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Introduction

People with HIV are living longer and healthier lives with the medical advances made in the last decade. As a result, there has been a focus on the concept of Prevention with Positives. The Healthy Living Project (HLP) collected data from 4 dierent sites (Los Angeles, San Francisco, Milwaukee, and New York City) on the sexual behavior of people living with HIV. We seek to jointly model the number of HIV+ and HIV- sex partners over the course of 15 sessions of counselling and seek to quantify any eect that the counselling may have had. Subjects were further divided into 4 subgroups based on risk prole (men who have sex with men (MSM), women, injection drug users (IDUs), and heterosexual men). For simplicity, only the site, subgroup, treatment, and time eects were evaluated in this project. Model parameters will be estimated using a Bayesian framework.

Data Description
A total of 621 subjects were examined over the course of baseline and 5 followup times. Subjects were eligible if they were at least 18 years of age, provided written consent, and reported at least 1 act of unprotected vaginal or anal intercourse in the previous 3 months with a partner of HIVor unknown serostatus at the baseline interview. At each observation time, subjects were asked to recall the number of sex partners they have had over the previous 3 months subdivided by serostatus. Partners of unknown status were categorized together with seronegatives. A graphical display of the number of seropositive and seronegative/unknown partners strateed by followup time is included in Graph 1 of the Appendix. Cursory examination of the data shows the presence of a few extreme outliers with extremely high partner counts while the majority of the subjects had below 20 dierent partners over a 3 month span. Los Angeles, San Francisco, and New York each contributed over 150 subjects to the dataset while Milwaukee contributed signicantly less with only 47 subjects. A specic breakdown of the dataset by location and risk group is also included in the Appendix.

Statistical Methods
Since count data is involved, a Poisson regression is the natural choice. Cursory evaluation showed mild positive correlation between HIV positive and HIV negative/unkown partners at diering followup times ranging from 0.02 to 0.2. To addresss this and evaluate any correlated eects that may have occured, Total HIV positive and HIV negative partners were modeled through a bivariate Poisson regression. We are primarily interested in evaluating any potential eects resulting from a counselling treatment that was given in 3 sessions at followup 1, 2, and 3. Subjects were then subsequently followed for 2 additional followup visits to evaluate if the eects were temporal in nature.

Model Notation:
+ Let our outcome of interest be represented as (Ni,j , Ni,j ), the number of HIV positive and nega-

tive/unknown partners for subject i at the j th followup time. We further specify xi,j as the row of the design matrix corresponding to subject i at the j th followup. 1 , 2 , and 0 represent vectors of xed eects that are respectively of dimensions 17x1, 17x1 and 11x1 corresponding to time, treatment, site, and group eects. i1 and i2 are the subject specic random eect corresponding to HIV positive and negative/unknown serostatus partners.

Model Specication:
Let
+ (Ni,j , Ni,j )|xi,j , 1 , 2 , 0 , i1 , i2 , BivPo(i1 1(i,j) , i2 2(i,j) , 0(i,j) )

with link functions ln k(i,j) = xi,j k k = 0, 1, 2

We further specify the i s to have a conjugate gamma distribution conditional on a hyperparameter

P (ik |k ) Ga(k , k )

k = 1, 2

such that E(ik |k ) = 1 and Var(ik |k ) =

1 k

Prior Specication:
Priors are set on the vectors of parameters 1 , 2 , 0 with two primary goals in mind. We want to both set priors that reect our estimation of the subjects behavior while simultaneously putting reasonable restrictions on the range of the parameters. Since little information was found in the literature on our outcome of interest and information found would vary widely based on the specic subject group recruited, we will employ some common sense in prior creation. For priors of 10 and 20 we note that at baseline, all subjects should have at least 1 sexual partner with an HIV- partner due to the exclusion criteria. We further state with less certainty that around 10 total partners were averaged by people at baseline. After conversion from to the parameter , this roughly corresponds to a lower bound on 10 and 20 of -0.7 and median of 1.6. (Values of lambda averages were split between the sero positive and sero negative partners) The choice of a normal prior that has a 95% condence interval from (-0.7, 3.9) would roughly place a prior for 10 and 20 to be:

P (k0 ) N(1.6, 1.3)

k = 1, 2

Eects of time, treatment, site and group have a multiplicative eect on the baseline through exp(j ). The mean of all the priors on these parameters were set to 0 to reect no prior bias on potential treatment eects. While no literature was found on eects of intervention on number of sex partners, some literature found regarding eects of intervention on number of unprotected sex acts showed eects corresponding to a 50 80% change. For simplicity, we set a variance on these priors to reect a normal distribution that has the potential for an 80% decrease in baseline at 2 standard deviation away. This then corresponds to a prior of:

P (1k ) N(0, 0.64) P (2k ) N(0, 0.64)

k = 1, . . . , 16 k = 1, . . . , 16

Priors for 0 are driven by an interest in maintaining a reasonable estimate since relatively little information on a dierence between negative values of exp (0 ) would exist in this model. We set priors for these as:

P (0k ) N(0, 2)

k = 0, . . . , 10

Finally priors on 1 and 2 reect our estimates of the variation between individuals which we believe to be quite large. But since this is something we have little prior information on, we will also maintain a relatively large variance as well using a Gamma distribution prior with a variance of 100 and mean of 5.

P (k ) Ga(0.25, 0.05)

k = 1, 2

Results and Discussion


Data was analyzed using MCMC with the R software. After an initial burn-in process, 200,000 iterations were used to gather the posterior distributions which were found to be approximately Gaussian. The large number of iterations was necessary since we found a semi-high autocorrelation when estimating the parameters. In general, estimates of the xed parameters had positive correlation up to lag 100 with the intercept term being specically dicult having postiive autocorrelation up to lag 500. I believe use of better blocking methodology may help to further alleviate this problem. Due to the number of parameters, focus shall be restricted to the points of interest. A thorough statistical breakdown of the posterior distributions of the covariates can be found in Table 3 of the Appendix. It is rst interesting to note that a time trend existed in both groups regardless of treatment status. It appears that the specic action of enrolling in the trial caused a shift in behavior towards having less sexual partners. For instance, at the rst followup, subjects had on average 45% less HIV seropositive partners and 32% less HIV seronegative partners than at baseline where they averaged 3 and 4.8 respectively. We go on further to note that this shift does not appear transient at least in the scope of the length of this trial as this decrease holds throughout all 5 followup periods. 4

In terms of counselling eects, there does not appear to be a decrease in the average number of HIV seropositive partners in the treatment group. In fact, followup periods 3 and 4 showed a statistically signicant increase before a decrease in the nal followup period. However, there does seem to be a counselling eect on the seronegative partner numbers. We see a decrease of 35% to 45% from baseline by the nal counselling session although it appears the eect may be transient since the change does not hold up in the nal followup period. It is nonetheless interesting that there may be some sero-sorting behavior induced from the counselling sessions. The covariance terms were all largely nonsigncant and showed that despite the correlation found in the raw data and our assumption that people who tended to have more HIV positive partners would also tend to have more HIV negative/unknown partners, the bivariate poisson model may not be appropriate for this outcome. I postulate this may be due to the environment that the subjects are in and their social circles. Furthermore, Graph 1 in the Appendix shows that the people who had an extreme number of sex partners seemed to categorize them all as either HIV positive or HIV negative/unknown. It may be that this categorization is simply due to laziness or lack of thorough knowledge in answering the questionaires. Our estimates for correspond to an estimate for the variance of the subject specic terms with show roughly a standard deviation of 1.31 for the HIV seropositive partner outcome and a standard deviation of 1.15 for the HIV seronegative partner outcomes. Our model is specied in such a way that this is a multiplicative eect on the average number of partners implying that subjects could easily have twice as many partners as another individual given the same current set of covariates. This estimate may be improved upon once additional predictive covariates are included in the model for future analysis. Finally, a sensitivity analysis for the prior specications was done to evaluate the eects of our priors. To do this, variance was increased by a factor of 10 making the priors far less informative. The change did very little to aect either the estimate or the variance of the 1 and 2 parameters reecting that the prior provided very little information in these estimates. However, the 0 estimates had their variance increased by about 6 fold and the estimates were more negative indicating that the priors did play a signicant role in the estimation of these posterior distributions. Overall, I

believe the counselling sessions had some eect on the number of HIV-/unknown partners but it is questionable whether the eect here is a lasting eect which is one of the primary concerns with behavioral interventions.