Robert Remien - Academia.edu (original) (raw)

Papers by Robert Remien

Objectives: No large, randomized head-to-head comparison of the tolerability of atazanavir (ATV) ... more Objectives: No large, randomized head-to-head comparison of the tolerability of atazanavir (ATV) and darunavir (DRV) for first-line treatment of HIV-1 is currently available. This study compared the tolerability of ATV-versus DRV-based combination antiretroviral therapy (cART) among US Medicaid patients receiving routine HIV care. Methods: Retrospective study using Medicaid claims data from 15 US states. Subjects were HIV patients 18-64 years of age initiating ATV-or DRV-based cART from 1/1/2003 to 7/1/2010, with continuous enrollment for 6 months before (baseline) and 6 months after (evaluation period) cART initiation, and at least 1 evaluation period medical claim. Outcomes were the incidence of new-onset medically attended (ICD-9-CM-coded or treated) tolerability issues during the evaluation period. Five specific issues were selected from published literature: gastrointestinal; lipid abnormalities; diabetes/hyperglycemia; rash; jaundice. ATV and DRV patients were propensity score matched (ratio 3:1) using demographic, clinical, and treatment covariates. Statistical analyses consisted of Kaplan-Meier survival analyses and multivariable Cox proportional hazards models adjusting for covariates lacking post-match statistical balance. Results: Matched study sample included 1848 ATV and 616 DRV patients; mean age 41 years, 50% female, 69% black. Incidence rates per 1,000 patient-months of observation were: gastrointestinal-ATV 43, DRV 60 (p = 0.01); lipid abnormalities-ATV 17, DRV 27 (p <0.01); diabetes/hyperglycemia-ATV 8, DRV 8 (p = 0.61); rash-ATV 87, DRV 111 (p = 0.007); jaundice-ATV 1.1, DRV 0.3 (p <0.01). After multivariable adjustment, hazard ratios for DRV (reference = ATV) were: gastrointestinal-1.25 (p = 0.04); lipid abnormalities-1.38 (p = 0.07); diabetes/hyperglycemia-0.84 (p = 0.55); rash-1.11 (p = 0.23). Too few instances of jaundice (12) occurred to support multivariable modeling. Conclusions: Medication tolerability can play a major role in the success or failure of cART. In this study, ATV patients had a significantly lower hazard of gastrointestinal issues and a lower hazard of lipid abnormalities that trended toward significance (p = 0.07).

International Journal of Environmental Research and Public Health, 2020

Immediate antiretroviral therapy (iART), defined as same-day initiation of ART or as soon as poss... more Immediate antiretroviral therapy (iART), defined as same-day initiation of ART or as soon as possible after diagnosis, has recently been recommended by global and national clinical care guidelines for patients newly diagnosed with human immunodeficiency virus (HIV). Based on San Francisco’s Rapid ART Program Initiative for HIV Diagnoses (RAPID) model, most iART programs in the US condense ART initiation, insurance acquisition, housing assessment, and mental health and substance use evaluation into an initial visit. However, the RAPID model does not explicitly address structural racism and homophobia, HIV-related stigma, medical mistrust, and other important factors at the time of diagnosis experienced more poignantly by African American, Latinx, men who have sex with men (MSM), and transgender patient populations. These factors negatively impact initial and subsequent HIV care engagement and exacerbate significant health disparities along the HIV care continuum. While iART has impro...

AIDS and behavior, Jan 17, 2015

Targeting couples is a promising behavioral HIV risk-reduction strategy, but the mechanisms under... more Targeting couples is a promising behavioral HIV risk-reduction strategy, but the mechanisms underlying the effects of such interventions are unknown. We report secondary analyses testing whether Social-Cognitive-Theory variables mediated the Eban HIV-risk-reduction intervention's effects on condom-use outcomes. In a multisite randomized controlled trial conducted in four US cities, 535 African American HIV-serodiscordant couples were randomized to the Eban HIV risk-reduction intervention or attention-matched control intervention. Outcomes were proportion condom-protected sex, consistent condom use, and frequency of unprotected sex measured pre-, immediately post-, and 6 and 12 months post-intervention. Potential mediators included Social-Cognitive-Theory variables: outcome expectancies and self-efficacy. Mediation analyses using the product-of-coefficients approach in a generalized-estimating-equations framework revealed that condom-use outcome expectancy, partner-reaction outco...

Family and HIV/AIDS, 2011

This chapter focuses on three areas. First, it discusses the state of science on couple-based mod... more This chapter focuses on three areas. First, it discusses the state of science on couple-based modalities to reduce HIV risk and STIs and improve adherence to HIV treatment. Second, it discusses the potential advantages of such a modality in both HIV prevention and treatment adherence. Third, it highlights the signifi cant gaps and limitations of couple-based HIV prevention and treatment and makes suggestions for future directions. Fourth, it examines the status of dissemination research and transportability of effective couple-based HIV prevention and treatment to real-world settings. Although advances have been made in HIV prevention science, until a short time ago, HIV prevention approaches did not adequately focus on couples. Effective couple-based intervention strategies are needed for primary prevention for serodiscordant couples, couples who do not know their HIV status, or who are both HIV negative but vulnerable. To date, few couple-focused ART adherence interventions have been tested; even though it is well established that social support is one of the most consistent correlates of adherence across a wide range of populations and diseases. So far all couple-based studies have been efficacy trials rather than effectiveness ones. It has yet to be determined whether any of the interventions is capable of widespread effectiveness under real-world conditions.

Journal of Urban Health, 2006

Internet access has caused a global revolution in the way people of all ages and genders interact... more Internet access has caused a global revolution in the way people of all ages and genders interact. Many have turned to the Internet to seek love, companionship, and sex, prompting researchers to move behavioral studies online. The sexual behavior of men who have sex with men (MSM) has been more closely studied than that of any other group online given the abundance of gay-oriented websites and concerns about increasing transmission of HIV and other sexually transmitted infections. Not only does the Internet provide a new medium for the conduct of behavioral research and for participant recruitment into an array of research studies, it has the as yet unrealized potential to reach huge numbers of MSM with innovative harm reduction and prevention messages tailored to individualized needs, interests, and risk behavior. Internet-based research on sexual behavior has many advantages in rapidity of recruitment of diverse samples which include individuals unreachable through conventional methods (i.e., non-gay identified and geographically and socially isolated MSM, etc.). Internet-based research also presents some new methodologic challenges in study design, participant recruitment, survey implementation, and interpretation of results. In addition, there are ethical issues unique to online research including difficulties in verifying informed consent, obstacles to surveying minors, and the ability to assure anonymity. This paper presents a review of Internet-based research on sexual behavior in MSM, a general discussion of the methodologic and ethical challenges of Internet-based research, and recommendations for future interdisciplinary research.

The Journal of Sexual Medicine, 2010

Introduction-Relatively little is known about sexual dysfunction (SD) in men who have sex with me... more Introduction-Relatively little is known about sexual dysfunction (SD) in men who have sex with men (MSM). Aim-In order to better understand SD symptoms in MSM, we assessed self-reported SD symptoms, individually and by latent class analysis (LCA). Methods-In 2004-2005 an Internet sample of U.S. MSM was recruited from gay-oriented sexual networking, chat and news websites. The analytic sample comprised 7,001 men aged 18 or older who reported lifetime male sex partners and oral or anal sex with a male partner in their most recent encounter within the past year. Main Outcome Measures-Seven questions on SD symptoms that occurred during the past 12 months inquired about low sexual desire, erection problems, inability to achieve an orgasm, performance anxiety, premature ejaculation, pain during sex, and sex not being pleasurable. Results-Self-reported symptoms of SD were high. Overall, 79% of men reported one or more SD symptoms in the past year, with low sexual desire, erection problems, and performance anxiety being the most prevalent. Four distinct underlying patterns of sexual functioning were identified by LCA: no/low SD, erection problems/performance anxiety, low desire/pleasure, and high SD/sexual pain. High SD/sexual pain was distinguished from the other patterns by club drug use and use of prescription and non-prescription erectile dysfunction medication before sex in the past year. Additionally, men associated with the high SD/sexual pain group were younger, single, more likely to have poor mental and physical health, and more likely to have been diagnosed with a sexually transmitted infection in the past year compared to men in the no/low SD group. Conclusions-LCA enabled us to identify underlying patterns of sexual functioning among this sample of MSM recruited online. Future research should investigate these distinct subgroups with SD symptoms in order to develop tailored treatments and counseling for SD.

Journal of Medical Internet Research, 2004

Background: Among men who have sex with men (MSM), the number of newly diagnosed human immunodefi... more Background: Among men who have sex with men (MSM), the number of newly diagnosed human immunodeficiency virus (HIV) infections has increased by approximately 60% since 1999. Factors that may be contributing to this resurgence include a widely reported increase in bacterial sexually transmitted diseases (STDs) among HIV-positive and HIV-negative MSM, as well as unsafe sexual practices. Objective: This research was undertaken to learn more about risk behaviors associated with an incident STD among MSM. Methods: A nested case-control study was conducted, using data from a cross-sectional Internet survey of MSM (N=2643), which investigated risk behaviors during a 6-month period in 2001. Chi-square and logistic regression methods were used to estimate the likelihood of acquiring an incident STD versus no STD. Results: Eighty-five percent of the respondents were white, 46% were under age 30, and 80% had met sex partners online; 7% were HIV-positive. Men with an incident STD were more likely than men without an STD to report drug use (crystal methamphetamine odds ratio 3.8; 95% confidence interval 2.1-6.7; cocaine OR 2.3; 95% CI 1.2-4.2; ecstasy OR 2.2; 95% CI 1.3-3.8; Viagra OR 2.1; 95% CI 1.2-3.7), alcohol before or during sex (OR 1.9; 95% CI 1.2-2.9), and high-risk sexual behavior (unprotected anal intercourse OR 5.0; 95% CI 2.8-8.9; multiple sex partners OR 5.9; 95% CI 2.5-13.8). In the multivariate analysis, significant independent predictors associated with an incident STD were crystal methamphetamine use (adjusted OR 2.0; 95% CI 1.1-3.8), unprotected anal intercourse (adjusted OR 3.4; 95% CI 1.9-6.3), and 6 or more sex partners during the study period (adjusted OR 3.3; 95% CI 1.4-7.8). Conclusion: Identifying and treating MSM who have STDs, or who are at increased risk for acquiring STDs, is crucial in preventing the further spread of disease. In addition, there is a need to integrate HIV/STD and substance use prevention and education into Web-based and community-based venues.

Journal of Medical Internet Research, 2014

JAIDS Journal of Acquired Immune Deficiency Syndromes, 2008

Objective-To examine factors that explain the effect of a cognitive-behavioral intervention on re... more Objective-To examine factors that explain the effect of a cognitive-behavioral intervention on reductions in HIV transmission risk among HIV-infected men who have sex with men (MSM). Method-Of the 1,910 HIV-infected MSM screened, 616 participants considered to be at risk of transmitting HIV were randomized to a 15-session, individually delivered cognitive-behavioral intervention (n = 301) or a wait-list control (n = 315). Results-Consistent with previous intent-to-treat findings, there was an overall reduction in transmission risk acts among MSM in both intervention and control arms, with significant intervention effects observed at the 5, 10, 15, and 20 month assessments (Risk Ratios = .78, .62, .48, and .38, respectively). These intervention-related decreases in HIV transmission risk acts appeared to be partially due to sustained serosorting practices. MSM in the intervention condition reported a significantly greater proportion of sexual partners who were HIV-infected at the 5 and 10 month assessments (Risk Ratio = 1.14 and 1.18). Conclusions-The Healthy Living Project, a cognitive-behavioral intervention, is efficacious in reducing transmission risk acts among MSM. This appears to have been due in large part to the fact that MSM in the intervention condition reported sustained serosorting practices.

JAIDS Journal of Acquired Immune Deficiency Syndromes, 2006

There is a dearth of evidence on the relative efficacy of intervention modalities to improve and ... more There is a dearth of evidence on the relative efficacy of intervention modalities to improve and maintain patient adherence to antiretroviral medications. Although empiric findings from research on HIV/AIDS, other diseases, and chronic medical conditions consistently demonstrate that social support plays an important role in facilitating adherence, few HIV/AIDS interventions have directly targeted this factor. Ewart&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s social action theory emphasizes the role of social relationships in behavior change and provides a comprehensive and useful guide to the development of interventions for adherence. We describe the development, content, and testing of SMART Couples, an effective antiretroviral adherence intervention that is grounded in social action theory and designed to enhance social support for ART adherence. Finally, we discuss some of the challenges of translating findings from the randomized clinical trial of this intervention into clinical practice and offer recommendations for integration of lessons learned into ongoing clinical care.

JAIDS Journal of Acquired Immune Deficiency Syndromes, 2013

Men who have sex with men, including transgender women, comprise a heterogeneous group of individ... more Men who have sex with men, including transgender women, comprise a heterogeneous group of individuals, whose sexual behaviors and gender identities may varying widely between cultures and among individuals. Their sources of increased vulnerability to HIV are diverse, including the increased efficiency of HIV transmission via unprotected anal intercourse, sexual role versatility, asymptomatic sexually transmitted infections, as well as behavioral factors that may be associated with condomless sex with multiple partners. Societal stigmatization of homosexual behavior and gender non-conformity may result in internalized negative feelings that lead to depression, other affective disorders, and substance use, which in turn are associated with increased risk taking behaviors. Social stigma and punitive civil environments may lead to delays in seeking HIV and STD screening, and later initiation of antiretroviral therapy. The iPrEX study demonstrated that chemoprophylaxis can decrease HIV acquisition in MSM, and the HPTN 052 study established the biological plausibility that earlier initiation of HAART can decrease HIV transmission to

JAIDS Journal of Acquired Immune Deficiency Syndromes, 2011

Objective: Dual threats of injection drug use and risky sexual practices continue to increase tra... more Objective: Dual threats of injection drug use and risky sexual practices continue to increase transmission of HIV and other sexually transmitted Infections (STIs) among drug-using couples in low-income communities in the United States. Two hypotheses were tested: (1) ''intervention effect''-whether the HIV risk-reduction intervention provided to the couple or individual partners would be more efficacious in decreasing number of unprotected sexual acts and having a lower cumulative incidence of biologically confirmed STIs over the 12-month follow-up period compared with the attention control condition; and (2) ''modality effect''-whether the HIV risk-reduction intervention would be more likely to decrease the number of unprotected sexual acts and have a lower cumulative STI incidence when delivered to a couple compared with the same intervention delivered to an individual. Design: Using a randomized controlled trial, 282 HIV-negative drug-using couples (564 individuals) were randomly assigned to receive either of the following: (1) couple-based risk reduction; (2) individual-based HIV risk reduction, or (3) couple-based wellness promotion, which served as an attention control condition. Results: Over 12-month follow-up, there was a 30% reduction in the incidence rate of unprotected acts of intercourse with the study partners compared with participants in the attention control arm. Moreover, over 12-month follow-up there was a 29% reduction in the same outcome in the couple arm compared with the individual arm with a 41% reduction at the 12-month follow-up. Conclusion: A couple-based approach that addresses drug and sexual risks and targets low-income active drug users may help curb the HIV epidemic.

Culture, Health & Sexuality, 2009

and-conditions-of-access.pdf This article may be used for research, teaching and private study pu... more and-conditions-of-access.pdf This article may be used for research, teaching and private study purposes. Any substantial or systematic reproduction, redistribution , reselling , loan or sub-licensing, systematic supply or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material. Resumen Los términos bareback e identidad bareback se usan cada vez má s en el discurso académico sobre VIH/SIDA sin ideas claras sobre su significado especifico. Con ayuda de entrevistas personales con una amplia muestra étnica de 120 hombres

Archives of Sexual Behavior, 2012

The emergence of barebacking (intentional unprotected anal intercourse in situations where there ... more The emergence of barebacking (intentional unprotected anal intercourse in situations where there is risk of HIV infection) among men who have sex with men (MSM) has been partially attributed to a decrease in HIV-related concerns due to improved anti-retroviral treatment. It is important to understand the level of concern these men have regarding HIV infection because it can affect their interest in risk reduction behaviors as well as their possible engagement in risk reduction interventions. As part of a study on MSM who use the Internet to seek sexual partners, 89 ethnic and racially diverse men who reported never having an HIV-positive test result completed an indepth qualitative interview and a computer-based quantitative assessment. Of the 82 men who were asked about concerns of HIV infection during the qualitative interviews, 30 expressed "significant concern" about acquiring HIV, while 42 expressed "moderate concern," and 10 expressed "minimal concern. Themes that emerged across the different levels of concern were their perceptions of the severity of HIV infection, having friends who are HIV positive, and their own vulnerability to HIV infection. However, these themes differed depending on the level of concern. Among the most frequently mentioned approaches to decrease risk of HIV infection, participants mentioned avoiding HIV-positive sex partners, limiting the number of partners with whom they barebacked, and not allowing partners to ejaculate inside their rectum. Findings suggest that many MSM who bareback would be amenable to HIV prevention efforts that do not depend solely on condom use.

American Journal of Public Health, 2008

Unprotected sexual intercourse remains a primary mode of HIV transmission in the United States. W... more Unprotected sexual intercourse remains a primary mode of HIV transmission in the United States. We found that receipt of services to reduce HIV transmission-risk behaviors was low among 3787 HIV-infected individuals and that men who have sex with men were especially unlikely to receive these services even though they were more likely to report unprotected sexual intercourse with seronegative and unknown serostatus casual partners. Greater efforts should be made to ensure that prevention counseling is delivered to all HIV-infected persons, especially men who have sex with men.

AIDS Education and Prevention, 2009

Data on intentional condomless anal intercourse in risky contexts, also known as "barebacking," a... more Data on intentional condomless anal intercourse in risky contexts, also known as "barebacking," among ethnic minority MSM, whose rates of HIV infection continue to rise, is extremely limited. In this study, thirty-one Latino MSM who seek barebacking partners via the Internet underwent indepth interviews about bareback sex and its association to pleasure, substance use, HIV concerns, and cultural identity. Participants reported engaging in bareback sex due to the physical and emotional pleasure they experience. They expressed concern about HIV infection and took steps to reduce risk of infection. While a majority of participants reported using alcohol or drugs in the context of bareback sex, substance use did not appear to propel the behavior. Crystal methamphetamine use, prevalent only among our HIV-positive participants, was related to very high HIV-risk behavior. In this sample, culture did not seem to play a large role in barebacking.

AIDS Care, 2008

Depression is a debilitating disorder and relatively high rates have been reported in studies of ... more Depression is a debilitating disorder and relatively high rates have been reported in studies of men who have sex with men (MSM). This study was undertaken to assess the utility of screening for, and characteristics associated with, depressive symptoms in an online survey of MSM. In 2003-2004, an online cross-sectional study was conducted among 2,964 MSM from the US and Canada. Using the two-item Patient Health Questionnaire (PHQ-2), 18% of the study participants screened positive for depressive symptoms within the past 3 months. Characteristics associated with a positive PHQ-2 screen for depressive symptoms in multivariate analysis included having less than a high school or college degree, being single (not having a primary male partner) or being married to a woman, being HIV-positive, and not having recent sex. Additionally, among men who screened positive on the PHQ-2, predictors of not having treatment from a mental health provider in the past year were low education, being black/African American/Canadian or Hispanic, and having no primary care provider. The Internet is a viable medium to reach and screen men at-risk for depression. Future work is needed for online outreach and connection to offline assessment as well as intervention.

AIDS Care, 2004

This study aimed to understand whether and how highly active antiretroviral treatment (HAART) aff... more This study aimed to understand whether and how highly active antiretroviral treatment (HAART) affects views and patterns of disclosure and how disclosure interacts with treatment decisions. One hundred and fifty-two HIV-positive adults (52 MSM, 56 women and 44 IDU men) from four US cities participated in two to three-hour, semi-structured interviews in 1998 Á/99. Results indicate that HAART interacts with and shapes HIV disclosure issues in several ways. Medications may 'out' people living with HIV. Thus, in different settings (e.g. work, prisons, drug rehabs and public situations), some try to hide medications or modify dosing schedules, which can contribute to non-adherence, and affect sexual behaviours. Disclosure of HIV and/or HAART may also result in antagonism from others who hold negative attitudes and beliefs about HAART, potentially impeding adherence. Observable side effects of medications can also 'out' individuals. Conversely, medications may improve appearance, delaying or impeding disclosure. Some wait until they are on HAART and look 'well' before disclosing; some who look healthy as a result of medication deny being HIV-positive. Alternatively, HIV disclosure can lead to support that facilitates initiation of, and adherence to, treatment. HIV disclosure and adherence can shape one another in critical ways. Yet these interactions have been under-studied and need to be further examined. Interventions and studies concerning each of these domains have generally been separate, but need to be integrated, and the importance of relationships between these two areas needs to be recognized.

AIDS Care, 2007

In the post-HAART era, critical questions arise as to what factors affect disclosure decisions an... more In the post-HAART era, critical questions arise as to what factors affect disclosure decisions and how these decisions are associated with factors such as high-risk behaviors and partner variables. We interviewed 1,828 HIV-positive men who have sex with men (MSM), of whom 46% disclosed to all partners. Among men with casual partners, 41.8% disclosed to all of these partners and 21.5% to none. Disclosure was associated with relationship type, perceived partner HIV status and sexual behaviors. Overall, 36.5% of respondents had unprotected anal sex (UAS) with partners of negative/unknown HIV status. Of those with only casual partners, 80.4% had /1 act of UAS and 58% of these did not disclose to all partners. This 58% were more likely to self-identify as gay (versus bisexual), be aware of their status for B/5 years and have more partners. Being on HAART, viral load and number of symptoms were not associated with disclosure. This study *the largest conducted to date of disclosure among MSM and one of the few conducted post-HAART *indicates that almost 1/5th reported UAS with casual partners without disclosure, highlighting a public health challenge. Disclosure needs to be addressed in the context of relationship type, partner status and broader risk-reduction strategies.