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MAI/NEHEC Monthly Health Disparities Update: February 2013

Last Updated: February 19, 2013

This newsletter is developed by the AIDS Action Committee of Massachusetts in collaboration with the New England AIDS Education and Training Center Minority AIDS Initiative Project.

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Featured in This Issue

Mass Incarceration and Housing Instability Undermine U.S. HIV/AIDS Response: "Over the past three decades in the United States, overlapping epidemics of mass incarceration and HIV/AIDS have become disproportionately concentrated among economically disadvantaged persons of color," according to a new report from the National Minority AIDS Council and Housing Works. The often poor HIV health outcomes of recently incarcerated persons "contribute to high community viral load that perpetuates ongoing HIV transmission" in the U.S.

Major Study Finds that About One in Five Transgender Women Worldwide Are Living with HIV: Transgender women have a very high prevalence of HIV infection and are in urgent need of prevention, treatment, and care services, according to a recent study by Johns Hopkins researcher Dr. Stefan Baral and his colleagues.  Their meta-analysis, which combined data from 39 studies involving more than 11,000 transgender women in 15 countries, found that about 19% of transgender women were living with HIV – an HIV prevalence rate nearly 50 times greater than that of other adults of reproductive age.

UNAIDS Report Highlights Essential Role of Women in Ending the HIV/AIDS Pandemic:  The United Nations Program on AIDS (UNAIDS) recently published the report, Women Out Loud: How Women Living with HIV Will Help the World End AIDS.  The report outlines ways in which addressing  HIV/AIDS disparities affecting women, as well as drawing and acting on women's knowledge, are essential for meeting the 10 target goals of the 2011 United Nations Political Declaration on HIV and AIDS.

Nearly 10,000 Americans Living with HIV/AIDS Projected to Lose Access to AIDS Drug Assistance Program if Budget Sequestration Cuts Take Effect:  "Applying sequestration cuts to domestic HIV/AIDS programming would provide negligible deficit reduction, but would have a devastating impact on people living with HIV/AIDS in America," according to a recent assessment by The Foundation for AIDS Research (amfAR) and the National Minority AIDS Council.  As a result of sequestration cuts, an estimated 9,750 HIV-infected persons – including over 6,500 persons of color – would lose access to the AIDS Drug Assistance Program.

New Black AIDS Institute Report Outlines Five-Year Strategy to Defeat AIDS in Black America:  Coinciding with Black HIV/AIDS Awareness Day earlier this month, the Black AIDS Institute released its new report Light at the End of the Tunnel, which presents an action plan to expand HIV testing, extend the coverage of prevention services for HIV and sexually transmitted infections, improve access to and retention in HIV care, and dramatically increase the number of Black Americans who achieve the full benefits of antiretroviral treatment.

Featured Health Resources: Materials for National Women and Girls HIV/AIDS Awareness Day

Research Reports on HIV Health Disparities and Affected Populations

News Roundup

Mass Incarceration and Housing Instability Undermine U.S. HIV/AIDS Response

"Over the past three decades in the United States, overlapping epidemics of mass incarceration and HIV/AIDS have become disproportionately concentrated among economically disadvantaged persons of color," according to a new report from the National Minority AIDS Council (NMAC) and Housing Works. The often poor HIV health outcomes of recently incarcerated persons "contribute to high community viral load that perpetuates ongoing HIV transmission" in the U.S.

The 38-page report, Mass Incarceration, Housing Instability, and HIV/AIDS: Research Findings and Policy Recommendations, examines the intersection between incarceration, homelessness, and HIV vulnerability, especially within the Black community.  "Each year, some 150,000 Americans living with HIV/AIDS are released from a correctional facility. Some are able to return to live with family – but studies show that as many as half of HIV-positive inmates leave prison or jail with no place to call home and no income to meet basic subsistence needs.  Formerly incarcerated persons with HIV/AIDS face unique barriers to housing that contribute to social instability long after return to the community," the report notes.

Black men are subjected to disproportionately high rates of incarceration – over six times that of White men and 2.6 times that of Hispanic men.  "This disparity cannot be accounted for solely by differences in criminal conduct, but rather reflects disproportionate law enforcement and sentencing practices that adversely affect Black Americans," according to the report.

"While it has long been understood that incarceration increases an individual's vulnerability to HIV, many have assumed that this is the result of increased risk behavior or exposure while in prison," said NMAC Director of Legislative and Public Affairs Kali Lindsey. "In reality, the evidence suggests that it is housing instability and the interruption of medical care resulting from incarceration that has the greatest impact on HIV vulnerability. With 25% of the world’s imprisoned population, our nation’s culture of mass incarceration has created a devastating and self-perpetuating cycle of poverty, homelessness, and criminal justice involvement that undermines our ability to successfully combat the spread of HIV, especially among African Americans."

The report makes a series of recommendations to address this cycle of vulnerability, including:

  • allowing formerly incarcerated persons access to federal housing and homeless assistance programs;
  • removing post-incarceration barriers to subsistence income and health insurance;
  • improving pre-release planning for inmates living with HIV or AIDS; and
  • evaluating the effectiveness of housing-based interventions for formerly incarcerated persons living with HIV.

Commenting on the report's findings, Housing Works Vice President Christine Campbell stated that, "With the science we now have on effectively treating people living with HIV or AIDS, as well as preventing its onward transmission, it is all the more urgent that we implement structural interventions that will render the maximum benefit from treatment and prevention.  This must include not only addressing the housing and health care needs of those leaving the correctional system, but also addressing our system of mass incarceration as a whole."

The report concludes, "We call on the HIV/AIDS, housing, public health, and criminal justice sectors to alleviate the overlapping burden of HIV infection and incarceration on individuals and communities by taking immediate steps to improve housing status among former prisoners living with HIV/AIDS and their families. Though much is likely to be eliminated or deferred during these difficult budget times, the failure to fund and bring to scale these proven and critically needed housing resources will end up costing much more than it saves."

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Major Study Finds that About One in Five Transgender Women Worldwide Are Living with HIV

Transgender women have a very high prevalence of HIV infection and are in urgent need of prevention, treatment, and care services, according to a recent study by Johns Hopkins researcher Dr. Stefan Baral and his colleagues.  The research team conducted a meta-analysis, which combined data from 39 studies involving more than 11,000 transgender women in 15 countries.  Their review of the research literature from 2000 through 2011 found that data on the HIV prevalence among transgender women were available only in countries with male-predominant HIV epidemics, including the U.S., six countries in the Asian-Pacific region, five in Latin America, and three in Europe. 

Overall, about one-fifth (19%) of the transgender women studied were living with HIV.  The calculated HIV prevalence rate was somewhat higher for transgender women in five high-income countries (21.6%) than the rate found in ten low- and middle-income countries (17.7%).  The researchers noted, however, that transgender women in all the countries studied had HIV prevalence rates roughly 50 times greater than that of other adults of reproductive age.

"In view of the limited worldwide data for transgender women and extraordinary disease burdens we have identified, the present HIV surveillance and prevention interventions for transgender women are clearly inadequate," the research team noted. "The high burden of HIV is probably a function of both low coverage rates for effective interventions, and an insufficient range of interventions to reduce HIV infection risks for this population. Transgender-specific interventions are scarce, and no randomized trials of prevention technologies have included sufficient transgender participants to assess efficacy for these people."

In addition, "Structural change will also be essential," according to the researchers. "Transgender women and communities are emerging and advocating for their rights as citizens, and their full inclusion in the HIV response. The sexual orientation and gender identity strategy of the Global Fund is a welcome example of expanding efforts at such inclusion.  Removing gender dysphoria/gender identity disorder from . . . the 11th International Classification of Diseases could provide support for increased visibility of transgender people with less fear of being automatically labeled mentally ill. Greater visibility should be coupled with transgender people and communities having a stronger voice." The researchers also recommended that transgender persons be specifically counted in national HIV surveillance programs and in HIV-focused research studies, rather than lumping data for transgender women with that for men who have sex with men.

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UNAIDS Report Highlights Essential Role of Women in Ending the HIV/AIDS Pandemic

"Despite the many successes we have seen [in fighting HIV/AIDS], women still face inequalities that will keep the AIDS response from reaching its full potential," according to a new 100-page report, Women Out Loud: How Women Living with HIV Will Help the World End AIDS, from the United Nations Program on AIDS (UNAIDS).  The report outlines ways in which addressing HIV/AIDS disparities in women, as well as drawing and acting on women's knowledge, are essential for meeting the 10 target goals of the 2011 United Nations Political Declaration on HIV and AIDS.  For each of these targets, the report provides key statistics and recommendations, a sampling of which are extracted below.

1. Reduce sexual transmission of HIV 50% by 2015: "Reducing sexual transmission by 50% by 2015 requires scaled-up access to comprehensive and nonjudgmental HIV services for women and girls throughout their lives. It will also be necessary to scale up access to comprehensive sexuality education in and out of school, and to expand youth-friendly services that empower young women to protect themselves. Recent evidence shows the cost-effectiveness of delivering sexuality education programs and services jointly at scale has the strongest impact."

2.  Reduce transmission of HIV among people who inject drugs 50% by 2015: "Women who inject drugs must have access to confidential and voluntary HIV counseling and testing. They also need reliable information and access to sexual and reproductive services for ending new infections in children and keeping mothers alive, as well as to protect their own health, free of stigma

and discrimination."

3.  Eliminate new HIV infections among children by 2015 and substantially reduce AIDS-related maternal deaths: "To reach the target of eliminating new child HIV infections and keeping their mothers alive, it is critical to protect the sexual and reproductive health and rights of all women living with HIV. These include their right to access voluntary and confidential HIV testing and counseling, accurate and nonjudgmental information, quality treatment and services, and to bear children in a safe environment, free of stigma, discrimination, and violence."

4.  Reach 15 million people living with HIV with lifesaving antiretroviral treatment by 2015:  "It is clear that to reach 15 million people with HIV treatment by 2015, efforts must be intensified to ensure increased uptake of treatment among women, especially in populations without easy access to care.  There is also a need to identify barriers that are stopping men from accessing care."

5.  Reduce TB deaths 50% in people living with HIV by 2015:  "More research is needed focusing on tuberculosis and HIV among women living with HIV. Networks of women living with HIV must be mobilized and supported to build knowledge and demand for better integration and earlier access to tuberculosis and HIV interventions in mother and child health services."

6.  Close the global AIDS resource gap by 2015 and reach annual global investment of $22 to $24 billion in low- and middle-income countries:  "Development partners and national governments must invest in networks and organizations of women living with HIV, enabling them to develop and  implement innovative strategies to meet women’s needs. Resource allocation that is intended to meet gender-responsive performance indicators and gender-responsive budgeting measures are a key to smart spending and improved tracking of resources targeting women and girls."

7.  Eliminate gender inequalities and gender-based abuse and violence and increase the capacity of women and girls to protect themselves from HIV:  "The AIDS response should include integrating services to counter and manage gender-based violence into HIV services. Women living with HIV must be supported to lead social transformation for gender equality, sexual and reproductive health and rights, and zero tolerance for violence within their societies. Men and boys must be engaged in this movement to engender a supportive environment at family, community, and national levels."

8.  Eliminate stigma and discrimination against people living with and affected by HIV through promotion of laws and policies that ensure the full realization of all human rights and fundamental freedoms: "Recent successes led by women against stigma, discrimination, and punitive laws show that negative legal and social environments can be addressed. This requires engaging women living with HIV and their advocates and ensuring that their experiences shape the response to the epidemic. These efforts must be in keeping with the Positive Health, Dignity, and Prevention Framework, which focuses on improving and maintaining the health and well-being of people living with HIV in a holistic manner."

9.  Eliminate HIV-related restrictions on entry, stay, and residence:  "In light of increasing migration and globalization, addressing the broader health and human rights issues of those on the move, including women migrants and those living with HIV, is key to global and national health. Successful efforts to remove restrictions on entry, stay, and residence have often involved coalitions of people living with HIV, advocates for the rights of migrants, women’s groups and human rights organizations working together."

10.  Eliminate parallel systems for HIV-related services to strengthen integration of the AIDS response in global health and development efforts: "To improve the response to the needs of women living with HIV, integration efforts must address gender inequalities, combat gender-based violence, improve access to education for all girls and women, and address the sexual and reproductive health needs of women throughout their life-cycles.  In addition, it is of key importance to champion and invest in women’s leadership and participation for a more effective and integrated HIV response. It is important to invest in strengthening the capacity of women to organize and lead beyond the delivery of care and support services, and also to ensure the full participation of women and girls."

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Nearly 10,000 Americans Living with HIV/AIDS Projected to Lose Access to AIDS Drug Assistance Program if Budget Sequestration Cuts Take Effect

"Applying sequestration cuts to domestic HIV/AIDS programming would provide negligible deficit reduction, but would have a devastating impact on people living with HIV/AIDS (PLWHA) in America," according to a recent assessment by The Foundation for AIDS Research (amfAR) and NMAC.  "It would also damage American leadership in health research, and limit the United States' ability to reduce the rate of new HIV infections, improve access to care, and reduce the disproportionate impact of HIV/AIDS on communities of color."

Sequestration Background: Under the Budget Control Act of 2011, the U.S. Congress was tasked with reducing the federal deficit by $1.2 trillion over the next decade.  Under that Act, failure to propose a plan to reduce the deficit by the agreed-upon deadline would trigger an enforcement mechanism resulting in automatic budget cuts in both defense and non-defense spending. This enforcement mechanism is called "sequestration."  The fiscal cliff deal reached by Congress in January delayed the start of sequestration from January 2 to March 1, 2013.  Unless Congress acts to avert sequestration, automatic budget cuts amounting to 5.2% of non-defense discretionary spending will kick in during March. To calculate the impact of sequestration on HIV/AIDS programs, amfAR and NMAC drew on figures from the Center on Budget and Policy Priorities. These projected impacts are summarized below, along with selected commentary (in quotes) by amfAR and NMAC:

AIDS Drug Assistance Program (ADAP):  As a result of sequestration cuts, an estimated 9,750 HIV-infected persons – including over 6,500 persons of color – would lose access to the ADAP, which provides antiretroviral medications to low-income PLWHA.  The loss of access to HIV treatment would also hamper efforts to reduce HIV transmission: "Recent research has shown that, in addition to saving and improving the lives of PLWHA, HIV treatment reduces the risk of transmitting HIV to an uninfected partner by 96%."

Housing Opportunities for Persons with AIDS Program (HOPWA):  If sequestration cuts to HOPWA take effect, an estimated 1,300 fewer households would receive permanent housing and 1,800 fewer households would receive short-term assistance to prevent homelessness.  The impact of the HOPWA cuts would be especially heavy on HIV-infected persons of color.  NMAC and amfAR estimate that 1,850 households that include at least one person of color would lose HOPWA housing services; 560 households that include at least one Hispanic person would lose housing services. 

AIDS Research Funding: The National Institutes of Health are projected to lose $157 million in AIDS research funding if sequestration cuts occur.  As a result, an estimated 290 AIDS research grants would go unfunded, including 30 specifically funding AIDS vaccine research.

CDC Funding for State and Local HIV Prevention Efforts: Under sequestration, more than $40 million in CDC funding would be cut from state and local HIV prevention efforts, including programs targeting young people and adults at high risk of infection.

If the U.S. Congress is able to reach budget agreement to avoid sequestration, we plan to report on the agreement in an upcoming issue of the Health Disparities Update.

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New Black AIDS Institute Report Outlines Five-Year Strategy to Defeat AIDS in Black America

Coinciding with Black HIV/AIDS Awareness Day earlier this month, the Black AIDS Institute released its new report Light at the End of the Tunnel, which presents a five-year strategy for dramatically increasing the number of Black Americans who experience the full benefits of antiretroviral treatment.  This would be achieved by focusing resources to expand HIV testing, extend the coverage of prevention services for HIV and sexually transmitted infections, improve access to and retention in HIV care in Black communities, and invest in scientific research aimed at preventing and curing HIV infection. 

The overarching goal of the five-year strategy is to "ensure that at least 80% of the over 500,000 Black Americans estimated to be living with HIV achieve viral suppression by 2017."   The report identifies the following five "strategic pillars" – activities that will provide the foundation for achieving this goal – and describes a series of action steps associated with each pillar. 

Ensure that at least 95% of Black Americans living with HIV know their HIV status:  "Invest in community-based treatment literacy programs to help Black communities understand the benefits of HIV testing, use state-of-the-art marketing and outreach strategies to promote HIV testing, and scale up multiple modes of testing delivery, including comprehensive implementation of provider-initiated HIV testing in health care settings."

Eliminate gaps in the HIV treatment cascade for Black Americans living with HIV:  "Capitalize on implementation of the Affordable Care Act to move as close as possible to universal health coverage, reauthorize a revised Ryan White to focus on effective linkage and retention strategies, integrate evidence-based treatment adherence supports into clinical and community-based practice, improve the monitoring of HIV clinical outcomes, and implement financial incentives for policy-makers, strategic planners, and clinicians to reduce patient loss at each stage of the treatment continuum."

Deliver high-impact HIV prevention services to all Black Americans at risk of HIV: "Refocus prevention services at the federal, state, and local level to achieve saturation coverage in Black communities; undertake a targeted national campaign to dramatically reduce STIs [sexually transmitted infections] in Black communities; capitalize on implementation of the Affordable Care Act to establish reliable new funding streams for evidence-based HIV prevention; and implement financial incentives for state and local health departments to demonstrate progress in reducing new HIV infections among Black Americans."

Invest in strategic HIV-related research to accelerate the end of AIDS in Black America: "Strengthen and sustain targeted research to accelerate progress toward development of a preventive vaccine and a cure for HIV; prioritize research to develop new HIV prevention tools for Black Americans, including  affordable vaginal and rectal microbicides; and implement focused research to enhance the efficiency and effectiveness of HIV prevention and treatment programs in Black communities, taking priority steps to rapidly translate research results into actual programs and practice."

Build the capacity needed in Black communities to accelerate the end of AIDS in Black America:

"Increase and sustain federal support for capacity-building in Black and Black-serving community-based organizations, with a particular focus on equipping Black communities with the means to increase HIV science and treatment literacy and to retool to contribute to the scaling-up of integrated biomedical and behavioral approaches to HIV prevention and treatment."

The report also provides timelines for each of the five strategic pillars with specific policy, funding, and research objectives, as well as interim targets for increased HIV testing, linkages to care, delivery of prevention services, investments in research, and capacity building.

Another noteworthy feature of Light at the End of the Tunnel is its emphasis on the transformative power of "coming out" concerning one's HIV status. The report states, "To lay the foundation for an end to AIDS, all people living with HIV need to come out of the closet and determine to live openly and proudly with HIV.  There are many reasons why coming out is so vital. First and foremost, the individual who lives openly with HIV is able to live a fuller, more complete life. It allows people in our lives to share our journey, offer us love and support, and know us in our fullness. People who live openly with HIV are also able to seek the services they need to thrive. Without fear that their HIV status will be discovered, people who live openly with HIV are able to visit the doctor or clinic of their choice, seek health-related information, network with and learn from other people living with HIV, and obtain care and support when they need it. Having an army of openly HIV-positive people in place also helps build demand for treatment. By bringing HIV into the light of day, people living with the disease are able to join together to advocate for their needs. And seeing HIV-positive people living long, happy, and healthy lives encourages at-risk individuals to seek HIV testing."

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Featured Health Resources for National Women and Girls HIV/AIDS Awareness Day (March 10)

National Women and Girls HIV/AIDS Awareness Day will be observed this year on Sunday, March 10.  The theme of the day is "Share Knowledge. Take Action." According to HHS's Office of Women's Health, which is the lead agency for the event, this awareness day is designed to "shed light on the disease's often overlooked impact on women and girls and empower people to make a difference."

In commemoration of this day, we've compiled an annotated list of online resources focusing on HIV/AIDS among women and girls in the U.S.

Fact Sheets and Reports

Women and HIV/AIDS in the United States.  Updated in December, this two-page fact sheet from the Kaiser Family Foundation provides excellent summary information on the impact of HIV/AIDS on U.S. women.  The fact sheet includes: a snapshot of the epidemic, a review of key trends and current cases, information on reproductive health and HIV transmission specific to women, access to and use of the healthcare system, and HIV testing, among others.

HIV among Women. This two-page CDC fact sheet presents information about trends in HIV/AIDS diagnoses and deaths among women, prevention challenges, and steps CDC is taking to address the needs of women affected by HIV/AIDS.

Women and HIV. One-page fact sheet from the AIDS InfoNet.  Also available in Spanish.

HIV among Pregnant Women, Infants, and Children in the United States. Newly published fact sheet from CDC.

Special Issues for Women. Educational lesson from AIDSmeds focusing on health issues of particular concern for HIV-infected women.  Also available in Spanish.

Diagnoses of HIV Infection and AIDS in the United States and Dependent Areas, 2010. This 79-page CDC report includes detailed information about HIV and AIDS cases and deaths among Americans, including breakdowns by gender, transmission category, and age.

Women, HIV, and AIDS.  This online document from Avert.org provides a global overview of  HIV/AIDS among women, with citations to more than 50 source research papers and reports.  Topics covered include: updates on HIV/AIDS among women in different geographical regions; women’s responsibilities for HIV care in affected families; specific effects of the epidemic on women and children; challenges that can make it difficult for women to protect themselves from infection; and issues that need to be addressed to reduce the impact of HIV/AIDS on women.

Selected Organizations and Web Sites

The Well Project: This web site focuses on HIV prevention, treatment, and wellness among women living with, or at risk for, HIV infection.  Many of the Well Project’s resources are also available in Spanish.

Women, Children and HIV:  This web site from the University of California-San Francisco Medical Center has extensive resources on the prevention and treatment of HIV in women and children worldwide.

International Community of Women Living with HIV/AIDS (ICW):  ICW describes itself as the only international network led and made up of HIV-positive women.  The ICW web site, which also has a Spanish interface, links to newsletters, training manuals, and other resources.

Women Organized to Respond to Life-Threatening Diseases (WORLD): WORLD advocates for programs and policies that address the needs of HIV-infected women and improve their quality of life.  Its projects include the Positive Women’s Network USA site.

Center for AIDS Prevention Studies (CAPS): The University of California-San Francisco's CAPS has compiled many fact sheets in English and Spanish on HIV prevention in different communities.  CAPS fact sheets include:

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Recent Research on HIV Health Disparities and Affected Populations

This newsletter section includes the titles, authors, and links to abstracts for recent research. Papers are listed alphabetically according to the lead author's last name.

Racial/Ethnic Disparities in Engagement in Care and Viral Suppression in a Large Urban HIV Clinic.  By Oluwatoyin Adeyemi, Britt Livak, and others, in Clinical Infectious Diseases

HIV Testing Beliefs in a Predominantly Hispanic Community Health Center During the Routine HIV Testing Era: Does English Language Ability Matter?  By Monisha Arya, Amber Amspoker, and others, in AIDS Patient Care and STDs.

Worldwide Burden of HIV in Transgender Women: A Systematic Review and Meta-Analysis.  By Stefan Baral, Tonia Poteat, and others, in The Lancet Infectious Diseases.

Perceived Discrimination and Physical Health Among HIV-Positive Black and Latino Men Who Have Sex with Men. By Laura Bogart, Hope Landrine, and others, in AIDS and Behavior.

An Assessment of the Feasibility and Acceptability of a Friendship-Based Social Network Recruitment Strategy to Screen At-Risk African American and Hispanic/Latina Young Women for HIV Infection.  By Cherrie Boyer, Lisa Hightow-Weidman, and others, in JAMA Pediatrics.

Experiences of HIV Stigma: The Role of Visible Symptoms, HIV Centrality, and Community Attachment for People Living with HIV. By Loren Brener, Denton Callander, and others, in AIDS Care.

Growing Older with HIV/AIDS: New Public Health Challenges.  By Sean Cahill and Robert Valadéz, in American Journal of Public Health.

An Event-Level Comparison of Risk-Related Sexual Practices Between Black and Other-Race Men Who Have Sex with Men: Condoms, Semen, Lubricant, and Rectal Douching.  By Sarah Calabrese, Joshua  Rosenberger, and others, in AIDS Patient Care and STDs.

Centralization of HIV services in HIV-positive African-American and Hispanic Youth Improves Retention in Care. By Jessica Davila, Nancy Miertschin, and others, in AIDS Care.

Patterns of Condom Use Among Students at Historically Black Colleges and Universities: Implications for HIV Prevention Efforts Among College-Age Young Adults. By Charbel El Bcheraoui, Madeline Sutton, and others, in AIDS Care.

Risk and Protective Factors Associated with Health-Related Quality of Life Among Older Gay and Bisexual Men Living With HIV Disease.  By Charles Emlet, Karen Fredriksen-Goldsen, and Hyun-Jun Kim, in Gerontologist.

A Loss of Moral Experience: Understanding HIV-Related Stigma in the New York City House and Ball Community.  By Gabriel Galindo, in American Journal of Public Health.

Missed Opportunities: Refusal to Confirm Reactive Rapid HIV Tests in the Emergency Department.  By Ishani Ganguli, Jamie Collins, and others, in PLoS One.

Prevalent and Incident Hepatitis C Virus Infection Among HIV-Infected Men Who Have Sex with Men Engaged in Primary Care in a Boston Community Health Center. By Shikha Garg, Lynn Taylor, and others, in Clinical Infectious Diseases.

African-Americans' Perceptions of Health Care Provider Cultural Competence that Promote HIV Medical Self-Care and Antiretroviral Medication Adherence.  By Gina Gaston, in AIDS Care.

The Cellular Generation and a New Risk Environment: Implications for Texting-Based Sexual Health Promotion Interventions Among Minority Young Men Who Have Sex with Men.  By Sheba George, Robert Phillips, and others, in AMIA Annual Symposium Proceedings.

Measurement Model Exploring a Syndemic in Emerging Adult Gay and Bisexual Men.  By Perry Halkitis, Robert Moeller, and others, in AIDS and Behavior.

Adversity and Syndemic Production Among Men Participating in the Multicenter AIDS Cohort Study: A Life-Course Approach.  By Amy Herrick, Sin How Lim, and others, in American Journal of Public Health.

Treatment Acceptance and Adherence in HIV Disease: Patient Identity and the Perceived Impact of Physician-Patient Communication.  By M. Barton Laws, Gary Rose, and others, in Patient Preference and Adherence.

Disparities in Engagement in Care and Viral Suppression Among Persons with HIV.  By Dharushana Muthulingam, Jennie Chin, and others, in Journal of Acquired Immune Deficiency Syndromes.

Overview of Substance Use Disorders and Incarceration of African American Males. By Venkata Mukku, Timothy Benson, and others, in Frontiers in Psychiatry.

What's God Got to Do with It? Engaging African-American Faith-Based Institutions in HIV Prevention.  By Amy Nunn, Alexandra Cornwall, and others, in Global Public Health.

Psychometric Properties of an HIV Knowledge Scale Administered With Populations at High Risk for HIV Infection.  By Willie Oglesby and Sonia Alemagno, in Health Promotion Practice.

Barriers to Care for Rural People Living with HIV: A Review of Domestic Research and Health Care Models.  By Jennifer Pellowski, in Journal of the Association of Nurses in AIDS Care.

Participation in Research Involving Novel Sampling and Study Designs to Identify Acute HIV-1 Infection Among Minority Men Who Have Sex with Men.  By Kristina Rodriguez, Delivette Castor, and others, in AIDS Care.

Self-disclosure of serostatus by youth who are HIV-positive: A Review.  Candace Thoth, Christy Tucker, Matthew Leahy, and Sunita Stewart, in Journal of Behavioral Medicine.

HIV Surveillance and Prevention in Transgender Women. By Frits van Griensven, Prempreeda Pramoj Na Ayutthaya, and Erin Wilson, in The Lancet Infectious Diseases.

Online Social Networking for HIV Education and Prevention: A Mixed-Methods Analysis. By Sean Young and Devan Jaganath, in Sexually Transmitted Diseases.

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