Costs per Diagnosis of Acute HIV Infection in Community-Based Screening Strategies: A Comparative Analysis of Four Screening Algorithms

BACKGROUND:

In nonhealthcare settings, widespread screening for acute human immunodeficiency virus (HIV) infection (AHI) is limited by cost and decision algorithms to better prioritize use of resources. Comparative cost analyses for available strategies are lacking.

METHODS:

To determine cost-effectiveness of community-based testing strategies, we evaluated annual costs of 3 algorithms that detect AHI based on HIV nucleic acid amplification testing (EarlyTest algorithm) or on HIV p24 antigen (Ag) detection via Architect (Architect algorithm) or Determine (Determine algorithm) as well as 1 algorithm that relies on HIV antibody testing alone (Antibody algorithm). The cost model used data on men who have sex with men (MSM) undergoing community-based AHI screening in San Diego, California. Incremental cost-effectiveness ratios (ICERs) per diagnosis of AHI were calculated for programs with HIV prevalence rates between 0.1% and 2.9%.

RESULTS:

Among MSM in San Diego, EarlyTest was cost-savings (ie, ICERs per AHI diagnosis less than $13.000) when compared with the 3 other algorithms. Cost analyses relative to regional HIV prevalence showed that EarlyTest was cost-effective (ie, ICERs less than $69.547) for similar populations of MSM with an HIV prevalence rate >0.4%; Architect was the second best alternative for HIV prevalence rates >0.6%.

CONCLUSIONS:

Identification of AHI by the dual EarlyTest screening algorithm is likely to be cost-effective not only among at-risk MSM in San Diego but also among similar populations of MSM with HIV prevalence rates >0.4%.

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By:  Hoenigl M1, Graff-Zivin J2, Little SJ3.

• 1Division of Infectious Diseases, University of California-San Diego Division of Pulmonology Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Austria.
• 2School of International Relations and Pacific Studies and Department of Economics, University of California-San Diego.
• 3Division of Infectious Diseases, University of California-San Diego 
• Clin Infect Dis. 2016 Feb 15;62(4):501-11. doi: 10.1093/cid/civ912. Epub 2015 Oct 27.

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Prevalence of Transmitted HIV Drug Resistance among Recently Infected Persons in San Diego, CA 1996-2013

BACKGROUND:

Transmitted drug resistance (TDR) remains an important concern when initiating antiretroviral therapy (ART). Here, we describe the prevalence and phylogenetic relationships of TDR among ART-naive, HIV-infected individuals in San Diego from 1996 to 2013.

METHODS:

Data were analyzed from 496 participants of the San Diego Primary Infection Cohort who underwent genotypic resistance testing before initiating therapy. Mutations associated with drug resistance were identified according to the WHO-2009 surveillance list. Network and phylogenetic analyses of the HIV-1 pol sequences were used to evaluate the relationships of TDR within the context of the entire cohort.

RESULTS:

The overall prevalence of TDR was 13.5% (67/496), with an increasing trend over the study period (P = 0.005). TDR was predominantly toward nonnucleoside reverse transcriptase inhibitors (NNRTIs) [8.5% (42/496)], also increasing over the study period (P = 0.005). By contrast, TDR to protease inhibitors and nucleos(t)ide reverse transcriptase inhibitors were 4.4% (22/496) and 3.8% (19/496), respectively, and did not vary with time. TDR prevalence did not differ by age, gender, race/ethnicity, or risk factors. Using phylogenetic analysis, we identified 52 transmission clusters, including 8 with at least 2 individuals sharing the same mutation, accounting for 23.8% (16/67) of the individuals with TDR.

CONCLUSIONS:

Between 1996 and 2013, the prevalence of TDR significantly increased among recently infected ART-naive individuals in San Diego. Around one-fourth of TDR occurred within clusters of recently infected individuals. These findings highlight the importance of baseline resistance testing to guide selection of ART and for public health monitoring.

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By:  Panichsillapakit T1, Smith DM, Wertheim JO, Richman DD, Little SJ, Mehta SR.

• 1*Department of Preventive and Social Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand; †Department of Medicine, University of California, San Diego, CA; ‡Veterans Affairs San Diego Healthcare System, San Diego, CA; and §Department of Pathology, University of California, San Diego, CA.

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Clear Links between Starting Methamphetamine and Increasing Sexual Risk Behavior: A Cohort Study among Men Who Have Sex with Men

It remains unclear if methamphetamine is merely associated with high risk behavior or if methamphetamine use causes high risk behavior. Determining this would require a randomized controlled trial, which is clearly not ethical. A possible surrogate would be to investigate individuals before and after starting the use of methamphetamine.

We performed a cohort study to analyze recent self-reported methamphetamine use and sexual risk behavior among 8,905 MSM receiving the "Early Test", a community-based, HIV screening program in San Diego, California, between April 2008 and July 2014 (total 17,272 testing encounters). Sexual risk behavior was evaluated using a previously published risk behavior score (San Diego Early Test [SDET] score) that predicts risk of HIV acquisition.

Methamphetamine use during the last 12 months (hereafter, recent-meth) was reported by 754/8,905 unique MSM (8.5%). SDET scores were significantly higher in the 754 MSM with recent-meth use compared to the 5,922 MSM who reported that they have never used methamphetamine (p<0.001). Eighty-two repeat testers initiated methamphetamine between testing encounter, with significantly higher SDET scores after starting methamphetamine.

Given the ethical impossibility of conducting a randomized, controlled trial, the results presented here provide the strongest evidence yet that initiation of methamphetamine use increases sexual risk behavior among HIV-uninfected MSM. Until more effective prevention or treatment interventions are available for methamphetamine users, HIV-uninfected MSM who use methamphetamine may represent ideal candidates for alternative effective prevention interventions (i.e., pre-exposure prophylaxis).

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By: Hoenigl M1, Chaillon A, Moore DJ, Morris SR, Smith DM, Little SJ.

• 1Division of Infectious Diseases, Department of Medicine, University of California San Diego (UCSD), La Jolla, California, United States 2 Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria 3 Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria 4 Department of Psychiatry, University of California San Diego (UCSD), La Jolla, California, United States 5 Veterans Affairs Healthcare System, San Diego, California, United States.

 

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Largest U.S. Cities That Still Allow LGBT Discrimination

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Risk Behavior and Sexually Transmitted Infections among Transgender Women and Men Undergoing Community-Based Screening for Acute and Early HIV Infection in San Diego

The transgender community represents an understudied population in the literature. The objective of this study was to compare risk behavior, and HIV and sexually transmitted infection (STI) rates between transgender women and transgender men undergoing community-based HIV testing.

With this retrospective analysis of a cohort study, we characterize HIV infection rates as well as reported risk behaviors and reported STI in 151 individual transgender women and 30 individual transgender men undergoing community based, voluntary screening for acute and early HIV infection (AEH) in San Diego, California between April 2008 and July 2014.HIV positivity rate was low for both, transgender women and transgender men undergoing AEH screening (2% and 3%, respectively), and the self-reported STI rate for the prior 12 months was 13% for both. Although transgender women appeared to engage in higher rates of risk behavior overall, with 69% engaged in condomless receptive anal intercourse (CRAI) and 11% engaged in sex work, it is important to note that 91% of transgender women reported recent sexual intercourse, 73% had more than 1 sexual partner, 63% reported intercourse with males, 37% intercourse with males and females, and 30% had CRAI.

Our results indicate that in some settings rates of HIV infection, as well as rates of reported STIs and sexual risk behavior in transgender men may resemble those found in transgender women. Our findings support the need for comprehensive HIV prevention in both, transgender women and men.

Full article at: http://goo.gl/fJmKVh

By: Green N1, Hoenigl M, Morris S, Little SJ.

• 1From the Division of Infectious Diseases, Department of Medicine, University of California San Diego (UCSD) (NG, MH, SM, SJL); Division of Family Medicine, University of California San Diego (UCSD), San Diego, CA (SM); Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine (MH); and Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria (MH).  

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Risk Behavior and Sexually Transmitted Infections among Transgender Women and Men Undergoing Community-Based Screening for Acute and Early HIV Infection in San Diego

The transgender community represents an understudied population in the literature. The objective of this study was to compare risk behavior, and HIV and sexually transmitted infection (STI) rates between transgender women and transgender men undergoing community-based HIV testing.With this retrospective analysis of a cohort study, we characterize HIV infection rates as well as reported risk behaviors and reported STI in 151 individual transgender women and 30 individual transgender men undergoing community based, voluntary screening for acute and early HIV infection (AEH) in San Diego, California between April 2008 and July 2014.

HIV positivity rate was low for both, transgender women and transgender men undergoing AEH screening (2% and 3%, respectively), and the self-reported STI rate for the prior 12 months was 13% for both. Although transgender women appeared to engage in higher rates of risk behavior overall, with 69% engaged in condomless receptive anal intercourse (CRAI) and 11% engaged in sex work, it is important to note that 91% of transgender women reported recent sexual intercourse, 73% had more than 1 sexual partner, 63% reported intercourse with males, 37% intercourse with males and females, and 30% had CRAI.

Our results indicate that in some settings rates of HIV infection, as well as rates of reported STIs and sexual risk behavior in transgender men may resemble those found in transgender women. Our findings support the need for comprehensive HIV prevention in both, transgender women and men.

Full article at: http://goo.gl/q0ZtT3

By: Green N1, Hoenigl M, Morris S, Little SJ.

• 1From the Division of Infectious Diseases, Department of Medicine, University of California San Diego (UCSD) (NG, MH, SM, SJL); Division of Family Medicine, University of California San Diego (UCSD), San Diego, CA (SM); Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine (MH); and Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria (MH).  

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Effect of Legal Status of Pharmacy Syringe Sales on Syringe Purchases by Persons Who Inject Drugs in San Francisco & San Diego, CA

Sharing blood-contaminated syringes is the main risk factor for acquiring and transmitting blood-borne infections among persons who inject drugs (PWID). To reduce this risk, in 2005, California enacted legislation allowing local health jurisdictions to legalize non-prescription syringe sales after approving a disease prevention demonstration project (DPDP). With San Francisco approving a DPDP immediately and San Diego never approving one, we compared PWID across cities for their use of pharmacies PWID to obtain syringes.

PWID age 18-30 years old were recruited into separate studies in San Francisco (n=243) and San Diego (n=338) between 2008 and 2011. We used multivariable logistic regression to compare the proportions of PWID who obtained syringes from pharmacies by city while controlling for sociodemographics, injection practices and other risk behaviors.

Overall, most PWID were White (71%), male (63%), and between the ages of 18-25 years (55%). Compared to San Francisco, a smaller proportion of PWID in San Diego had bought syringes from pharmacies in the prior three months (16.9% vs. 49.8%; p<0.001), which remained statistically significant after adjusting for sociodemographic and behavioral factors (adjusted odds ratio=4.45, 95% confidence interval: 2.98, 6.65).

Use of pharmacies to obtain syringes was greater where it was legal to do so. Public health policy can influence HIV and hepatitis C associated risk among PWID; however, implementation of these policies is crucial for the benefits to be realized.

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By: Siddiqui SS1, Armenta RF2, Evans JL3, Yu M3, Cuevas-Mota J2, Page K3, Davidson P2, Garfein RS4.

• 1Graduate School of Public Health, San Diego State University, San Diego, CA, USA.
• 2Division of Global Public Health, School of Medicine, University of California San Diego, San Diego, CA, USA.
• 3Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA.
• 4Division of Global Public Health, School of Medicine, University of California San Diego, San Diego, CA, USA. Electronic address: rgarfein@ucsd.edu.  

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Repeat HIV-Testing Is Associated with an Increase in Behavioral Risk among Men Who Have Sex with Men

The Center for Disease Control and Prevention recommends that high-risk groups, like sexually active men who have sex with men (MSM), receive HIV testing and counseling at least annually. The objective of this study was to investigate the relationship between voluntary repeat HIV testing and sexual risk behavior in MSM receiving rapid serologic and nucleic acid amplification testing.

We performed a cohort study to analyze reported risk behavior among MSM receiving the “Early Test”, a community-based, confidential acute and early HIV infection screening program in San Diego, California, between April 2008 and July 2014. The study included 8,935 MSM receiving 17,333 “Early Tests”. A previously published risk behavior score for HIV acquisition in MSM (i.e. Menza score) was chosen as an outcome to assess associations between risk behaviors and number of repeated tests.

At baseline, repeat-testers (n = 3,202) reported more male partners and more condomless receptive anal intercourse (CRAI) when compared to single-testers (n = 5,405, all P <0.001). In 2,457 repeat testers there was a strong association observed between repeated HIV tests obtained and increased risk behavior, with number of male partners, CRAI with high risk persons, non-injection stimulant drug use, and sexually transmitted infections all increasing between the first and last test. There was also a linear increase of risk (i.e. high Menza scores) with number of tests up to the 17th test. In the multivariable mixed effects model, more HIV tests (OR = 1.18 for each doubling of the number of tests, P <0.001) and younger age (OR = 0.95 per 5-year increase, P = 0.006) had significant associations with high Menza scores.

This study found that the highest risk individuals for acquiring HIV (e.g. candidates for antiretroviral pre-exposure prophylaxis) can be identified by their testing patterns. Future studies should delineate causation versus association to improve prevention messages delivered to repeat testers during HIV testing and counseling sessions.

Below:  Percentage of high (i.e. ≥5 Menza-score points) HIV behavioral risk scores as modified from [23], by number of HIV tests in repeat testers. The bubble size reflects the denominator used to calculate the percentage of high scores. Linear Reg stands for linear regression, assuming a linear relationship between the y-axis (high risk score) and the x-axis (number of tests). Loess stands for local regression, a smoothing technique that allows one to see a pattern without assuming a particular distribution

Table 1

Comparison demographics and risk behavior at baseline. Reported by individuals with a single HIV test during the study period versus those with repeated HIV tests (those with two or more tests, and the subpopulation with five or more tests)

Risk factor/risk behavior (within 12 months prior to test) and demographics	Single testers a	Repeat testers (2 or more tests) a	P value b	Repeat tester (5 or more tests) a	P value b
N	5402	3202		814
Number of male partners (median, IQR)	5 (3–10)	6 (3–12)	<0.001	6 (4–14)	<0.001
10 or more male partners	1624/5397 (30.1 %)	1120/3197 (35.0 %)	<0.001	319 (39.2 %)	<0.001
Intercourse with females also	594/5389 (11.0 %)	277/3192 (8.7 %)	<0.001	64/813 (7.9 %)	0.007
CIAI with male	3188/5347 (59.6 %)	1974/3170 (62.3 %)	0.016	491/804 (61.1 %)	n.s.
CRAI	2611/5343 (48.9 %)	1664/3167 (52.5 %)	0.001	434/802 (54.1 %)	0.003
CRAI and 5 or more male partners	1544/5342 (28.9 %)	1102/3165 (34.8 %)	<0.001	306/802 (38.2 %)	<0.001
CRAI and 10 or more male partners	892/5342 (16.7 %)	632/3165 (20.0 %)	<0.001	181/802 (22.6 %)	<0.001
CRAI with HIV positive	214/5097 (4.2 %)	121/2947 (4.1 %)	n.s.	19/725 (2.6 %)	0.043
CRAI with PWID	56/5281 (1.1 %)	29/3129 (0.9 %)	n.s.	4/790 (0.5 %)	n.s.
CRAI with sex worker	21/5147 (0.4 %)	9/3052 (0.3 %)	n.s.	1/764 (0.1 %)	n.s.
Worked as sex worker	84/3799 (2.2 %)	45/2004 (2.3 %)	n.s.	8/424 (1.9 %)	n.s.
Syphilis c	101 (1.9 %)	59 (1.8 %)	n.s.	23 (2.8 %)	n.s.
Gonorrhea c	274 (5.1 %)	193 (6.0 %)	n.s.	47 (5.8 %)	n.s.
Chlamydia c	214 (4.0 %)	129 (4.0 %)	n.s.	48 (5.9 %)	0.01
Any STI c	596 (11.0 %)	402 (12.6 %)	0.033	126 (15.5 %)	<0.001
Methamphetamine, not injected	363 (6.7 %)	189 (5.9 %)	n.s.	44 (5.4 %)	n.s.
Non-injection stimulant drug use (i.e. methamphetamine, cocaine, poppers, GHB, ketamine, XTC)	1316 (24.4 %)	765 (23.9 %)	n.s.	176 (21.6 %)	n.s.
IDU	77 (1.4 %)	37 (1.2 %)	n.s.	5 (0.6 %)	n.s.
IDU with shared needles	35/5378 (0.7 %)	7/3180 (0.2 %)	0.006	0	0.021
Demographic data
Age (years; median, IQR)	33 (26–43)	32 (26–42)	0.011	32 (26–41)	n.s.
Male	5402 (100 %)	3202 (100 %)	n.s.	814 (100 %)
Hispanic origin	1434/5249 (27.3 %)	850/3105 (27.4 %)	n.s.	203/785 (25.9 %)	n.s.
Race	–	–	<0.001	–	<0.001
Caucasian	3513/5066 (69.3 %)	2112/3021 (69.9 %)	n.s.	547/783 (69.9 %)	n.s.
African-American	317/5066 (6.3 %)	143/3021 (4.7 %)	0.005	39/783 (5.0 %)	n.s.
Asian	398/5066 (7.9 %)	195/3021 (6.5 %)	0.022	52/783 (6.6 %)	n.s.
Pacific Islander	142/5066 (2.8 %)	53/3021 (1.8 %)	0.004	11/783 (1.4 %)	0.030
Native American	37/5066 (0.7 %)	15/3021 (0.5 %)	n.s.	1/783 (0.1 %)	n.s.
Other	659/5066 (13.0 %)	503/3021 (16.7 %)	<0.001	133/783 (17.0 %)	0.002

CIAI, Condomless insertive anal intercourse; CRAI, Condomless receptive anal intercourse; GHB, Gamma hydroxybutyrate; IDU, Injection drug use; IQR, Inter-quartile range; MSM, Men who have sex with men; n.s., Not significant; PWID, Person who injects drugs; STI, Sexually transmitted infection; XTC, Ecstasy

a Data available from all individuals if denominator not depicted

b Calculated using χ 2 or Mann–Whitney U-test

c All self-reported diagnosis within the last 12 months

Full article at: http://goo.gl/W41EKW

By: Martin Hoenigl, Christy M. Anderson, Nella Green, Sanjay R. Mehta, Davey M. Smith, and Susan J. Little

AntiViral Research Center, Division of Infectious Diseases, Department of Medicine, University of California, San Diego, 200 West Arbor Drive #8208, San Diego, CA 92103 USA

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Survival Tactics and Strategies of Methamphetamine-Using HIV-Positive Men Who Have Sex with Men in San Diego

In this article, two ways that HIV-positive drug users survive under the supervision of law enforcement agencies, community health organizations, and social welfare offices are differentiated. 

• First, strategies are long-ranging and often carefully planned, and they involve conscious utilization and manipulation of bureaucratic processes. 
• Second, tactics are short-ranging and often haphazard, and they are used to survive on daily or weekly bases, with entrenched problems and structural solutions avoided or ignored. 

Data from three years of ethnographic fieldwork with 14 methamphetamine-using HIV-positive men who have sex with men in San Diego, California is used to expand upon these two categories, explaining the different, often ineffectual, ways these men accessed care, services, shelter, drugs, and companionship. 

This article also examines the policy implications of taking in consideration these different kinds of survival methods, arguing for intensive client-specific interventions when working with long-term addicts with multiple health problems.

Full article at:  http://goo.gl/gzWBKf

By: Theodore K. Gideonse

Center for World Health, Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, United States of America

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Prevalence and Correlates of the Use of Prefilled Syringes among Persons Who Inject Drugs in San Diego, CA

Persons who inject drugs (PWID) are at increased risk for blood-borne virus (BBV) infections and overdose resulting from high-risk injecting practices. Studies of prefilled syringe use (PFSU) using a syringe that already contained drug solution when it was obtained by the user), an injection practice previously described in Eastern Europe, suggest that it increases susceptibility to BBV. However, little is known about this practice in the USA. 

Data were obtained from an ongoing cohort study of PWID to determine the prevalence and assess correlates of PFSU in San Diego, CA. Baseline interviews assessed socio-demographics and drug use behaviors. Logistic regression was used to identify factors independently associated with ever using a prefilled syringe (yes/no). Participants (n = 574) were predominately males (73.9 %) and white (50.9 %) with a mean age of 43.4 years (range 18-80); 33.3 % reported ever using prefilled syringes, although only 4.9 % reported use in the past 6 months. 

In multivariable analyses, PFSU was independently associated with ever having a rushed injection due to police presence, ever being in prison, injecting most often in public versus private places in the past 6 months, and injecting drugs in Mexico. 

Results indicate that a history of PFSU is common and associated with environmental factors that may also increase risk for adverse health outcomes. Studies are needed to better understand PFSU in order to develop interventions to prevent adverse outcomes associated with their use.

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By: Armenta RF1,2, Roth AM3, Wagner KD4, Strathdee SA1, Brodine SK2, Cuevas-Mota J1, Munoz FA1, Garfein RS5.

• 1Division of Global Public Health, Department of Medicine, School of Medicine, University of California San Diego, 9500 Gilman Drive, MC-0507, San Diego, CA, 92093-0507, USA.
• 2Division of Epidemiology, Graduate School of Public Health, San Diego State University, San Diego, CA, USA.
• 3Department of Community Health & Prevention, School of Public Health, Drexel University, Philadelphia, PA, USA.
• 4School of Community Health Sciences, University of Nevada, Reno, NV, USA.
• 5Division of Global Public Health, Department of Medicine, School of Medicine, University of California San Diego, 9500 Gilman Drive, MC-0507, San Diego, CA, 92093-0507, USA.  
  
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Prevalence & Mental Health Correlates of Insomnia in First-Encounter Veterans With & Without Military Sexual Trauma

There is limited information about prevalence of insomnia in general populations of veterans of recent wars in Iraq and Afghanistan...

53.1% of veterans without military sexual trauma (MST) and 60.8% of veterans with MST had clinically significant insomnia symptoms, with the MST subsample reporting more severe symptoms. Insomnia was more prevalent than depression, hypomania, PTSD, and substance misuse. Veterans with insomnia were more likely to seek care for physical health problems and primary care versus mental health concerns. For the veteran sample without MST, age, combat service, traumatic brain injury, pain, and depression were associated with worse insomnia. For the MST subsample, employment status, pain, and depression were associated with worse insomnia.

Study findings indicate a considerably higher rate of insomnia in veterans compared to what has been found in the general population. Insomnia is more prevalent, and more severe, in veterans with MST. Routine insomnia assessments and referrals to providers who can provide evidence-based treatment are crucial.

Via:  http://ht.ly/ScStb 

By: Jenkins MM, Colvonen PJ, Norman SB, Afari N, Allard CB, Drummond SP.

Correlates of Self-Efficacy for Condom Use among Male Clients of Female Sex Workers in Tijuana, Mexico

Male clients of female sex workers (FSWs) in Tijuana, Mexico engage in high levels of unprotected sex. While behavioral change theories posit that self-efficacy predicts condom use, correlates of self-efficacy for condom use remain largely unstudied. We examined these correlates among male clients of FSWs in Tijuana. 

Eligible male clients were at least 18 years of age, HIV-negative, lived in Tijuana or San Diego, reported unprotected sex with a Tijuana FSW at least once in the past four months, and agreed to be treated for sexually transmitted infections (STIs). Participants completed an interviewer-administered questionnaire including demographics, substance use, psychosocial and psychosexual characteristics (e.g., outcome expectancies for negotiation of safer sex, social support, and sexual sensation seeking), and sexual behaviors. Participants also underwent HIV/STI testing. 

A stepwise hierarchical multiple regression analysis identified correlates of self-efficacy for condom use. Of 393 male clients, median age was 37 years. Participants were mostly Spanish-speaking and employed. Factors independently associated with higher self-efficacy for condom use were higher positive outcome expectancies for negotiation of safer sex, lower sexual sensation seeking scores, and higher social support scores. 

Both psychosocial and psychosexual factors may influence self-efficacy for condom use among male clients of FSWs. These factors represent central constructs in sociocognitive models that explain behavioral change and could be intervention targets for improving self-efficacy for condom use and, ultimately, safer sex behavior.

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By: Tyson Volkmann,1 Karla D. Wagner,2 Steffanie A. Strathdee,2 Shirley J. Semple,3 Danielle C. Ompad,4 Claudia V. Chavarin,3 and Thomas L. Patterson3

²Division of Global Public Health, Department of Medicine, University of California, San Diego, La Jolla, CA, USA

³Department of Psychiatry, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093-0680, USA

⁴

²Division of Global Public Health, Department of Medicine, University of California, San Diego, La Jolla, CA, USA

³Department of Psychiatry, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093-0680, USA

⁴

1Joint Doctoral Program in Public Health, San Diego State University and University of California, San Diego, San Diego, CA, USA
2Division of Global Public Health, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
3Department of Psychiatry, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093-0680, USA
4Department of Nutrition, Food Studies, and Public Health and Center for Health, Identity, Behavior and Prevention Studies, Steinhardt School of Culture, Education, and Human Development, New York University, New York, NY, USA

1Joint Doctoral Program in Public Health, San Diego State University and University of California, San Diego, San Diego, CA, USA

1Joint Doctoral Program in Public Health, San Diego State University and University of California, San Diego, San Diego, CA, USA