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AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 25 of 50 Research Studies DisplayedRentsch CT, Edelman EJ, Justice AC
Patterns and correlates of prescription opioid receipt among US Veterans: a national, 18-year observational cohort study.
A better understanding of predisposition to transition to high-dose, long-term opioid therapy after initial opioid receipt could facilitate efforts to prevent opioid use disorder (OUD). In this study, the investigators extracted data on 69,268 patients in the Veterans Aging Cohort Study who received any opioid prescription between 1998 and 2015. They identified four distinguishable dose trajectories. The authors indicate that their measures could potentially be used in future prevention research, including genetic discovery.
AHRQ-funded; HS021112; HS023258.
Citation: Rentsch CT, Edelman EJ, Justice AC .
Patterns and correlates of prescription opioid receipt among US Veterans: a national, 18-year observational cohort study.
AIDS Behav 2019 Dec;23(12):3340-49. doi: 10.1007/s10461-019-02608-3..
Keywords: Opioids, Medication, Substance Abuse, Human Immunodeficiency Virus (HIV), Pain, Chronic Conditions
Brault MA, Spiegelman D, Hargreaves J
Treatment as prevention: concepts and challenges for reducing HIV incidence.
This paper reviews the results and lessons learned from four large-scale HIV antiretroviral therapy (ART) clinical trials that were held in sub-Saharan Africa to reduce HIV transmission. These trials used treatment as prevention (TasP) to improve overall health and protect HIV-uninfected sexual partners from infection. There were seemingly inconsistent findings in the major TasP trials held in South African, Kenya, Uganda, Botswana, and Zambia. The review highlighted implementation challenges and identified approaches to optimize programs and incentivize uptake and engagement in HIV testing and ART-based care.
AHRQ-funded; HS023000.
Citation: Brault MA, Spiegelman D, Hargreaves J .
Treatment as prevention: concepts and challenges for reducing HIV incidence.
J Acquir Immune Defic Syndr 2019 Dec 1;82 Suppl 2:S104-s12. doi: 10.1097/qai.0000000000002168..
Keywords: Human Immunodeficiency Virus (HIV), Prevention, Infectious Diseases, Public Health, Screening
Fleming J, Berry SA, Moore RD
U.S. Hospitalization rates and reasons stratified by age among persons with HIV 2014-15.
The objective of this study was to evaluate hospitalization rates and reasons stratified by age among persons with HIV in longitudinal HIV care. Results showed that hospitalization rates increased significantly with age for cardiovascular disease, endocrine, renal, pulmonary, and oncology. All-cause hospitalization rates increased with older age, especially among non-communicable diseases, while non-AIDS defining infection remained the leading cause for hospitalization.
AHRQ-funded; 290201100007C.
Citation: Fleming J, Berry SA, Moore RD .
U.S. Hospitalization rates and reasons stratified by age among persons with HIV 2014-15.
AIDS Care 2019 Dec 8:1-10. doi: 10.1080/09540121.2019.1698705..
Keywords: Human Immunodeficiency Virus (HIV), Hospitalization
Tracer H, Jasmin W
AHRQ Author: Tracer H
Screening for HIV Infection and Preexposure Prophylaxis for the Prevention of HIV Infection.
This case study provides questions and answers on the topic of screening for HIV infection and preexposure prophylaxis for the prevention of HIV infection.
AHRQ-authored.
Citation: Tracer H, Jasmin W .
Screening for HIV Infection and Preexposure Prophylaxis for the Prevention of HIV Infection.
Am Fam Physician 2019 Nov 15;100(10):637-38..
Keywords: U.S. Preventive Services Task Force (USPSTF), Human Immunodeficiency Virus (HIV), Screening, Prevention
Olivieri-Mui BL, Koethe B, Briesacher B
Economic barriers to antiretroviral therapy in nursing homes.
In this study, the investigators’ aim was to clarify if persons living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) have adequate economic access to antiretroviral therapy (ART) when admitted to nursing homes (NHs). They concluded that people living with HIV in NHs do not always receive lifesaving ART, but the reasons are unclear and appear unrelated to economic barriers.
AHRQ-funded; HS025662.
Citation: Olivieri-Mui BL, Koethe B, Briesacher B .
Economic barriers to antiretroviral therapy in nursing homes.
J Am Geriatr Soc 2020 Apr;68(4):777-82. doi: 10.1111/jgs.16288..
Keywords: Human Immunodeficiency Virus (HIV), Nursing Homes, Long-Term Care, Medication, Access to Care
Stringer KL, Marotta P, Baker E
Substance use stigma and antiretroviral therapy adherence among a drug-using population living with HIV.
Among people living with HIV (PLWH), HIV-related stigma predicts nonadherence to antiretroviral therapy (ART); however, the role of stigma associated with drug use is largely unknown. The this study the investigators examined the association between substance use (SU) stigma and optimal ART adherence in a sample of 172 self-reported HIV-infected drug users.
AHRQ-funded; HS013852.
Citation: Stringer KL, Marotta P, Baker E .
Substance use stigma and antiretroviral therapy adherence among a drug-using population living with HIV.
AIDS Patient Care STDS 2019 Jun;33(6):282-93. doi: 10.1089/apc.2018.0311..
Keywords: Human Immunodeficiency Virus (HIV), Social Stigma, Patient Adherence/Compliance, Medication, Substance Abuse
Rice WS, Stringer KL, Sohail M
Accessing pre-exposure prophylaxis (PrEP): perceptions of current and potential prEP users in Birmingham, Alabama.
Limited studies to date assess barriers to and facilitators of pre-exposure prophylaxis (PrEP) uptake and utilization using a patient-centered access to care framework, among diverse socio-demographic groups, or in the U.S. Deep South, an area with disproportionate HIV burden. In this study, the investigators examine perceptions of PrEP access in qualitative interviews with 44 current and potential PrEP users in Birmingham, Alabama.
AHRQ-funded; HS013852.
Citation: Rice WS, Stringer KL, Sohail M .
Accessing pre-exposure prophylaxis (PrEP): perceptions of current and potential prEP users in Birmingham, Alabama.
AIDS Behav 2019 Nov;23(11):2966-79. doi: 10.1007/s10461-019-02591-9..
Keywords: Human Immunodeficiency Virus (HIV), Prevention, Healthcare Utilization, Patient-Centered Healthcare, Racial and Ethnic Minorities, Health Literacy, Education: Patient and Caregiver, Access to Care, Health Promotion
Zullo AR, Adams JW, Gantenberg JR
Examining neighborhood poverty-based disparities in HIV/STI prevalence: an analysis of Add Health data.
The purpose of the study was to estimate the effect of exposure to neighborhood poverty in adolescence on HIV/STI prevalence in early adulthood. The investigators found that strong evidence for neighborhood poverty-based differences in HIV/STI prevalence was not observed. They suggest that researchers should continue to investigate the effect of neighborhood-level socioeconomic position measures and, if warranted, identify etiologically relevant exposure periods.
AHRQ-funded; HS022998.
Citation: Zullo AR, Adams JW, Gantenberg JR .
Examining neighborhood poverty-based disparities in HIV/STI prevalence: an analysis of Add Health data.
Ann Epidemiol 2019 Nov;39:8-14.e4. doi: 10.1016/j.annepidem.2019.09.010..
Keywords: Children/Adolescents, Low-Income, Vulnerable Populations, Disparities, Social Determinants of Health, Human Immunodeficiency Virus (HIV), Infectious Diseases, Young Adults, Health Status
McKellar MS, Kuchibhatla MN, Oursler KAK
Racial differences in change in physical functioning in older male veterans with HIV.
Little is known about longitudinal change in physical functioning of older African American/Black and White HIV-infected persons. In this study, the investigators examined up to 10 years of data on African American and White men with HIV infection and comparable HIV-negative men age 50-91 years from the Veterans Aging Cohort Study Survey sample.
AHRQ-funded; HS021112; HS023464; HS023258.
Citation: McKellar MS, Kuchibhatla MN, Oursler KAK .
Racial differences in change in physical functioning in older male veterans with HIV.
AIDS Res Hum Retroviruses 2019 Nov/Dec;35(11-12):1034-43. doi: 10.1089/aid.2018.0296..
Keywords: Human Immunodeficiency Virus (HIV), Health Status, Racial and Ethnic Minorities, Elderly, Men's Health
Kim B, Callander D, DiClemente R
Location of pre-exposure prophylaxis services across New York City neighborhoods: do neighborhood socio-demographic characteristics and HIV incidence Matter?
This study analyzed the New York City geographic distribution of pre-exposure prophylaxis (PrEP) providers and the relationship between their location, neighborhood characteristics, and HIV incidence using spatial analytic methods. Results showed that neighborhood socio-demographic measures of race/ethnicity, income, insurance coverage, or same-sex couple household, were not associated with PrEP provider density, and PrEP providers were located in high HIV-incidence neighborhoods. These findings validate the need for ongoing policy interventions in relation to PrEP provider locations in New York City and inform the design of future PrEP implementation strategies, such as public health campaigns and navigation assistance for low-cost insurance.
AHRQ-funded; HS026120.
Citation: Kim B, Callander D, DiClemente R .
Location of pre-exposure prophylaxis services across New York City neighborhoods: do neighborhood socio-demographic characteristics and HIV incidence Matter?
AIDS Behav 2019 Oct;23(10):2795-802. doi: 10.1007/s10461-019-02609-2..
Keywords: Human Immunodeficiency Virus (HIV), Prevention, Access to Care, Social Determinants of Health
Fredericksen RJ, Yang FM, Gibbons LE
Development and content validation of measures assessing adherence barriers and behaviors for use in clinical care.
The authors developed brief, computer-administered patient-reported measures in English and Spanish assessing prescribed medication adherence behaviors and barriers for use with patients living with chronic diseases focusing on clinical relevance, brevity, and content validity for use in clinical care.
AHRQ-funded; HS022242.
Citation: Fredericksen RJ, Yang FM, Gibbons LE .
Development and content validation of measures assessing adherence barriers and behaviors for use in clinical care.
Res Social Adm Pharm 2019 Sep;15(9):1168-76. doi: 10.1016/j.sapharm.2018.10.001..
Keywords: Patient Adherence/Compliance, Medication, Chronic Conditions, Human Immunodeficiency Virus (HIV)
Wang D
A comparison of in-person and online training in a statewide clinical education program for dissemination of HIV, HCV and STD clinical evidence.
This study compared in-person and online training for dissemination of clinical evidence of HIV, HCV, and STD. The study used 250 clinicians completing four training courses in dual formats over a three-month period. Online training was the preferred format by clinicians.
AHRQ-funded; HS022057.
Citation: Wang D .
A comparison of in-person and online training in a statewide clinical education program for dissemination of HIV, HCV and STD clinical evidence.
Stud Health Technol Inform 2019 Aug 21;264:2003-04. doi: 10.3233/shti190756..
Keywords: Human Immunodeficiency Virus (HIV), Hepatitis, Sexual Health, Evidence-Based Practice, Training, Patient-Centered Outcomes Research
Wang L, Krebs E, Min JE
Combined estimation of disease progression and retention on antiretroviral therapy among treated individuals with HIV in the USA: a modelling study.
Accurately estimating HIV disease progression and retention on antiretroviral therapy (ART) can help inform interventions to control HIV microepidemics and mathematical models used to inform health-resource allocation decisions. The objective of the study was to estimate the monthly probabilities of on-ART CD4 T-cell count progression, mortality, ART dropout, and ART reinitiation using a continuous-time multistate Markov model. The investigators also aimed to validate health-state transition probability estimates to ensure they accurately reproduced the regional HIV microepidemics across the USA.
AHRQ-funded; 290201100007C.
Citation: Wang L, Krebs E, Min JE .
Combined estimation of disease progression and retention on antiretroviral therapy among treated individuals with HIV in the USA: a modelling study.
Lancet HIV 2019 Aug;6(8):e531-e39. doi: 10.1016/s2352-3018(19)30148-1.
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Keywords: Human Immunodeficiency Virus (HIV), Medication
Adamson B, Garrison L, Barnabas RV
Competing biomedical HIV prevention strategies: potential cost-effectiveness of HIV vaccines and PrEP in Seattle, WA.
The authors estimated the cost-effectiveness of HIV vaccines considering their potential interaction with pre-exposure prophylaxis (PrEP) and condom use. They concluded that access to an HIV vaccine is desirable, as it could increase the overall effectiveness of combination HIV prevention efforts and improve population health. They recommended carefully considering the design of policies that guide interactions between vaccine and PrEP utilization and potential competition when planning for the rollout and scale-up of HIV vaccines.
AHRQ-funded; HS013853.
Citation: Adamson B, Garrison L, Barnabas RV .
Competing biomedical HIV prevention strategies: potential cost-effectiveness of HIV vaccines and PrEP in Seattle, WA.
J Int AIDS Soc 2019 Aug;22(8):e25373. doi: 10.1002/jia2.25373..
Keywords: Human Immunodeficiency Virus (HIV), Prevention, Healthcare Costs, Vaccination
Sun CJ, Tobin K, Spikes P
Correlates of same-sex behavior disclosure to health care providers among Black MSM in the United States: implications for HIV prevention.
Disclosure of same-sex behavior to health care providers (HCPs) by men who have sex with men (MSM) has been argued to be an important aspect of HIV prevention. However, Black MSM are less likely to disclose compared to white MSM. This analysis of data collected in the United States from 2006-2009 identified individual and social network characteristics of Black MSM that were associated with disclosure that may be leveraged to increase disclosure.
AHRQ-funded; HS022981.
Citation: Sun CJ, Tobin K, Spikes P .
Correlates of same-sex behavior disclosure to health care providers among Black MSM in the United States: implications for HIV prevention.
AIDS Care 2019 Aug;31(8):1011-18. doi: 10.1080/09540121.2018.1548753..
Keywords: Human Immunodeficiency Virus (HIV), Racial and Ethnic Minorities, Sexual Health, Men's Health, Prevention
McManus KA, Debolt C, Elwood S
Facilitators and barriers: clients' perspective on the Virginia AIDS Drug Assistance Program's Affordable Care Act implementation.
This study examined low-income HIV patients’ perspective on the Virginia AIDS Drug Assistance Program (ADAP) Affordable Care Act (ACA) implementation. Patients were recruited at three HIV clinics in Virginia with the goal of enrolling greater than 5% of those who were eligible for the Qualified Health Plan (QHP). The recruitment goals were met with 53 patients enrolled. Two-thirds of patients were recruited to the QHP via case managers and social workers at the HIV clinics. Concerns about privacy using the mail-order pharmacy was the biggest barrier with 9 out of 10 participants. Otherwise, most participants had positive perceptions of the QHP.
AHRQ-funded; HS024196.
Citation: McManus KA, Debolt C, Elwood S .
Facilitators and barriers: clients' perspective on the Virginia AIDS Drug Assistance Program's Affordable Care Act implementation.
AIDS Res Hum Retroviruses 2019 Aug;35(8):734-45. doi: 10.1089/aid.2018.0254..
Keywords: Human Immunodeficiency Virus (HIV), Access to Care, Medication, Low-Income, Vulnerable Populations
Hill LM, Golin CE, Gottfredson NC
Drug use mediates the relationship between depressive symptoms and adherence to ART among recently incarcerated people living with HIV.
The purpose of this study was to identify the mechanisms involved with antiretroviral therapy (ART) non-adherence among people living with HIV (PLHIV) after release from prison. Results showed that, on average, study participants achieved 79% ART adherence. Greater symptoms of depression were associated with greater drug use, which was in turn associated with lower adherence. Lower adherence self-efficacy was associated with depressive symptoms, but not with adherence. Results suggested that depression screening and targeted mental health and substance use services for depressed individuals at risk of substance use constitute important steps to promote adherence to ART after prison release.
AHRQ-funded; HS000032.
Citation: Hill LM, Golin CE, Gottfredson NC .
Drug use mediates the relationship between depressive symptoms and adherence to ART among recently incarcerated people living with HIV.
AIDS Behav 2019 Aug;23(8):2037-47. doi: 10.1007/s10461-018-2355-3..
Keywords: Behavioral Health, Depression, Human Immunodeficiency Virus (HIV), Medication, Patient Adherence/Compliance, Substance Abuse, Vulnerable Populations
Lipira L, Williams EC, Huh D
HIV-related stigma and viral suppression among African-American women: exploring the mediating roles of depression and ART nonadherence.
Investigators recruited a sample of African-American women living with HIV to participate in a stigma-reduction intervention. The women lived in Chicago and Birmingham from 2013 to 2015. The relationship between HIV-related stigma and viral suppression was evaluated and the role of depression and nonadherence to antiretroviral therapy (ART) was assessed. Among 100 women who participated 95% reported some level of HIV-related stigma. Those who reported higher levels of stigma did have lower odds of being virally suppressed. The indirect effects of depression and ART nonadherence were not statistically significant.
AHRQ-funded; HS013853.
Citation: Lipira L, Williams EC, Huh D .
HIV-related stigma and viral suppression among African-American women: exploring the mediating roles of depression and ART nonadherence.
AIDS Behav 2019 Aug;23(8):2025-36. doi: 10.1007/s10461-018-2301-4..
Keywords: Depression, Human Immunodeficiency Virus (HIV), Medication, Behavioral Health, Patient Adherence/Compliance, Racial and Ethnic Minorities, Social Stigma, Women
Wallace DD, Pack A, Uhrig Castonguay B
Validity of social support scales utilized among HIV-infected and HIV-affected populations: a systematic review.
This systematic review aimed to identify validated social support scales utilized among HIV-infected and HIV-affected populations. After a systematic literature search was conducted, a total of 17 studies remained with two of them assessing multiple social support scales, which brought the total number of scales up to 19. Most scales assessed positive social support behaviors with perceived social support (n=14) being the most common behavior compared to perceived social support. There was a reliability range of 0.67 to 0.97. Validity was mostly based on content and construct and rarely for criterion-related measures.
AHRQ-funded; HS000032.
Citation: Wallace DD, Pack A, Uhrig Castonguay B .
Validity of social support scales utilized among HIV-infected and HIV-affected populations: a systematic review.
AIDS Behav 2019 Aug;23(8):2155-75. doi: 10.1007/s10461-018-2294-z..
Keywords: Human Immunodeficiency Virus (HIV)
Chou R, Dana T, Grusing S
Screening for HIV infection in asymptomatic, nonpregnant adolescents and adults: updated evidence report and systematic review for the US Preventive Services Task Force.
Untreated HIV infection can result in significant morbidity, mortality, and HIV transmission. A 2012 review for the US Preventive Services Task Force (USPSTF) found antiretroviral therapy (ART) associated with improved clinical outcomes and decreased transmission risk in persons with CD4 cell counts less than 500/mm3. The objective of this study was to update the 2012 review on HIV screening to inform the USPSTF.
AHRQ-funded; 290201500009I.
Citation: Chou R, Dana T, Grusing S .
Screening for HIV infection in asymptomatic, nonpregnant adolescents and adults: updated evidence report and systematic review for the US Preventive Services Task Force.
JAMA 2019 Jun 18;321(23):2337-48. doi: 10.1001/jama.2019.2592..
Keywords: U.S. Preventive Services Task Force (USPSTF), Children/Adolescents, Human Immunodeficiency Virus (HIV), Screening, Prevention, Evidence-Based Practice
Selph SS, Bougatsos C, Dana T
Screening for HIV Infection in pregnant women: updated evidence report and systematic review for the US Preventive Services Task Force.
Prenatal screening for HIV can inform use of interventions to reduce the risk of mother-to-child transmission. The US Preventive Services Task Force (USPSTF) previously found strong evidence that prenatal HIV screening reduced risk of mother-to-child transmission. The previous evidence review was conducted in 2012. The objective of this study was to update the 2012 review on prenatal HIV screening to inform the USPSTF.
AHRQ-funded; 290201500009I.
Citation: Selph SS, Bougatsos C, Dana T .
Screening for HIV Infection in pregnant women: updated evidence report and systematic review for the US Preventive Services Task Force.
JAMA 2019 Jun 18;321(23):2349-60. doi: 10.1001/jama.2019.2593..
Keywords: U.S. Preventive Services Task Force (USPSTF), Human Immunodeficiency Virus (HIV), Screening, Pregnancy, Women, Evidence-Based Practice
Chou R, Evans C, Hoverman A
Preexposure prophylaxis for the prevention of HIV infection: evidence report and systematic review for the US Preventive Services Task Force.
The purpose of this study was to synthesize evidence on the benefits and harms of PrEP (preexposure prophylaxis), instruments for predicting incident HIV infection, and PrEP adherence, to inform the US Preventive Services Task Force. The study found that in adults at increased risk of HIV infection, PrEP with oral tenofovir disoproxil fumarate monotherapy or tenofovir disoproxil fumarate/emtricitabine was associated with decreased risk of acquiring HIV infection compared with placebo or no PrEP, with effectiveness decreasing with suboptimal adherence. Most adverse events were mild and reversible.
AHRQ-funded; 290201500009I.
Citation: Chou R, Evans C, Hoverman A .
Preexposure prophylaxis for the prevention of HIV infection: evidence report and systematic review for the US Preventive Services Task Force.
JAMA 2019 Jun 11;321(22):2214-30. doi: 10.1001/jama.2019.2591..
Keywords: Evidence-Based Practice, Human Immunodeficiency Virus (HIV), Medication, Prevention, U.S. Preventive Services Task Force (USPSTF)
Crockett KB, Edmonds A, Johnson MO
Neighborhood racial diversity, socioeconomic status, and perceptions of HIV-related discrimination and internalized HIV stigma among women living with HIV in the United States.
This study sought to evaluate whether internalized HIV stigma and perceived HIV-related discrimination in health care settings differ based on individual- and neighborhood-level characteristics of women living with HIV (WLHIV). The authors also wanted to determine whether neighborhoods with more racial diversity was associated less internalized HIV stigma and discrimination regardless of individual race. A total of 1256 WLHIV enrolled in the Women’s Interagency HIV Study (WIHS) from 10 sites in US metropolitan areas were recruited. They completed surveys on internalized HIV stigma and HIV-related discrimination and also provided residential information so it could be geocoded and linked with census-tract level indicators. Greater neighborhood racial diversity was associated with less stigma and HIV-related discrimination. Neighborhood median income was positively associated with stigma and discrimination, while individual income was negatively associated with stigma and discrimination.
AHRQ-funded; HS013852.
Citation: Crockett KB, Edmonds A, Johnson MO .
Neighborhood racial diversity, socioeconomic status, and perceptions of HIV-related discrimination and internalized HIV stigma among women living with HIV in the United States.
AIDS Patient Care STDS 2019 Jun;33(6):270-81. doi: 10.1089/apc.2019.0004..
Keywords: Human Immunodeficiency Virus (HIV), Social Determinants of Health, Social Stigma
Lipira L, Williams EC, Nevin PE
Religiosity, social support, and ethnic identity: exploring "resilience resources" for African-American women experiencing HIV-related stigma.
The objective of this study was to evaluate whether religiosity, social support, and ethnic identity moderate the effects of HIV-related stigma on depression among African-American women living with HIV. Results showed that the protective effects of religiosity may be leveraged in interventions for African-American women living with HIV struggling with HIV-related stigma.
AHRQ-funded; HS013853.
Citation: Lipira L, Williams EC, Nevin PE .
Religiosity, social support, and ethnic identity: exploring "resilience resources" for African-American women experiencing HIV-related stigma.
J Acquir Immune Defic Syndr 2019 Jun;81(2):175-83. doi: 10.1097/qai.0000000000002006..
Keywords: Human Immunodeficiency Virus (HIV), Racial and Ethnic Minorities, Social Stigma, Women, Depression, Behavioral Health
Schnall R, Carcamo J, Porras T
Use of the phase-based model of smoking treatment to guide intervention development for persons living with HIV who self-identify as African American tobacco smokers.
To address the issue of developing effective tobacco cessation interventions for persons with HIV, this study conducted six focus group sessions with 45 African American smokers who are living with HIV in order to understand barriers to smoking cessation and strategies to help overcome these barriers. The participants articulated key components for incorporation into tobacco cessation intervention: personalized plans for quitting, reminders about the plan, and a support system. Participants also described barriers to use of pharmacotherapy, such as adverse side effects of nicotine gum and patch, and expressed concerns about negative health effects of some oral medications. The authors conclude that their findings provide information on the components of a tobacco cessation intervention for persons living with HIV.
AHRQ-funded; HS025071.
Citation: Schnall R, Carcamo J, Porras T .
Use of the phase-based model of smoking treatment to guide intervention development for persons living with HIV who self-identify as African American tobacco smokers.
Int J Environ Res Public Health 2019 May 15;16(10). doi: 10.3390/ijerph16101703..
Keywords: Human Immunodeficiency Virus (HIV), Primary Care: Models of Care, Racial and Ethnic Minorities, Tobacco Use, Tobacco Use: Smoking Cessation