Socioeconomic Disconnection as a Risk Factor for Increased HIV Infection in Young Men Who Have Sex with Men

PURPOSE:

HIV disproportionately affects young men who have sex with men (YMSM), particularly black YMSM. Increasingly, researchers are turning to social, economic, and structural factors to explain these disproportionate rates. In this study, we explore the relationship between socioeconomic disconnection and HIV status and factors related to HIV infection, including drug use, condomless anal sex, and binge drinking. We operationalize socioeconomic disconnection in this young population as lack of engagement in educational and employment opportunities.

METHODS:

Baseline data were analyzed from a longitudinal cohort study of YMSM aged 16-20 years recruited from the Chicago area (N = 450). Bivariate analyses of the association of socioeconomic disconnection and HIV-positive status, drug and alcohol use, and condomless anal sex were assessed using chi-square tests. The relationship of socioeconomic disconnection and HIV-positive status was then examined in multivariate logistic regression models, controlling for age and race/ethnicity and significant behavioral factors.

RESULTS:

Among study participants, 112 (25%) were not in school, 310 (69%) were not currently working, and 81 (18%) were neither in school nor working. Black MSM were more likely to be socioeconomically disconnected (neither in school nor working; n = 56, 23.3%). The results revealed that disconnected YMSM were more likely to binge drink (AOR = 2.34; 95% CI = 1.16, 4.74) and be HIV positive (AOR = 2.24; 95% CI = 1.04, 4.83). Subpopulation analysis for black participants revealed similar associations (AOR of binge drinking = 2.92; 95% CI = 1.07, 8.01; AOR of HIV positive = 2.38; 95% CI = 1.03, 5.51). Controlling for substance use, the association between disconnection and HIV-positive status remained significant (AOR = 2.37; 95% CI = 1.08, 5.20).

CONCLUSION:

Socioeconomic disconnection is significantly and positively associated with HIV status among YMSM, suggesting that the two factors are related. Socioeconomic factors present an important area for future research focusing on HIV infection in this high-risk group.

Purchase full article at:  http://goo.gl/2Xn2nb

By:  Gayles TA1, Kuhns LM1, Kwon S1, Mustanski B2, Garofalo R1.

• 1 Division of Adolescent Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University , Chicago, Illinois.
• 2 IMPACT Program, Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University , Chicago, Illinois. 
• LGBT Health. 2016 Mar 22. 

More at:  https://twitter.com/hiv insight

And: http://twitter.com/Prison Health

Mediators of the Relation Between Community Violence and Sexual Risk Behavior mong Adults Attending a Public Sexually Transmitted Infection Clinic

Prior research shows that violence is associated with sexual risk behavior, but little is known about the relation between community violence (i.e., violence that is witnessed or experienced in one's neighborhood) and sexual risk behavior. 

To better understand contextual influences on HIV risk behavior, we asked 508 adult patients attending a publicly funded STI clinic in the U.S. (54 % male, M _age = 27.93, 68 % African American) who were participating in a larger trial to complete a survey assessing exposure to community violence, sexual risk behavior, and potential mediators of the community violence-sexual risk behavior relation (i.e., mental health, substance use, and experiencing intimate partner violence). 

A separate sample of participants from the same trial completed measures of sexual behavior norms, which were aggregated to create measures of census tract sexual behavior norms. 

Data analyses controlling for socioeconomic status revealed that higher levels of community violence were associated with more sexual partners for men and with more episodes of unprotected sex with non-steady partners for women. 

For both men and women, substance use and mental health mediated the community violence-sexual risk behavior relation; in addition, for men only, experiencing intimate partner violence also mediated this relation. 

These results confirm that, for individuals living in communities with high levels of violence, sexual risk reduction interventions need to address intimate partner violence, substance use, and mental health to be optimally effective.

Purchase full article at:   http://goo.gl/JuhzWs

By:  Senn TE1, Walsh JL2,3, Carey MP2.

• 1School of Nursing, University of Rochester, Box SON, 601 Elmwood Ave., Rochester, NY, 14642, USA. Theresa_Senn@urmc.rochester.edu.
• 2Centers for Behavioral and Preventive Medicine, The Miriam Hospital and Brown University, 164 Summit Ave., Providence, RI, 02906, USA.
• 3Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research, Medical College of Wisconsin, Milwaukee, WI, USA. 
• Arch Sex Behav. 2016 Mar 21.

More at:  https://twitter.com/hiv insight

And: http://twitter.com/Prison Health

The Use of Cash Transfers for HIV Prevention - Are We There Yet?

Poverty and social inequality are significant drivers of the HIV epidemic and are risk factors for acquiring HIV. As such, many individuals worldwide are at risk for new HIV infection, especially young women in East and Southern Africa. By addressing these drivers, social protection programmes may mitigate the impact of poverty and social inequality on HIV risk. 

There is reason to believe that social protection can be used successfully for HIV prevention; social protection programmes, including cash transfers, have led to positive health outcomes and behaviour in other contexts, and they have been used successfully to promote education and increased income and employment opportunities. 

Furthermore, cash transfers have influenced sexual behaviour of young women and girls, thereby decreasing sexual risk factors for HIV infection. When HIV outcomes have been measured, several randomised controlled trials have shown that indirectly, cash transfers have led to reduced HIV prevalence and incidence. 

In these studies, school attendance and safer sexual health were directly incentivised through the cash transfer, yet there was a positive effect on HIV outcomes. In this review, we discuss the growth of social protection programmes, their benefits and impact on health, education and economic potential, and how these outcomes may affect HIV risk. 

We also review the studies that have shown that cash transfers can lead to reduced HIV infection, including study limitations and what questions still remain with regard to using cash transfers for HIV prevention.

Purchase full article at:   http://goo.gl/bk1xKh

By:  Taaffe J1, Cheikh N1, Wilson D1.

• 1 The World Bank Group , Washington , DC , USA. 
• Afr J AIDS Res. 2016 Mar;15(1):17-25. doi: 10.2989/16085906.2015.1135296.

More at:  https://twitter.com/hiv insight

And: http://twitter.com/Prison Health

Content Analysis and User Characteristics of a Smartphone-Based Online Support Group for People Living with HIV

BACKGROUND:

Although there is growing interest in mobile applications and online support groups to enhance chronic disease self-management, little is known about their potential impact for people living with HIV (PLWH).

INTRODUCTION:

We developed an innovative online support group delivered through a community message board (CMB) within a clinic-affiliated smartphone application Positive Links (PL). We analyzed characteristics of posters and nonposters to the CMB and evaluated content posted to the CMB.

MATERIALS AND METHODS:

For this study, 38 HIV-infected patients received cell phones with the PL application that included the opportunity to interact with other users on a CMB. Logistic regressions investigated associations between participant characteristics and posting. CMB messages were downloaded and analyzed qualitatively.

RESULTS:

24 participants posted to the CMB; 14 did not. Participants had lower odds of posting if they were white (p = 0.028) and had private insurance (p = 0.003). Participants had higher odds of posting if they had unsuppressed viral loads (p = 0.034). Of the 840 CMB messages over 8 months, 62% had psychosocial content, followed by community chat (29%), and biomedical content (10%).

DISCUSSION:

Psychosocial content was most prevalent on this CMB, in contrast to other online forums dominated by informational content. Participants who posted expressed support for each other, appreciation for the community, and a perception that the app played a positive role in their HIV self-management.

CONCLUSIONS:

This CMB on a clinic-affiliated mobile application may reach vulnerable populations, including racial/ethnic minorities and those of lower socioeconomic status, and provide psychosocial support to PLWH.

Purchase full article at:   http://goo.gl/yqWMgg

By:  Flickinger TE1, DeBolt C1, Wispelwey E1, Laurence C2, Plews-Ogan E1, Waldman AL1, Reynolds G3, Cohn WF1, Beach MC4, Ingersoll K1, Dillingham R1.

• 1 Department of Medicine, University of Virginia School of Medicine , Charlottesville, Virginia.
• 2 Department of Medicine, Wake Forest School of Medicine , Winston Salem, North Carolina.
• 3 Health Decision Technologies , Oakland, California.
• 4 Department of Medicine, Johns Hopkins University School of Medicine , Baltimore, Maryland.
• Telemed J E Health. 2016 Mar 22 

More at:  https://twitter.com/hiv insight

And: http://twitter.com/Prison Health

An Empirical Analysis of White Privilege, Social Position and Health

Accumulated evidence has demonstrated that social position matters for health. Those with greater socioeconomic resources and greater perceived standing in the social hierarchy have better health than those with fewer resources and lower perceived standing. Race is another salient axis by which health is stratified in the U.S., but few studies have examined the benefit of White privilege. 

In this paper, we investigated how perceptions of inequality and subjective and objective social status affected the health and well-being of N = 630 White residents in three Boston neighborhoods lying on a social gradient differentiated by race, ethnicity, income and prestige. Outcomes were self-rated health, dental health, and happiness. Results suggested that: neighborhood residence was not associated with health after controlling for individual level factors (e.g., positive ratings of the neighborhood, education level); objective measures of socioeconomic status were associated with better self-reported and dental health, but subjective assessments of social position were more strongly associated; and White residents living in the two wealthiest neighborhoods, and who perceived Black families as welcome in their neighborhoods enjoyed better health than those who believed them to be less welcome. However, those who lived in the least wealthy and most diverse neighborhood fared worse when reporting Black families to be welcome. 

These results suggest that White privilege and relative social position interact to shape health outcomes.

Below:  Relationship between perceived neighborhood welcome to Black families and health outcomes (self-rated health, dental health, and happiness). Values for self-rated health ranged from 1 to 4; dental health from 1 to 5; and happiness from 0 to 2. For both self-rated health and dental health, lower scores are better.

Full article at:   http://goo.gl/V2gSZ3

By:  Kwate NO1, Goodman MS2.

• 1Departments of Human Ecology and Africana Studies, Rutgers, The State University of New Jersey, 55 Dudley Rd, Cook Office Building, New Brunswick, NJ 08901-8520, USA. Electronic address: nokwate@rci.rutgers.edu.
• 2Division of Public Health Sciences Department of Surgery, Washington University in St. Louis School of Medicine, 660 S. Euclid Avenue, Campus Box 8100, St. Louis, MO 63110, USA. 
• Soc Sci Med. 2014 Sep;116:150-60. doi: 10.1016/j.socscimed.2014.05.041. Epub 2014 Jun 13.

More at:  https://twitter.com/hiv insight

And: http://twitter.com/Prison Health

Economic, Legal, and Social Hardships Associated with HIV Risk among Black Men Who Have Sex with Men in Six US Cities

We assessed whether economic, legal, and social hardships were associated with human immunodeficiency virus (HIV) risk among a sample of Black men who have sex with men (MSM) and whether associations were moderated by city of residence. 

The study analyzed baseline and follow-up data from HIV Prevention Trials Network 061 (N = 1553). Binary logistic regression assessed associations between hardships and HIV risk indicators. Multivariate regressions were used to test if city of residence had a moderating effect for hardships and HIV risks. Adjusted analyses showed that Black MSM with recent job loss were more likely to engage in condomless insertive anal intercourse and that those with recent financial crisis were more likely to have had two or more male sexual partners in the past 6 months. Black MSM with recent convictions were more likely to have a sexually transmitted infection at 6 months, while those who were unstably housed were more likely to have a sexually transmitted infection at 12 months. 

There were no city of residence and hardship interaction effects on HIV risks. Hardships are important factors that influence HIV risk for Black MSM. Integrating strategies that address structural factors that influence HIV risk may enhance HIV prevention interventions implementation efforts.

Purchase full article at:   http://goo.gl/HGgbpG

By:  Nelson LE1,2, Wilton L3,4, Moineddin R5, Zhang N6, Siddiqi A7,8, Sa T6, Harawa N9,10, Regan R11,12, Dyer TP13, Watson CC14, Koblin B15, Del Rio C16,Buchbinder S17, Wheeler DP18, Mayer KH19; HPTN 061 Study Team.

• 1School of Nursing, University of Rochester, Rochester, NY, USA. laron_nelson@urmc.rochester.edu.
• 2Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada. laron_nelson@urmc.rochester.edu.
• 3College of Community and Public Affairs, State University of New York at Binghamton, Binghamton, NY, USA.
• 4Faculty of Humanities, University of Johannesburg, Johannesburg, South Africa.
• 5Faculty of Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.
• 6Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
• 7Dalla Lana School of Public Health, Divisions of Epidemiology and Social & Behavioural Health Sciences, University of Toronto, Toronto, ON, Canada.
• 8Gillings School of Public Health, Department of Health Behavior, University of North Carolina Chapel Hill, Chapel Hill, NC, USA.
• 9College of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA.
• 10David Geffen School of Medicine, General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA, USA.
• 11David Geffen School of Medicine, Department of Family Medicine, University of California Los Angeles, Los Angeles, CA, USA.
• 12School of Medicine, Division of Infectious Diseases, Emory University, Atlanta, GA, USA.
• 13School of Public Health, Department of Epidemiology and Biostatistics, University of Maryland College Park, College Park, MD, USA.
• 14School of Public Health, George Washington University, Washington, DC, USA.
• 15New York Blood Center, New York, NY, USA.
• 16Rollins School of Public Health, Hubert Department of Global Health and School of Medicine, Department of Medicine, Emory University, Atlanta, GA, USA.
• 17San Francisco Department of Public Health, HIV Research Section, San Francisco, CA, USA.
• 18School of Social Welfare, State University of New York Albany, Albany, NY, USA.
• 19Fenway Health, The Fenway Institute, Boston, MA, USA. 
• J Urban Health. 2016 Feb 1.

More at:  https://twitter.com/hiv insight

And: http://twitter.com/Prison Health

Food Insecurity in HIV-Hepatitis C Virus Co-Infected Individuals in Canada: The Importance of Co-Morbidities

While research has begun addressing food insecurity (FI) in HIV-positive populations, knowledge regarding FI among individuals living with HIV-hepatitis C virus (HCV) co-infection is limited. 

This exploratory study examines sociodemographic, socioeconomic, behavioral, and clinical factors associated with FI in a cohort of HIV-HCV co-infected individuals in Canada. We analyzed longitudinal data from the Food Security and HIV-HCV Co-infection Study of the Canadian Co-infection Cohort collected between November 2012-June 2014 at 15 health centres. FI was measured using the Household Food Security Survey Module and classified using Health Canada criteria. Generalized estimating equations were used to assess factors associated with FI. 

Among 525 participants, 59 % experienced FI at their first study visit (baseline). Protective factors associated with FI (p < 0.05) included: enrolment at a Quebec study site, employment, and average personal monthly income. Risk factors for FI included: recent injection drug use, trading away food, and recent experiences of depressive symptoms. 

FI is common in this co-infected population. Engagement of co-infected individuals in substance use treatments, harm reduction programs, and mental health services may mitigate FI in this vulnerable subset of the HIV-positive population.

Purchase full article at:   http://goo.gl/d20K1v

By:  Cox J1,2,3, Hamelin AM4, McLinden T4, Moodie EE4, Anema A5,6, Rollet-Kurhajec KC7, Paradis G4, Rourke SB8,9,10, Walmsley SL11,12, Klein MB7; Canadian Co-infection Cohort Investigators.

• 1Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Purvis Hall, 1020 Pine Avenue West, Montreal, QC, H3A 1A2, Canada. joseph.cox@mcgill.ca.
• 2Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC, Canada. joseph.cox@mcgill.ca.
• 3CIHR Canadian HIV Trials Network, Vancouver, BC, Canada. joseph.cox@mcgill.ca.
• 4Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Purvis Hall, 1020 Pine Avenue West, Montreal, QC, H3A 1A2, Canada.
• 5Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
• 6Department of Medicine, Boston Children's Hospital, Boston, MA, USA.
• 7Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC, Canada.
• 8Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
• 9The Ontario HIV Treatment Network, Toronto, ON, Canada.
• 10Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
• 11Department of Medicine, University of Toronto, Toronto, ON, Canada.
• 12Division of Infectious Diseases, University Health Network, Toronto, ON, Canada. 

More at:  https://twitter.com/hiv insight

And: http://twitter.com/Prison Health

Tuberculosis Mortality and Living Conditions in Bern, Switzerland, 1856-1950

Background

Tuberculosis (TB) is a poverty-related disease that is associated with poor living conditions. We studied TB mortality and living conditions in Bern between 1856 and 1950.

Methods

We analysed cause-specific mortality based on mortality registers certified by autopsies, and public health reports 1856 to 1950 from the city council of Bern.

Results

TB mortality was higher in the Black Quarter (550 per 100,000) and in the city centre (327 per 100,000), compared to the outskirts (209 per 100,000 in 1911–1915). TB mortality correlated positively with the number of persons per room (r = 0.69, p = 0.026), the percentage of rooms without sunlight (r = 0.72, p = 0.020), and negatively with the number of windows per apartment (r = -0.79, p = 0.007). TB mortality decreased 10-fold from 330 per 100,000 in 1856 to 33 per 100,000 in 1950, as housing conditions improved, indoor crowding decreased, and open-air schools, sanatoria, systematic tuberculin skin testing of school children and chest radiography screening were introduced.

Conclusions

Improved living conditions and public health measures may have contributed to the massive decline of the TB epidemic in the city of Bern even before effective antibiotic treatment became finally available in the 1950s.

Below:  Changes in the mortality due to injuries (including homicide), communicable (infectious diseases and infant death) and non-communicable diseases (including cancer) in the capital city of Bern, Switzerland, between 1856 and 1950

Below:  Trends in TB mortality in the city of Bern, Switzerland, between1856 to 1950, in relation to important events for TB control

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

By:  

Kathrin Zürcher, Marie Ballif, Marcel Zwahlen, Matthias Egger, Lukas Fenner

Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland

Marie Ballif, Lukas Fenner

Swiss Tropical and Public Health Institute, Basel, Switzerland

Marie Ballif, Lukas Fenner

University of Basel, Basel, Switzerland

Hans L. Rieder

Epidemiology, Biostatistics and Prevention Institute, University of Zürich, Zürich, Switzerland

More at:  https://twitter.com/hiv insight

And: http://twitter.com/Prison Health

Trends in Genital Warts by Socioeconomic Status After the Introduction of the National HPV Vaccination Program in Australia: Analysis of National Hospital Data

BACKGROUND:

Human papillomavirus (HPV) vaccination targeting females 12-13 years commenced in Australia in 2007, with catch-up of females 13-26 years until the end of 2009. No analyses of HPV vaccination program impact by either socioeconomic or geographic factors have been reported for Australia.

METHODS:

Hospital admissions between July 2004-June 2011 involving a diagnosis of genital warts were obtained from a comprehensive national database. We compared sex- and age-specific admission rates in July 2006-June 2007 (pre-vaccination period) and July 2010-June 2011 (post-vaccination period) according to Index of Relative Socio-economic Disadvantage, nationally and stratified by remoteness area relating to the individual's area of residence, using Poisson/ negative binomial models.

RESULTS:

Admission rates per 100,000 population in females aged 10-19 years (predominantly vaccinated at school), reduced from 42.2 to 6.0 (rate reduction 86.7 %; 95 % CI:82.2-90.0 %) in more disadvantaged areas and from 26.8 to 4.0 (85.0 %; 95 % CI:79.7-88.9 %) in less disadvantaged areas. In females aged 20-29 years (predominantly vaccinated in the community), the decreases were from 73.9 to 26.4 (66.0 %; 95 % CI:57.7-72.6 %) and from 61.9 to 23.8 (61.6 %; 95 % CI:52.9-68.7 %) in more and less disadvantaged areas, respectively. The reductions were similar in more vs less disadvantaged areas both inside major cities (88.6 %; 95 % CI: 82.2-92.7 % vs 87.9 %; 95 % CI:82.6-91.6 % in females aged 10-19 years; 64.0 %; 95 % CI:57.0-69.9 % vs 63.8 %; 95 % CI:52.9-72.1 % for females aged 20-29 years) and outside major cities (88.8 %; 95 % CI: 83.7-92.3 % vs 85.8 %; 95 % CI:73.5-92.4 % in females aged 10-19 years; 71.1 %; 95 % CI:58.8-79.7 % vs 67.6 %; 95 % CI:48.2-79.8 % for females aged 20-29 years). Admission rates in males aged 20-29 years also reduced, by 23.0 % (95 % CI:4.8-37.8 %) and 39.4 % (95 % CI:28.9-48.3 %) in more versus less disadvantaged areas respectively.

CONCLUSIONS:

The relative reduction in genital warts appears similar in young females across different levels of disadvantage, including within and outside major cities, both for females predominantly vaccinated at school and in the community.

Below:  Admissions involving a diagnosis of genital warts (per 100,000 population), by age and socioeconomic status, in a) females and b) males. Males aged 10–19 years were excluded due to the small number of admissions

Below:  Admissions involving a diagnosis of genital warts (per 100,000 population), by age, socioeconomic status and remoteness area of residence. a Females 10–19 years; b Females 20–29 years; c Females 30–39 years; d Males 20–29 years; e Males 30–39 years

Below:  Admission rate ratio (relative to pre-vaccination mean) by age, SES and remoteness area of residence (females). a and b 10–19 years; c and d 20–29 years; e and f 30–39 years

Below:  Admission rate ratio (relative to pre-vaccination mean) by age, SES and remoteness area of residence (males). a and b 20–29 years; c and d 30–39 years

Purchase full article at:   http://goo.gl/Z3KijK

By:  Smith MA1,2,3, Liu B4,5, McIntyre P6, Menzies R7,8,9, Dey A10, Canfell K11,12,13.

• 1School of Public Health, University of Sydney, Sydney, NSW, 2006, Australia. megan.smith@nswcc.org.au.
• 2Prince of Wales Clinical School, UNSW Australia, Sydney, NSW, 2052, Australia. megan.smith@nswcc.org.au.
• 3Present address: Cancer Research Division, Cancer Council NSW, Kings Cross NSW 1340, PO Box 572, Sydney, NSW, 2011, Australia. megan.smith@nswcc.org.au.
• 4School of Public Health and Community Medicine, UNSW Australia, Sydney, NSW, 2052, Australia. bette.liu@unsw.edu.au.
• 5The Sax Institute, Sydney, PO Box K617, Haymarket, NSW, 1240, Australia. bette.liu@unsw.edu.au.
• 6National Centre for Immunisation Research and Surveillance Children's Hospital, Westmead, Locked Mail Bag 4001, Sydney, 2145, NSW, Australia. peter.mcintyre@health.nsw.gov.au.
• 7National Centre for Immunisation Research and Surveillance Children's Hospital, Westmead, Locked Mail Bag 4001, Sydney, 2145, NSW, Australia. r.menzies@unsw.edu.au.
• 8Sydney Medical School, University of Sydney, Sydney, NSW, 2006, Australia. r.menzies@unsw.edu.au.
• 9Present address: School of Public Health and Community Medicine, UNSW Australia, Sydney, NSW, 2052, Australia. r.menzies@unsw.edu.au.
• 10National Centre for Immunisation Research and Surveillance Children's Hospital, Westmead, Locked Mail Bag 4001, Sydney, 2145, NSW, Australia. aditi.dey@health.nsw.gov.au.
• 11School of Public Health, University of Sydney, Sydney, NSW, 2006, Australia. karen.canfell@nswcc.org.au.
• 12Prince of Wales Clinical School, UNSW Australia, Sydney, NSW, 2052, Australia. karen.canfell@nswcc.org.au.
• 13Present address: Cancer Research Division, Cancer Council NSW, Kings Cross NSW 1340, PO Box 572, Sydney, NSW, 2011, Australia. karen.canfell@nswcc.org.au. 
• BMC Infect Dis. 2016 Feb 1;16(1):52. doi: 10.1186/s12879-016-1347-z.

More at:  https://twitter.com/hiv insight

And: http://twitter.com/Prison Health