Faculty Bibliography

BACKGROUND:American/Black and Latine (AABL) young/emerging adults living with HIV in the United States (US) have consistently failed to meet targets for HIV care/medication engagement. Among this population, those with non-suppressed HIV viral load are understudied, along with immigrants and those with serious socioeconomic deprivation. Guided by social action theory, we took a mixed methods approach (sequential explanatory design) to describe sociodemographic, background, and contextual factors, and their relationships to HIV management, among a diverse cohort. METHODS:Participants (N = 271) received structured baseline assessments and HIV viral load testing. Primary outcomes were being well-engaged in HIV care and HIV viral suppression. A subset (N = 41) was purposively sampled for maximum variability for in-depth interviews. Quantitative data were analyzed with descriptive statistics and logistic regression, and used to develop a research question about life contexts. Qualitative data were analyzed with directed content analysis, and the joint display method was used to integrate results. RESULTS:Participants were 25 years old, on average (SD = 2). The majority (59%) were Latine/Hispanic and the reminder African American/Black. Almost all were assigned male sex at birth (96%) and sexual minorities (93%). Half (49%) were born outside the US and 33% spoke primarily Spanish. They were diagnosed with HIV four years prior on average (SD = 3). Most were well-engaged in HIV care (72%) and evidenced viral suppression (81%). Speaking Spanish was associated with a higher odds of care engagement, and adverse childhood experiences and income from federal benefits were associated with a lower odds. None of the factors predicted viral suppression. Qualitative results highlighted both developmentally typical (insufficient financial resources, unstable housing) and atypical challenges (struggles with large bureaucracies, HIV disclosure, daily medication use). Federal benefits and the local HIV social services administration were critical to survival. Immigrant participants came to the US to escape persecution and receive HIV care, but HIV management was often disrupted. Overall qualitative results highlighted both risk and protective factors, and resilience. Qualitative results added detail, nuance, and richness to the quantitative findings. CONCLUSIONS:The present study advances what is known about the backgrounds and contexts of diverse and understudied AABL young/emerging adults living with HIV.

OBJECTIVE:Examine the relationship between race and ethnicity and area-level social deprivation and Medicare home health care (HHC) agency quality for seriously ill older adults receiving HHC. METHODS:A linear probability fixed effects model analyzed the association between patient-level predictors and HHC agency quality (star-rating), controlling for neighborhood level fixed effects. Linear mixed regression modeled the relationship between area-level social deprivation and receiving care from a high-quality HHC agency. An interaction term between race and social deprivation index quartiles examined whether racial disparities in accessing high-quality HHC agencies depended on the level of neighborhood social deprivation. RESULTS:< .001). The effect of race on access to high-quality HHC persisted regardless of the level of neighborhood social deprivation. CONCLUSIONS:For people living with serious illness, living in areas with higher social deprivation is associated with lower-quality HHC. Patient race and ethnicity has a consistent effect reducing access to high-quality HHC agencies, regardless of neighborhood. Future research must investigate ways to improve access to high-quality HHC for racial and ethnic historically marginalized populations who are seriously ill, especially in areas of high social deprivation. This includes understanding what policies, organizational structures, or care processes impede or improve access to high-quality care.

Transgender and gender-expansive young people, ages 13-24 years, experience disproportionate HIV risk yet are among those with the lowest US PrEP uptake rates (< 10%). Factors influencing PrEP outcomes for this population are poorly understood. This study examines the effects of gender minority stressors, gender affirmation, and heavy substance use on their PrEP outcomes using data from the CDC's 2018 START study (N = 972). A conceptual model integrating the gender minority stress and gender affirmation models was developed, mapping relevant START items onto it. Structural equation modeling (Mplus-8.9) was used to examine factors related to their PrEP intentions. Most participants were 18-24 (68%), trans-female (46%), white (45%), and reported heavy substance use (40%). Medical discrimination increased internalized transphobia (b = 0.097, SE = 0.034, p = 0.005) and perceived stigma (b = 0.087, SE = 0.034, p = 0.010). Family rejection increased perceived stigma (b = 0.181, SE = 0.032, p < 0.001) and heavy substance use (b = 0.260, SE = 0.053, p < 0.001). Perceived stigma also increased heavy substance use (b = 0.106, SE = 0.037, p = 0.004). Perceived stigma (b=-0.085, SE = 0.027, p = 0.002) and heavy substance use (b=-0.161, SE = 0.031, p < 0.001) decreased PrEP intentions, while gender affirmation increased them (b = 0.045, SE = 0.019, p = 0.020). A 1-point increase in gender affirmation reduced heavy substance use risk by -0.179 (SE = 0.030, p < 0.001) in the presence of family rejection and by -0.074 (SE = 0.041, p = 0.074) when perceived stigma was present. This study underscores heavy substance use as a potential barrier to PrEP uptake for transgender/gender-expansive youth. Future research could explore how gender affirmation acts as a protective factor against the negative impact of family rejection and perceived stigma on heavy substance behaviors among these populations.

Improving engagement along the HIV care continuum and reducing racial/ethnic disparities are necessary to end the HIV epidemic. Research on African American/Black and Latine (AABL) younger people living with HIV (LWH) is essential to this goal. However, a number of key subgroups are challenging to locate and engage, and are therefore under-represented in research. Primary among these are persons with non-suppressed HIV viral load, severe socioeconomic disadvantage, transgender/gender expansive identities, and refugee/migrant/immigrant populations. Research in community settings is needed to complement studies conducted in medical institutions. The present study describes the efficiency of recruitment strategies used in the community to enroll AABL young and emerging adults LWH ages 19-28 years. Strategies were designed to be culturally responsive and structurally salient. They were: peer-to-peer, social media, classified advertisements (newspaper, craigslist), subway ads, dating apps (Jack'd, Positive Singles), and direct recruitment in community-based organizations. Data were analyzed using mainly descriptive statistics and interpreted using a consensus building approach. We screened 575 individuals in a first step, 409 were eligible (71%), of these 297 presented to the second screening step (73%), but 112 were lost. Almost all presenting at the second step were eligible (98%, 291/297) and 94% enrolled (274/291). Peer-to-peer, dating app (Jack'd), direct recruitment, and craigslist were the most efficient strategies. Recruitment on dating apps was superior to the peer-to-peer approach in yielding eligible participants (OR = 1.5; 95% CI: 0.98-2.3; p = 0.06). The sample enrolled was diverse with respect to HIV viral suppression, gender identify, sexual orientation, immigration status, and barriers to HIV care engagement. We discuss the advantages and disadvantages of each strategy. Recruitment is a vital aspect of research and warrants attention in the empirical literature.

BACKGROUND:Ketamine's potential for treating depression has drawn increased clinical interest in recent years. However, despite growing therapeutic use, recreational use among individuals with depression remain underexplored. METHODS:We analyzed data from the 2015-2022 National Survey on Drug Use and Health focusing on adults in the US. Trends in past-year ketamine use, overall and by depression status, were estimated separately for 2015-2019 and 2021-2022 due to methodological changes in the survey. We also delineated correlates of ketamine use in each period, focusing on depression, sociodemographic characteristics, and other past-year drug use. RESULTS:Overall ketamine use prevalence increased from 2015 to 2019 (from 0.11 % to 0.20 %, an 81.8 % increase, p < 0.01) and from 2021 to 2022 (from 0.20 % to 0.28 %, a 40.0 % increase, p < 0.05). From 2015 to 2019, use increased among adults with and without depression (by 139.3 % [p < 0.05] and 66.7 % [p < 0.05], respectively), while from 2021 to 2022, an increase occurred only among those without depression (by 38.9 %, p < 0.05). Multivariable models revealed that depression was associated with increased odds of ketamine use in 2015-2019 (aOR = 1.80, 95 % CI: 1.12-2.89) but not in later years. New sociodemographic correlates emerged in 2021-2022, including adults aged 26-34 and those with a college degree being at higher odds for use. Various drugs (especially ecstasy/MDMA and gamma-hydroxybutyrate) were consistently associated with higher odds of use. CONCLUSION/CONCLUSIONS:We identified differential patterns and correlates of ketamine use over time. Shifts may be related to the evolving ketamine landscape and/or changing survey methodology. Monitoring of use patterns is crucial to inform prevention and harm reduction strategies.

INTRODUCTION/BACKGROUND:Opioid withdrawal is a regular occurrence for many people who use illicit opioids (PWUIO) involving acute physical and psychological pain. Yet, there is very little data on the withdrawal experience of people in methadone maintenance treatment (MMT) and almost none from the patients' experience. Learning more about patients' withdrawal experiences can help to inform policies and practices that are better suited to address withdrawal and may improve patient satisfaction as well as uptake and retention. METHODS:This article is based on 29 semi-structured interviews with people who use illicit opioids who reported recent withdrawal experience. The study conducted interviews remotely via Zoom between April and August 2022 and later transcribed them professionally. The study team then coded data thematically using Atlas.ti, based on a combination of inductive and deductive coding strategies and informed by the literature and study aims. RESULTS:Participants described withdrawal as a significant issue that negatively impacts their treatment experience and increases the likelihood of treatment cessation. Their accounts of withdrawal were complex and often involved multiple factors; however, feeling underdosed and missing clinic dosing hours were seen as important vectors that led to their withdrawal experiences. Importantly, participants framed feeling underdosed and missing clinic dosing hours as institutional problems, resulting primarily from clinic policies, practices, and culture rather than from patients' decisions or individual behavior. Specifically, they cited restricted access to take-home doses, limited hours of operation, and a punitive focus on complete abstinence as factors that made withdrawal difficult to avoid. CONCLUSIONS:Patients' accounts demonstrate a disconnect between providers' focus on promoting complete abstinence and patients, who were often using MMT for more pragmatic reasons that did not include complete abstinence from all drugs. These findings support growing calls for the integration of MMT into the mainstream healthcare system by making it available via prescription from office-based medical settings and dispensed through pharmacies.

OBJECTIVE:To identify primary care structures and processes that have the highest and lowest impact on chronic disease management and screening and prevention outcomes as well as to assess the feasibility of implementing these structures and processes into practice. DESIGN/METHODS:A two-round Delphi study was conducted to establish consensus on the impact and feasibility of 258 primary care structures and processes. PARTICIPANTS/METHODS:29 primary care providers, health system leaders and health services researchers in the USA. OUTCOMES/RESULTS:Primary outcomes were (1) consensus on the impact of each structure and process on chronic disease management and screening and prevention outcomes, separately and (2) consensus on feasibility of implementation by primary care practices. RESULTS:Consensus on high impact and feasibility of implementation was reached on four items for chronic disease management: 'Providers use motivational interviewing to help patients set goals', 'Practice has designated staff to manage patient panel', 'Practice has onsite providers or staff that speak the most dominant, non-English language spoken by patients' and 'Practice includes mental health providers and/or behavioural health specialists in care team' and seven items for screening and prevention: 'Practice utilizes standing protocols and orders', 'Practice generates reports to alert clinicians to missed targets and to identify gaps in care, such as overdue visits, needed vaccinations, screenings or other preventive services', 'Practice has designated staff to manage patient panel', 'Practice sets performance goals and uses benchmarking to track quality of care', 'Practice uses performance feedback to identify practice-specific areas of improvement', 'Practice builds quality improvement activities into practice operations' and 'Pre-visit planning data are reviewed during daily huddles'. Only 'Practice has designated staff to manage patient panel' appeared on both lists. CONCLUSION/CONCLUSIONS:Findings suggest that practices need to focus on implementing mostly distinct, rather than common, structures and processes to optimise chronic disease and preventive care.

INTRODUCTION/BACKGROUND:The overdose crisis in the U.S. disproportionately impacts people experiencing homelessness. Permanent supportive housing (PSH) - permanent, affordable housing with voluntary support services - is an effective, evidence-based intervention to address homelessness. However, overdose risk remains high even after entering PSH for individual and structural reasons. In this study, we aimed to refine a set of evidence-based overdose prevention practices (EBPs) and an associated implementation support package for PSH settings using focus groups with PSH tenants, frontline staff, and leaders. METHODS:Our community-academic team identified an initial set of overdose EBPs applicable for PSH through research, public health guidance, and a needs assessment. We adapted these practices based on feedback from focus groups with PSH leaders, staff, and tenants. Focus groups followed semi-structured interview guides developed using the EPIS (Exploration, Preparation, Implementation, Sustainment) framework constructs of inner context, outer context, and bridging factors related to overdose prevention and response. RESULTS:We conducted 16 focus groups with 40 unique participants (14 PSH tenants, 15 PSH staff, 11 PSH leaders); focus groups were held in two iterative rounds and individuals could participate in one or both rounds. Participants were diverse in gender, race, and ethnicity. Focus group participants were enthusiastic about the proposed EBPs and implementation strategies, while contributing unique insights and concrete suggestions to improve upon them. The implementation support package contains an iteratively refined PSH Overdose Prevention (POP) Toolkit with 20 EBPs surrounding overdose prevention and response, harm reduction, and support for substance use treatment and additional core implementation strategies including practice facilitation, tenant-staff champion teams, and learning collaboratives. CONCLUSIONS:This manuscript describes how robust community-academic partnerships and input from people with lived experience as tenants and staff in PSH informed adaptation of evidence-based overdose prevention approaches and implementation strategies to improve their fit for PSH settings. This effort can inform similar efforts nationally in other settings serving highly marginalized populations. We are currently conducting a randomized trial of the refined overdose prevention implementation support package in PSH.

Research suggests that hair color, hair dyeing, and perspiration can bias hair test results regarding drug exposure, but research is needed to examine such associations in a multivariable manner. In this epidemiology study, adults were surveyed entering nightclubs and dance festivals in New York City, and 328 provided hair samples, which were analyzed using ultra-high-performance liquid chromatography-tandem mass spectrometry to determine the level of detection of cocaine and 3,4-methylenedioxymethamphetamine (MDMA). Reporting use was not an inclusion criterion for analysis. We used two-part multivariable models to delineate associations of hair color, past-year hair dyeing, and frequency of past-month hat wearing (which may increase perspiration) in relation to any vs. no detection of cocaine and MDMA as well as level of detection, controlling for hair length, self-reported past-year cocaine/ecstasy/MDMA use, and age, sex, and race/ethnicity. Those reporting having dyed their hair were at increased odds of having any level of cocaine detected (adjusted odds ratio [aOR] = 3.75, 95% CI confidence interval [CI]: 1.85-6.70), and compared to those with brown hair, those with blond(e) hair on average had lower levels of cocaine (ng/mg) detected (beta = -7.97, p = 0.025). Those reporting having dyed their hair were at increased odds of having any level of MDMA detected (aOR = 3.05, 95% CI: 1.44-6.48), and compared to those who reported never wearing a hat, those who reported wearing a hat daily or almost daily on average had lower levels of MDMA (ng/mg) detected (beta = -6.61, p = 0.025). This study demonstrates the importance of using multivariable models to delineate predictors of drug detection.

BACKGROUND:Engaging researchers as research subjects is key to informing the development of effective and relevant research practices. It is important to understand how best to engage researchers as research subjects. METHODS:factorial experiment, as part of a Multiphase Optimization Strategy, was performed to evaluate effects of four recruitment strategy components on participant opening of an emailed survey link and survey completion. Participants were members of three US-based national health research consortia. A stratified simple random sample was used to assign potential survey participants to one of 16 recruitment scenarios. Recruitment strategy components were intended to address both intrinsic and extrinsic sources of motivation, including: $50 gift, $1,000 raffle, altruistic messaging, and egoistic messaging. Multivariable generalized linear regression analyses adjusting for consortium estimated component effects on outcomes. Potential interactions among components were tested. Results are reported as adjusted odds ratios (aOR) with 95% confidence intervals (95% CI). RESULTS:Surveys were collected from June to December 2023. A total of 418 participants were included from the consortia, with final analytical sample of 400 eligible participants. Out of the final sample, 82% (341) opened the survey link and 35% (147) completed the survey. Altruistic messaging increased the odds of opening the survey (aOR 2.02, 95% CI: 1.35-2.69, p = 0.033), while egoistic messaging significantly reduced the odds of opening the survey (aOR 0.56, 95%CI 0.38-0.75, p = 0.08). The receipt of egoistic messaging increased the odds of completing the survey once opened (aOR 1.81, 95%CI: 1.39-2.23, p < 0.05). There was a significant negative interaction effect between the altruistic appeal and egoistic messaging strategies for survey completion outcome. Monetary incentives did not a have a significant impact on survey completion. CONCLUSION/CONCLUSIONS:Intrinsic motivation is likely to be a greater driver of health researcher participation in survey research than extrinsic motivation. Altruistic and egoistic messaging may differentially impact initial interest and survey completion and when combined may lead to improved rates of recruitment, but not survey completion. Further research is needed to determine how to best optimize message content and whether the effects observed are modified by survey burden.