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The Information-Motivation-Behavioral Skills (IMB) Model has been used to understand adherence to medications and intentions to uptake pre-exposure prophylaxis (PrEP) to prevent HIV infection. In the current study, the IMB Model was used to understand factors that predict adherence to PrEP among a community-based cohort of 204 Black men who have sex with men (MSM) and transgender women (TGW) using structural equation modeling. PrEP motivation was directly associated with PrEP behavioral skills (β = 0.320, p = 0.009), and PrEP behavioral skills were directly associated with PrEP adherence (β = 0.416, p = 0.001). PrEP knowledge and PrEP motivation were not associated with PrEP adherence, directly or indirectly. The analysis identified intervenable factors that predicted PrEP adherence. Screening for motivation and behavioral skills could be used to identify where additional support to improve PrEP adherence is needed, or whether to offer alternative PrEP modalities or delivery strategies., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

We assessed the geographic variation in socio-demographics, mobility, and built environmental factors in relation to COVID-19 testing, case, and death rates in New York City (NYC). COVID-19 rates (as of June 10, 2020), relevant socio-demographic information, and built environment characteristics were aggregated by ZIP Code Tabulation Area (ZCTA). Spatially adjusted multivariable regression models were fitted to account for spatial autocorrelation. The results show that different sets of neighborhood characteristics were independently associated with COVID-19 testing, case, and death rates. For example, the proportions of Blacks and Hispanics in a ZCTA were positively associated with COVID-19 case rate. Contrary to the conventional hypothesis, neighborhoods with low-density housing experienced higher COVID-19 case rates. In addition, demographic changes (e.g. out-migration) during the pandemic may bias the estimates of COVID-19 rates. Future research should further investigate these neighborhood-level factors and their interactions over time to better understand the mechanisms by which they affect COVID-19., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Objective: The HIV Prevention Trials Network (HPTN) 065 trial sought to expand HIV screening of emergency department (ED) patients in Bronx, New York, and Washington, D.C. This study assessed the testing costs associated with different expansion processes and compared them with costs of a hypothetical optimized process., Methods: Micro-costing studies were conducted in two participating EDs in each city that switched from point-of-care (POC) to rapid-result laboratory testing. In three EDs, laboratory HIV testing was only conducted for patients having blood drawn for clinical reasons; in the other ED, all HIV testing was conducted with laboratory testing. Costs were estimated through direct observation and interviews to document process flows, time estimates, and labor and materials costs. A hypothetical optimized process flow used minimum time estimates for each process step. National wage and fringe rates and local reagent costs were used to determine the average cost (excluding overhead) per completed nonreactive and reactive test in 2013 U.S. dollars., Results: Laboratory HIV testing costs in the EDs ranged from $17.00 to $23.83 per completed nonreactive test, and POC testing costs ranged from $17.64 to $37.60; cost per completed reactive test ranged from $89.29 to $123.17. Costs of hypothetical optimized HIV testing with automated process steps were approximately 45% lower for nonreactive tests and 20% lower for reactive tests. The cost per ED visit to conduct expanded HIV testing in each hospital ranged from $1.21 to $3.96., Conclusion: An optimized process could achieve additional cost savings but would require an investment in electronic system interfaces to further automate testing processes.

Objective: To assess the effectiveness of a peer-based intervention on adherence to and completion of latent tuberculous infection (LTBI) treatment., Methods: Patients prescribed self-administered LTBI treatment were enrolled in a randomized controlled trial of an experimental, peer-based adherence support intervention. Primary outcomes were treatment adherence and completion. Adherence was assessed through self-report, electronic monitoring devices and clinic visits., Results: Of 250 participants, 70% were male; 71% were Black and 20% Latino; the mean age was 40 years; 67% were foreign-born and 39% were married. No significant baseline differences were noted between the intervention groups. Treatment completion was 61% in the intervention group compared to 57% in the controls (P = 0.482). The corresponding completion rate for other clinic patients was 44%. Foreign birth, marriage and history of mental illness were associated with non-completion of treatment after controlling for the intervention group; increased completion rates were found among foreign-born married persons and older participants. A substantial difference in adherence rates was observed between the intervention groups. Adherence among non-completers decreased early, while adherence among completers remained constant., Conclusions: The peer-based intervention was not significantly associated with LTBI treatment completion, but was associated with greater adherence. Findings suggest the importance of interventions to support adherence that target early non-adherence with LTBI treatment, particularly in the first 2 months, when there is a substantial risk of default.

Setting: Harlem Hospital Directly Observed Therapy (DOT) Program, New York City., Objective: To identify various pathways to tuberculosis (TB) diagnosis, and determine time to diagnosis and reasons for delay, to ensure rapid diagnosis of TB and prompt initiation of appropriate treatment., Design: Cross-sectional survey of the help-seeking behavior of TB patients within 2 months of their enrollment into DOT from May 2001 to December 2004., Results: The average total delay between symptom onset and a patient's diagnosis of TB was 18 weeks among 39 patients. The average delay to diagnosis attributed to patient delay and health care system delay were 10.5 and 7.5 weeks, respectively. Patients visited on average 1.6 sources of care prior to receiving a TB diagnosis. Foreign-born patients in particular were found to have more complex paths to diagnosis. The most common reason for delaying seeking care reported by patients was that they didn't think it was serious' (29.1%)., Conclusion: There was a substantial time interval between the onset of symptoms and TB diagnosis due to both patient and health care system delay. Foreign-born status, economic and social factors, and missed opportunities for diagnosis by the health care system played important roles in delaying TB diagnoses for the marginalized patients in this study.

Women clients of a methadone maintenance treatment clinic were targeted for an intervention aimed to reduce unsafe sex. The hierarchical model was the basis of the single intervention session, tested among 63 volunteers. This model requires the educator to discuss and demonstrate a full range of barriers that women might use for protection, ranking these in the order of their known efficacy. The model stresses that no one should go without protection. Two objections, both untested, have been voiced against the model. One is that, because of its complexity, women will have difficulty comprehending the message. The second is that, by demonstrating alternative strategies to the male condom, the educator is offering women a way out from persisting with the male condom, so that instead they will use an easier, but less effective, method of protection. The present research aimed at testing both objections in a high-risk and disadvantaged group of women. By comparing before and after performance on a knowledge test, it was established that, at least among these women, the complex message was well understood. By comparing baseline and follow-up reports of barriers used by sexually active women before and after intervention, a reduction in reports of unsafe sexual encounters was demonstrated. The reduction could be attributed directly to adoption of the female condom. Although some women who had used male condoms previously adopted the female condom, most of those who did so had not used the male condom previously. Since neither theoretical objection to the hierarchical model is sustained in this population, fresh weight is given to emphasizing choice of barriers, especially to women who are at high risk and relatively disempowered. As experience with the female condom grows and its unfamiliarity decreases, it would seem appropriate to encourage women who do not succeed with the male condom to try to use the female condom, over which they have more control.

Infection with human immunodeficiency virus (HIV) has been associated with increased rates of single- and multidrug-resistant (MDR) tuberculosis in the New York City area. In order to examine the relationship of HIV infection to drug-resistant tuberculosis in other selected regions of the United States, we established a registry of cases of culture-proven tuberculosis. Data were collected from sites participating in an NIH-funded, community-based HIV clinical trials group. All cases of tuberculosis, regardless of HIV status, which occurred between January 1992 and June 1994 were recorded. Overall, 1,373 cases of tuberculosis were evaluated, including 425 from the New York City area, and 948 from seven other metropolitan areas. The overall prevalence of resistance to one or more drugs was 20.4%, and 5.6% of isolates were resistant to both isoniazid and rifampin (MDR). In the New York City area, HIV-infected patients were significantly more likely than persons not known to be HIV-infected, to have resistance to at least one drug (37% versus 19%) and MDR (19% versus 6%). In other geographic areas, overall drug resistance was 16%, and only 2.2% of isolates were MDR. In multiple logistic regression analyses, HIV infection was shown to be a risk factor for drug-resistant tuberculosis, independent of geographic location, history of prior therapy, age, and race. We concluded that HIV infection is associated with increased rates of resistance to antituberculosis drugs in both the New York City area and other geographic areas. MDR tuberculosis is occurring predominantly in the New York City area and is highly correlated with HIV infection.

Objectives: A directly observed therapy program was established at Harlem Hospital, New York, NY, in 1993 to promote high tuberculosis treatment completion rates., Methods: The Harlem program used an on-site surrogate family model. Treatment completion rate, visit adherence rate, human immuno-deficiency virus seroprevalence, and time to sputum culture conversion were assessed., Results: Out of 145 enrolled patients with suspected and confirmed tuberculosis, 95 (92 confirmed and 3 suspected) continued treatment. The visit adherence rate was 91.1 +/- 7.9%, with one patient (1%) lost to follow-up., Conclusion: High rates of treatment completion and visit adherence were achieved because of unique program characteristics. Thus, directly observed therapy is advocated as a means of ensuring treatment completion.

Background: Investigations of outbreaks of multidrug-resistant tuberculosis have found low rates of treatment response and very high mortality, and they have mainly involved patients with advanced human immunodeficiency virus (HIV) infection. For patients without HIV infection, one study reported an overall rate of response to treatment of 56 percent, and the mortality from tuberculosis was 22 percent. We investigated treatment response and mortality rates in 26 HIV-negative patients in New York with multidrug-resistant tuberculosis., Methods: We obtained detailed data from seven teaching hospitals in New York City on patients with multidrug-resistant tuberculosis--defined as tuberculosis resistant at least to isoniazid and rifampin--who were HIV-negative on serologic testing. Lengths of times from diagnosis to the initiation of appropriate therapy and from the initiation of appropriate therapy to conversion to negative cultures were assessed. Therapeutic responses were evaluated by both microbiologic and clinical criteria., Results: Between March 1991 and September 1994, 26 HIV-negative patients were identified and treated. Of the 25 patients for whom adequate data were available for analysis, 24 (96 percent) had clinical responses; all 17 patients for whom data on microbiologic response were available had such a response. The median times from diagnosis to the initiation of appropriate therapy and from the initiation of therapy to culture conversion were 44 days (range, 0 to 181) and 69 days (range, 2 to 705), respectively. Side effects requiring the discontinuation of medication occurred in 4 of 23 patients (17 percent) who were treated with second-line antituberculosis medications. The median follow-up for the 23 patients who responded and who received appropriate therapy was 91 weeks (range, 41 to 225)., Conclusions: In this report from New York City, HIV-negative patients with multidrug-resistant tuberculosis, contrary to previous reports, responded well to appropriate chemotherapy, both clinically and microbiologically.

With the increased incidence of tuberculosis and especially of resistant cases in the United States, directly observed therapy as a mechanism for ensuring completion of therapy has been advocated. This mechanism has been primarily pioneered and utilized in developing countries. Few models have been tailored to specific patient populations in this country. At Harlem Hospital, in recognition of the special needs and characteristics of our patients with tuberculosis, we have developed a unique program. This program revolves around a family model with all components of the program contributing to the cohesiveness of all the program participants and staff. In the brief period since its inception, the program has been successful in enrolling and retaining a large number of patients with tuberculosis.

An acceptability study of the female condom undertaken at New York's Harlem Hospital between August 1993 and February 1994 enrolled 52 women aged 18-57, 41 of whom (79%) used the female condom at least once. Of these, one-half used the female condom at least three times and 40% used it once; on average, women used it 2.4 times. Two-thirds of users liked the female condom either very much or somewhat, 20% were neutral and 15% stated that they did not like it. One-half of the women reported that their partner liked the device, while 17% said he felt neutral about it and approximately one-quarter said he disliked it. Seventy-three percent of respondents and 44% of their partners preferred the female condom to the male condom.

Objective: To describe more fully HIV-1 and tuberculosis (TB) coinfection in TB patients attending New York City Department of Health chest clinics (1989-1991) and one inner-city hospital (1990-1991)., Design: An unlinked serosurvey using HIV-1-antibody testing of remnant blood specimens collected for routine medical purposes., Subjects: A total of 1414 clinic and 856 hospital patients., Outcome Measures: HIV seropositivity and TB infection/disease., Results: A total of 327 (23%) of the clinic patients were HIV-1-positive, with a significantly higher seroprevalence in men (29 versus 15%, P < 0.001) and in young and middle-aged adults aged 30-50 years (P < 0.001). HIV-1 prevalence by TB diagnostic class was: class 2 (purified protein derivative-positive and chest radiograph-negative), 11% (64 out of 570); class 3 (active disease), 34% (197 out of 582); class IV (old/inactive disease), 30% (39 out of 130). Of the hospital patients 487 (57%) were HIV-1-positive. HIV-1 seroprevalence was 55% for those who were identified or believed to be HIV-1-negative on admission as indicated on the medical chart. HIV-1 seroprevalence in the clinic population decreased initially, but later increased, although not to study onset levels., Conclusions: There is considerable overlap between the TB and HIV epidemics in New York City; a part of the increasing TB incidence may be independent of HIV coinfection. The control of TB will necessitate prompt diagnosis of TB and HIV-1, appropriate TB treatment and/or chemoprophylaxis, and a greater commitment to tackle the social conditions associated with the spread of the disease.

Background: The human immunodeficiency virus (HIV) epidemic has increasingly involved intravenous drug users. Few studies have attempted to define its clinical and laboratory characteristics in this population., Methods: We recruited 223 intravenous drug users from New York, NY, for a prospective study of the natural course of HIV infection. Medical history, physical examination, medical staging, and immunologic assessments were performed at 6-month intervals. We examined the baseline findings among this cohort., Results: Of the total cohort, 65.9% were men and 34.1% were women, with 70.9% African American, 12.6% white, 11.7% white Latino, and 4.9% black Latino. At baseline, 44.4% were HIV negative and 55.6% were HIV positive. No significant association was noted between ethnicity, gender, and serologic status. Also no significant difference was noted for homelessness either across serologic status or gender. There was a trend toward an association between gender and use of drugs during the week before interview; the women showed higher drug use. A significant association was noted between HIV serologic status and reported history of pneumonia, oral candidiasis, cough, night sweats, fever, and lymphadenopathy on physical examination. In a regression model, white blood cell count, hematocrit, symptom/sign complex score, and CD4 cell number were significantly associated with HIV status., Conclusion: This study provided important historical, clinical, and immunologic characteristics that are useful in the identification and evaluation of the HIV-infected intravenous drug user.

A cohort of 334 intravenous (IV) drug users from New York City drug treatment programs were followed over a mean 9-month period. Among the 165 who were seropositive at enlistment, four developed clinical AIDS, for an annual rate of 3%. Elevated IgA was a significant predictor of developing AIDS. Among 72 subjects who were initially seronegative and who were re-interviewed, four were seropositive at follow-up, for a seroconversion rate of 7% per year among seronegatives. Among seropositive subjects who did not develop AIDS or fatal AIDS related complex (ARC), continued drug injection was associated with rate of T4 cell loss, and there was a non-significant trend for males to lose T4 cells more rapidly than females. While it was not possible to distinguish the mechanism underlying the relationship between continued drug injection and T4 cell loss, seropositive IV drug users should be warned that continued injection may lead to increased HIV-related immunosuppression as well as, if injection equipment is shared, risking viral transmission to others.

Intravenous (IV) users of illicit drugs have accounted for 17% of AIDS cases seen in the United States. Previous research has shown that more than half of IV drug abusers entering a drug detoxification program in New York City had serologic evidence of exposure to the virus believed to cause AIDS. Spread of AIDS among drug abusers presumably occurs by transmission of the virus via shared needles, works, or drug-containing solutions. Secondary spread of AIDS from IV drug abusers to others may occur by venereal transmission or by perinatal transmission to infants. In this article, relevant characteristics of the AIDS epidemic are presented to assist the staff of drug treatment programs in their work with IV drug abusers. Suggestions regarding the education of drug treatment personnel and the dissemination of information about AIDS to drug abusers and their families are offered. Fact sheets on AIDS for drug treatment and prison staff, and for drug abusers with and without the disease are presented. Finally, possible approaches to the prevention of AIDS in drug users are discussed.

We report here the results of a survey of 308 intravenous drug abusers recruited from hospital-based methadone maintenance or drug detoxification programmes located in Manhattan, New York City. Complete interviews and serological analyses for antibodies to human immunodeficiency virus (HIV) using both enzyme-linked immunosorbent and Western blot assays were obtained from 290 (94%) of the subjects. HIV antibodies were found by both assays in 147 (50.7%) of the tested subjects; conflicting results were found in three (1%) of the subjects; and negative results on both tests were found in 140 (48.3%) of the subjects. Logistic regression analysis identified significant relative risks for HIV infection associated with the frequency of drug injection and the proportion of injections in 'shooting galleries'. Additional risk among men was associated with a history of homosexual relations. Traditional efforts taken by subjects to clean syringes between uses, such as washing with water or alcohol, showed no evidence of being protective. Programmes aimed at prevention of HIV infection should focus on reducing use of shooting galleries and sharing of needles and syringes as well as reducing intravenous drug abuse generally.

Social researchers and epidemiologists, as well as their major institutions and the general public, have been slow to address the racial and ethnic aspects of the AIDS epidemic. Whether measured by categories associated with major routes of infection, age level, gender, or by diminished length of survival, blacks and Hispanics are disproportionately affected by AIDS. Education, care, and outreach efforts based upon stereotypes of gay white males will have to yield to greater attention to cultural differences--and potential strengths--within each of the special "communities at risk." Evidence indicates areas of social resistance along with unique possibilities for change.