal of Applied Social Psychology
Claiming HIV Infection From Improbable Modes as a Possible Coping Strategy
Journal of Applied Social Psychology, 40(2):
AIDSDeterminants of HIV-1 transmission in men who have sex with men: a combined clinical, epidemiological and phylogenetic approachAIDS
Samj South African Medical Journal
Is it time to change our HIV testing policy in health care facilities?
Samj South African Medical Journal, 96():
Cleveland Clinic Journal of Medicine
HIV screening for all: The new standard of care
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Janac-Journal of the Association of Nurses in AIDS CareChanges in Transmission Risk Behaviors Across Stages of HIV Disease Among People Living With HIVJanac-Journal of the Association of Nurses in AIDS Care
American Journal of Public HealthAccessing Social Networks With High Rates of Undiagnosed HIV Infection: The Social Networks Demonstration ProjectAmerican Journal of Public Health
AIDS Patient Care and StdsInfluencing Risk Behavior of Sexually Transmitted Infection Clinic Visitors: Efficacy of a New Methodology of Motivational Preventive CounselingAIDS Patient Care and Stds
AIDS and BehaviorUnderstanding Differences in HIV Sexual Transmission among Latino and Black Men who have Sex with Men: The Brothers y Hermanos StudyAIDS and Behavior
Drug and Alcohol DependenceSerosorting for hepatitis C status in the sharing of injection equipment among Seattle area injection drug usersDrug and Alcohol Dependence
Archives of Internal Medicine
Detecting Acute Human Immunodeficiency Virus Infection Using 3 Different Screening Immunoassays and Nucleic Acid Amplification Testing for Human Immunodeficiency Virus RNA, 2006-2008
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Journal of Medical VirologyCurrent HIV epidemiology and revised recommendations for HIV testing in health-care settingsJournal of Medical Virology
Gender differences in the diagnosis and treatment of HIV
Gender Medicine, 4(4):
American Journal of Public HealthHIV prevalence and associated risk behaviors in New York City's house ball communityAmerican Journal of Public Health
Acute retroviral syndrome: A challenge for primary care
AIDS Reader, 18(6):
Relation between HIV viral load and infectiousness: a model-based analysis
Archivos Argentinos De Pediatria
The pediatrician in AIDS epoch - 20 years later
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American Journal of Public HealthDeterminants of Recent HIV Infection Among Seattle-Area Men Who Have Sex with MenAmerican Journal of Public Health
Academic Emergency MedicineAcceptance of Rapid HIV Screening in a Southeastern Emergency DepartmentAcademic Emergency Medicine
Sexual behaviour of people living with HIV in London: implications for HIV transmission
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American Journal of Preventive MedicinePartner notification - A promising approach to addressing the HIV/AIDS racial disparity in the united statesAmerican Journal of Preventive Medicine
Journal of Medical VirologyEarly diagnosis of HIV infectionJournal of Medical Virology
Clinical Infectious DiseasesEvidence-based efforts to prevent HIV infection: An overview of current status and future challengesClinical Infectious Diseases
Sahara J-Journal of Social Aspects of Hiv-AIDS
Provider-initiated HIV testing in health care settings: Should it include client-centered counselling?
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Implementation ScienceThe impact of provider-initiated (opt-out) HIV testing and counseling of patients with sexually transmitted infection in Cape Town, South Africa: a controlled trialImplementation Science
AIDS and BehaviorProvider-related Barriers to Rapid HIV Testing in US Urban Non-profit Community Clinics, Community-based Organizations (CBOs) and HospitalsAIDS and Behavior
American Journal of Preventive MedicinePartner counseling and referral services for HIV infectionAmerican Journal of Preventive Medicine
Jama-Journal of the American Medical Association
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AIDS Patient Care and StdsDescription of a novel pediatric emergency department-based HIV screening program for adolescentsAIDS Patient Care and Stds
AIDS Patient Care and StdsHIV Testing Factors Associated with Delayed Entry into HIV Medical Care among HIV-Infected Persons from Eighteen States, United States, 2000-2004AIDS Patient Care and Stds
International Journal of Gynecology & ObstetricsKnowledge, awareness, and attitudes of female sex workers toward HPV infection, cervical cancer, and cervical smears in ThailandInternational Journal of Gynecology & Obstetrics
AIDS and BehaviorIntentional Abstinence Among Homeless and Unstably Housed Persons Living with HIV/AIDSAIDS and Behavior
Substance Use & MisuseBehavior change and health-related interventions for heterosexual risk reduction among drug usersSubstance Use & Misuse
Hot topics in pediatric HIV/AIDS
Pediatric Annals, 36(7):
Hiv MedicineDiagnosed and undiagnosed HIV-infected populations in EuropeHiv Medicine
Sexual HealthImportance of promoting HIV testing for preventing secondary transmissions: modelling the Australian HIV epidemic among men who have sex with menSexual Health
Cadernos De Saude Publica
Initiation of antiretroviral therapy in HIV-infected patients with severe immunodeficiency in Belo Horizonte, Minas Gerais State, Brazil
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AIDS and BehaviorUse of a Rapid HIV Home Test to Screen Sexual Partners: An Evaluation of its Possible Use and Relative RiskAIDS and Behavior
Journal of Substance Abuse TreatmentHIV screening among substance-abusing veterans in careJournal of Substance Abuse Treatment
Journal of General Internal MedicineEvaluation of the Sustainability of an Intervention to Increase HIV TestingJournal of General Internal Medicine
Mainstrearning HIV testing
Journal of General Internal MedicineHIV testing of at risk patients in a large integrated health care systemJournal of General Internal Medicine
Bmc Health Services ResearchA novel emergency department based prevention intervention program for people living with HIV: evaluation of early experiencesBmc Health Services Research
Janac-Journal of the Association of Nurses in AIDS CareHIV testing in emergency departments: A recommendation with missed opportunitiesJanac-Journal of the Association of Nurses in AIDS Care
AIDS Care-Psychological and Socio-Medical Aspects of AIDS/HivBarriers and facilitators to HIV testing and linkage to primary care: narratives of people with advanced HIV in the SoutheastAIDS Care-Psychological and Socio-Medical Aspects of AIDS/Hiv
AIDS and BehaviorPsychosocial Characteristics and Sexual Behaviors of People in Care for HIV Infection: An Examination of Men Who Have Sex with Men, Heterosexual Men and WomenAIDS and Behavior
AIDS Patient Care and StdsInitial Outcomes of Provider-Initiated Routine HIV Testing and Counseling During Outpatient Care at a Rural Ugandan Hospital: Risky Sexual Behavior, Partner HIV Testing, Disclosure, and HIV Care SeekingAIDS Patient Care and Stds
Clinical Infectious DiseasesAddressing Research Priorities for Prevention of HIV Infection in the United StatesClinical Infectious Diseases
American Journal of Preventive MedicineThe effectiveness of HIV partner counseling and referral services in increasing identification of HIV-positive individuals - A systematic reviewAmerican Journal of Preventive Medicine
American Journal of Public HealthThe magnitude of key HIV prevention challenges in the United States: Implications for a new national HIV prevention planAmerican Journal of Public Health
AIDS Patient Care and StdsKnowledge of the Centers for Disease Control and Prevention's 2006 Routine HIV Testing Recommendations among New York City Internal Medicine ResidentsAIDS Patient Care and Stds
Jaids-Journal of Acquired Immune Deficiency Syndromes
Twenty-Five Years of HIV: Lessons for Low Prevalence Scenarios
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Annual Review of Clinical PsychologyThe Past, Present, and Future of HIV Prevention: Integrating Behavioral, Biomedical, and Structural Intervention Strategies for the Next Generation of HIV PreventionAnnual Review of Clinical Psychology
International Journal of Std & AIDS2008 European Guideline on HIV testingInternational Journal of Std & AIDS
Sexual HealthDelayed diagnosis of HIV infection in Victoria 1994 to 2006Sexual Health
Ajar-African Journal of AIDS ResearchHIV behavioural surveillance among refugees and surrounding host communities in Uganda, 2006Ajar-African Journal of AIDS Research
AIDS and BehaviorTransgender Female Youth and Sex Work: HIV Risk and a Comparison of Life Factors Related to Engagement in Sex WorkAIDS and Behavior
AIDS and BehaviorStrategies Used in the Detection of Acute/Early HIV Infections. The NIMH Multisite Acute HIV Infection Study: IAIDS and Behavior
Archives of Sexual BehaviorHIV and Sexual Risk Behavior among Commercial Sex Workers in the NetherlandsArchives of Sexual Behavior
Tropical Medicine & International HealthAdoption of safer infant feeding and postpartum sexual practices and their relationship to maternal HIV status and risk of acquiring HIV in ZimbabweTropical Medicine & International Health
Jama-Journal of the American Medical Association
HIV/AIDS diagnoses among blacks - Florida, 1999-2004 (Reprinted from MMWR, vol 56, pg 69-73, 2007)
Jama-Journal of the American Medical Association, 297():
Expert Review of Anti-Infective TherapyBeyond the end of exceptionalism: integrating HIV testing into routine medical care and HIV preventionExpert Review of Anti-Infective Therapy
AIDS Patient Care and StdsPatients' attitudes about rapid oral HIV screening in an urban, free dental clinicAIDS Patient Care and Stds
AIDS Patient Care and StdsImplementation and evaluation of a clinic-based behavioral intervention: Positive steps for patients with HIVAIDS Patient Care and Stds
Bmc Infectious DiseasesHIV Testing and Care in Canadian Aboriginal Youth: A community based mixed methods studyBmc Infectious Diseases
Journal of Medical ScreeningComparison of emergency department HIV testing data with visit or patient as the unit of analysisJournal of Medical Screening
American Journal of Preventive MedicineWritten Informed-Consent Statutes and HIV TestingAmerican Journal of Preventive Medicine
Journal of Health Care for the Poor and Underserved
Increasing the Reach of HIV Testing to Young Latino MSM: Results of a Pilot Study Integrating Outreach and Services
Journal of Health Care for the Poor and Underserved, 20(3):
Journal of Community HealthHIV Testing Practices and Attitudes on Prevention Efforts in Six Diverse Chicago CommunitiesJournal of Community Health
New England Journal of Medicine
Applying public health principles to the HIV epidemic
New England Journal of Medicine, 353():
Annals of Internal Medicine
Expanded HIV screening in the United States: Effect on clinical outcomes, HIV transmission, and costs
Annals of Internal Medicine, 145():
New England Journal of Medicine
Public health principles for the HIV epidemic - Reply
New England Journal of Medicine, 354(8):
Clinical Infectious DiseasesImpact of counseling in voluntary counseling and testing programs for persons at risk for or living with HIV infectionClinical Infectious Diseases
International Journal of Tuberculosis and Lung Disease
Provider-initiated HIV testing and counselling for TB patients and suspects in Nairobi, Kenya
International Journal of Tuberculosis and Lung Disease, 12(3):
Bmc Public HealthContributions to early HIV diagnosis among patients linked to care vary by testing venueBmc Public Health
Developing World BioethicsEthics of mandatory premarital HIV testing in Africa: The case of Goma, Democratic Republic of CongoDeveloping World Bioethics
Journal of Women & AgingTheory-Based Policy Development for HIV Prevention in Racial/Ethnic Minority Midlife and Older WomenJournal of Women & Aging
Public Health Reports
Written consent for human immunodeficiency virus testing
Public Health Reports, 122(4):
Plos MedicineLate HIV diagnosis: Bad medicine and worse public healthPlos Medicine
Sexually Transmitted DiseasesTelephone notification of HIV test results: Impact in king County, WashingtonSexually Transmitted Diseases
AIDS Patient Care and StdsMissed Opportunities for Earlier HIV Diagnosis in an Emergency Department Despite an HIV Screening ProgramAIDS Patient Care and Stds
AIDS Patient Care and StdsSexual Risk Behavior and Behavior Change among Persons Newly Diagnosed with HIV: The Impact of Targeted Outreach Interventions among Hard-to-Reach PopulationsAIDS Patient Care and Stds
Clinical Infectious DiseasesLate Presentation for Human Immunodeficiency Virus Care in the United States and CanadaClinical Infectious Diseases
AIDS Patient Care and StdsSafeTalk, a Multicomponent, Motivational Interviewing-Based, Safer Sex Counseling Program for People Living with HIV/AIDS: A Qualitative Assessment of Patients' ViewsAIDS Patient Care and Stds
Population Studies-A Journal of DemographyThe limited effect of knowing they are HIV-positive on the sexual and reproductive experiences and intentions of infected adolescents in UgandaPopulation Studies-A Journal of Demography
Clinical Infectious DiseasesChanging epidemiology of HIV/AIDS in the United States: Implications for enhancing and promoting HIV testing strategiesClinical Infectious Diseases
Janac-Journal of the Association of Nurses in AIDS Care"Universal Action-Now"Janac-Journal of the Association of Nurses in AIDS Care
Sexual HealthTime to roll out rapid testing for HIV? Yes, but with appropriate safeguardsSexual Health
Health CommunicationPrevention Options for Positives: The Effects of a Health Communication Intervention for Men Who Have Sex With Men Living With HIV/AIDSHealth Communication
Psychological MedicineHIV testing among individuals with a severe mental illness: review, suggestions for research, and clinical implicationsPsychological Medicine
International Journal of Std & AIDSExperience in the USAInternational Journal of Std & AIDS
AIDS Patient Care and StdsRisk-Based HIV Testing in South Carolina Health Care Settings Failed to Identify the Majority of Infected IndividualsAIDS Patient Care and Stds
American Family Physician
Applying HIV Testing Guidelines in Clinical Practice
American Family Physician, 80():
International Journal of Drug PolicyHIV infection and risk behaviour of primary fentanyl and amphetamine injectors in Tallinn, Estonia: Implications for interventionInternational Journal of Drug Policy
Next Steps for Ukraine Abolition of Hiv Registries, Implementation of Routine Human Immunodeficiency Virus Testing and Expansion of Services
HIV self-testing: a time to revise current policy
Annals of Emergency MedicineTo test or not to test? HIV, emergency departments, and the new centers for disease control and prevention guidelinesAnnals of Emergency Medicine
British Medical Journal
Time to move towards opt-out testing for HIV in the UK
British Medical Journal, 334():
Journal of Womens HealthContraceptive use among US women with HIVJournal of Womens Health
Sexually Transmitted DiseasesLate diagnosis of HIV in young men in north CarolinaSexually Transmitted Diseases
Studies in Family Planning
The sexual ethics of HIV testing and the rights and responsibilities of partners
Studies in Family Planning, 38(4):
AIDS Patient Care and StdsHeterosexual HIV and Sexual Partnerships Between Injection Drug Users and Noninjection Drug UsersAIDS Patient Care and Stds
Evaluation & the Health ProfessionsWho Chooses a Rapid Test for HIV in Los Angeles County, California?Evaluation & the Health Professions
New England Journal of Medicine
Home testing for HIV
New England Journal of Medicine, 354(5):
Jama-Journal of the American Medical Association
Missed opportunities for earlier diagnosis of HIV infection - South Carolina, 1997-2005 (Reprinted from MMWR, vol 55, pg 1269-1271, 2006)
Jama-Journal of the American Medical Association, 297(2):
AIDS and BehaviorRepeat voluntary HIV counseling and testing (VCT), sexual risk behavior and HIV incidence in Rakai, UgandaAIDS and Behavior
Long-term psychosocial challenges for people living with HIV: let's not forget the individual in our global response to the pandemic
Journal of Law Medicine & Ethics
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Journal of Law Medicine & Ethics, 35(4):
AddictionMitigating risky sexual behaviors among Russian narcology hospital patients: the PREVENT (Partnership to Reduce the Epidemic Via Engagement in Narcology Treatment) randomized controlled trialAddiction
Journal of Urban Health-Bulletin of the New York Academy of MedicineHIV Testing Rates, Testing Locations, and Healthcare Utilization among Urban African-American MenJournal of Urban Health-Bulletin of the New York Academy of Medicine
AIDS Patient Care and StdsHigh-Volume Rapid HIV Testing in an Urban Emergency DepartmentAIDS Patient Care and Stds
Public Health Reports
Implementing Packaged HIV-Prevention Interventions for HIV-Positive Individuals: Considerations for Clinic-Based and Community-Based Interventions
Public Health Reports, 125():
HIV testing in patients with TB
Tropical Doctor, 36(2):
Jama-Journal of the American Medical Association
HIV prevention for a threatened continent - Implementing positive prevention in Africa
Jama-Journal of the American Medical Association, 296(7):
Bulletin of the World Health Organization
Promoting self-testing for HIV in developing countries: potential benefits and pitfalls
Bulletin of the World Health Organization, 84():
Jama-Journal of the American Medical Association
Rapid HIV testing among racial/ethnic minority men at gay pride events - Nine US cities, 2004-2006 (Reprinted from MMWR, vol 56, pg 602, 2007)
Jama-Journal of the American Medical Association, 298(6):
AIDS Education and Prevention
Sexual behaviors of individuals with HIV living in south India: A qualitative study
AIDS Education and Prevention, 19(4):
Jaids-Journal of Acquired Immune Deficiency Syndromes
Late diagnosis of HIV infection: Epidemiological features, consequences and strategies to encourage earlier testing
Jaids-Journal of Acquired Immune Deficiency Syndromes, 46():
Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA
A meta-analysis of the effectiveness of alternative HIV counseling and testing methods to increase knowledge of HIV status
National Institute of Allergy and Infectious Diseases, Nih, Vol 1: Frontiers in Research
NIAID HIV/AIDS Prevention Research
National Institute of Allergy and Infectious Diseases, Nih, Vol 1: Frontiers in Research, ():
Clinical Infectious DiseasesImplementation of HIV Testing at 2 New York City Bathhouses: From Pilot to Clinical ServiceClinical Infectious Diseases
AIDS and BehaviorHIV Partner Notification: Predictors of Discussion and Agreements from Provider ReportsAIDS and Behavior
AddictionInterventions with injection drug users in UkraineAddiction
Integrating HIV care and HIV prevention: legal, policy and programmatic recommendations
Journal of Aging and HealthSelf-Silencing and Age as Risk Factors for Sexually Acquired HIV in Midlife and Older WomenJournal of Aging and Health
Current Hiv Research
Delayed Diagnosis of HIV Infection in a Multicenter Cohort: Prevalence, Risk Factors, Response to HAART and Impact on Mortality
Current Hiv Research, 7(2):
Stanford Law Review
Racing the Closet
Stanford Law Review, 61(6):
AIDS and BehaviorDrug Use, High-Risk Sex Behaviors, and Increased Risk for Recent HIV Infection among Men who Have Sex with Men in Chicago and Los AngelesAIDS and Behavior
American Journal of Public HealthDental Examinations as an Untapped Opportunity to Provide HIV Testing for High-Risk IndividualsAmerican Journal of Public Health
American Journal of Public HealthAssessment of HIV testing of urban injection drug users: Implications for expansion of HIV testing and prevention effortsAmerican Journal of Public Health
Journal of Infectious DiseasesPrimary HIV infection, phylogenetics, and antiretroviral preventionJournal of Infectious Diseases
American Journal of MedicineLate diagnosis of HIV infection: The role of age and sexAmerican Journal of Medicine
Annals of Emergency MedicineImplementing an HIV and sexually transmitted disease screening program in an emergency departmentAnnals of Emergency Medicine
AIDS and BehaviorCorrelates of risk patterns and Race/Ethnicity among HIV-Positive men who have sex with menAIDS and Behavior
Journal of the National Medical Association
Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings
Journal of the National Medical Association, 100(1):
Annals of Emergency MedicineResults of a Rapid HIV Screening and Diagnostic Testing Program in an Urban Emergency DepartmentAnnals of Emergency Medicine
International Journal of Std & AIDSA randomized trial of computer-based reminders and audit and feedback to improve HIV screening in a primary care settingInternational Journal of Std & AIDS
AIDS and BehaviorLack of Understanding of Acute HIV Infection among Newly-Infected Persons-Implications for Prevention and Public Health: The NIMH Multisite Acute HIV Infection Study: IIAIDS and Behavior
AIDS and BehaviorMental Health Treatment to Reduce HIV Transmission Risk Behavior: A Positive Prevention ModelAIDS and Behavior
AIDS Patient Care and Stds
Supporting adherence to highly active antiretroviral therapy and protected sex among people living with HIV/AIDS: The role of patient-provider communication in Rio De Janeiro, Brazil
AIDS Patient Care and Stds, 20(9):
Jama-Journal of the American Medical Association
HIV screening in health care settings - Public health and civil liberties in conflict?
Jama-Journal of the American Medical Association, 296():
Current Opinion in Infectious DiseasesSexual networks and the transmission of drug-resistant HIVCurrent Opinion in Infectious Diseases
Current Opinion in Infectious DiseasesLate diagnosis of HIV infection: major consequences and missed opportunitiesCurrent Opinion in Infectious Diseases
Current Opinion in Obstetrics and GynecologyPartner notification in the clinician's office: patient health, public health and interventionsCurrent Opinion in Obstetrics and Gynecology
JAIDS Journal of Acquired Immune Deficiency SyndromesInfections Prevented by Increasing HIV Serostatus Awareness in the United States, 2001 to 2004JAIDS Journal of Acquired Immune Deficiency Syndromes
JAIDS Journal of Acquired Immune Deficiency SyndromesUndiagnosed HIV Prevalence Among Adults and Adolescents in the United States at the End of 2006JAIDS Journal of Acquired Immune Deficiency Syndromes
JAIDS Journal of Acquired Immune Deficiency SyndromesDetecting Unsuspected HIV Infection With a Rapid Whole-Blood HIV Test in an Urban Emergency DepartmentJAIDS Journal of Acquired Immune Deficiency Syndromes
JAIDS Journal of Acquired Immune Deficiency SyndromesCharacteristics of Recently HIV-Infected Men Who Use the Internet to Find Male Sex Partners and Sexual Practices With Those PartnersJAIDS Journal of Acquired Immune Deficiency Syndromes
JAIDS Journal of Acquired Immune Deficiency SyndromesCircumcision Status and HIV Infection Among Black and Latino Men Who Have Sex With Men in 3 US CitiesJAIDS Journal of Acquired Immune Deficiency Syndromes
JAIDS Journal of Acquired Immune Deficiency SyndromesUpdated Annual HIV Transmission Rates in the United States, 1977-2006JAIDS Journal of Acquired Immune Deficiency Syndromes
JAIDS Journal of Acquired Immune Deficiency SyndromesUndiagnosed HIV Infection Among New York City Jail Entrants, 2006: Results of a Blinded SerosurveyJAIDS Journal of Acquired Immune Deficiency Syndromes
JAIDS Journal of Acquired Immune Deficiency SyndromesRoutine Voluntary HIV Testing in Durban, South Africa: The Experience From an Outpatient DepartmentJAIDS Journal of Acquired Immune Deficiency Syndromes
Journal of Public Health Management and PracticeTEST: A Public Health and Law Enforcement Collaboration to Increase HIV/AIDS Prevention in Westchester County, New YorkJournal of Public Health Management and Practice
Journal of Public Health Management and PracticeThe Continued Spread of HIV in the United States: Prevention Failure or Systems Defect?Journal of Public Health Management and Practice
Sexually Transmitted DiseasesHerpes Simplex Virus-2 and HIV Among Noninjecting Drug Users in New York CitySexually Transmitted Diseases
Sexually Transmitted DiseasesVoluntary Rapid Human Immunodeficiency Virus (HIV) Testing in JailsSexually Transmitted Diseases
Sexually Transmitted DiseasesNormalizing HIV Testing in a Busy Urban Sexually Transmitted Infections ClinicSexually Transmitted Diseases
Sexually Transmitted DiseasesSerosorting May Increase the Risk of HIV Acquisition Among Men Who Have Sex With MenSexually Transmitted Diseases
Sexually Transmitted DiseasesMissed Opportunities for HIV Testing Among High-Risk HeterosexualsSexually Transmitted Diseases
HIV-positive persons; HIV/AIDS; high-risk sexual behavior; HIV transmission; meta-analysis
© 2005 Lippincott Williams & Wilkins, Inc.
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