Faculty Bibliography

BACKGROUND:Permanent supportive housing (PSH) is the gold standard intervention for chronic homelessness, but PSH tenants face high risk for overdose due to a combination of individual and environmental risk factors. Little research has examined overdose prevention in PSH. METHODS:We conducted baseline surveys with staff from 20 New York PSH buildings participating in an overdose prevention technical assistance intervention study. PSH staff from participating buildings were invited via email to complete a brief online survey about their knowledge of overdose and perspectives on implementing overdose prevention practices in PSH. RESULTS:Surveys were completed by 178 staff of 286 invitations sent (response rate 62.2%). Average score on the Brief Opioid Overdose Knowledge (BOOK) questionnaire was 8.62 (SD 2.64) out of 12 points. Staff felt very positively (91.6-97.2% agreed or completely agreed) regarding the appropriateness and acceptability of implementing overdose prevention practices in PSH, but less certain about the feasibility of implementing these practices (62.4-65.5% agreed or completely agreed). Most (77.3%) felt it was mostly or definitely true that overdose prevention was a top priority in their building. Most PSH staff (median = 85.0%) but fewer tenants (median = 22.5%) had received a naloxone kit and training in overdose response. CONCLUSION/CONCLUSIONS:Staff feel positively about the acceptability and appropriateness of implementing overdose response practices in PSH, but somewhat more uncertain about the feasibility of implementing these practices. This study's results help hone targets for interventions to help PSH buildings take steps to reduce tenant overdose risk.

Racial/ethnic disparities in COVID-19, including incidence, hospitalization, and death rates, are serious and persistent. Among those at highest risk for COVID-19 and its adverse effects are African American/Black and Latine (AABL) frontline essential workers in public-facing occupations (e.g., food services, retail). Testing for COVID-19 in various scenarios (when exposed or symptomatic, regular screening testing) is an essential component of the COVID-19 control strategy in the United States. However, AABL frontline workers have serious barriers to COVID-19 testing at the individual (insufficient knowledge, distrust, cognitive biases), social (norms), and structural levels of influence (access). Thus, testing rates are insufficient and interventions are needed. The present study is grounded in the multiphase optimization strategy (MOST) framework. It tests the main and interaction effects of a set of candidate behavioral intervention components to increase COVID-19 testing rates in this population. The study enrolled adult AABL frontline essential workers who were not up-to-date on COVID-19 vaccination nor recently tested for COVID-19. It used a factorial design to examine the effects of candidate behavioral intervention components, where each component was designed to address a specific barrier to COVID-19 testing. All participants received a core intervention comprised of health education. The candidate components were motivational interviewing counseling (MIC), a behavioral economics intervention (BEI), peer education (PE), and access to testing (either self-test kits [SK] or a navigation meeting [NM]). The primary outcome was COVID-19 testing in the follow-up period. Participants were assessed at baseline, randomly assigned to one of 16 experimental conditions, and assessed six- and 12-weeks later. The study was carried out in English and Spanish. We used a logistic regression model and multiple imputation to examine the main and interaction effects of the four factors (representing components): MIC, BEI, PE, and Access. We also conducted a sensitivity analysis using the complete case analysis. Participants (N = 438) were 35 years old on average (SD = 10). Half identified as men/male (52%), and 48% as women/female/other. Almost half (49%) were African American/Black, and 51% were Latine/Hispanic (12% participated in Spanish). A total of 32% worked in food services. Attendance in components was very high (~ 99%). BEI had positive effect on the outcome (OR = 1.543; 95% CI: [0.977, 2.438]; p-value = 0.063) as did Access, in favor of SK (OR = 1.351; 95% CI: [0.859, 2.125]; p-value = 0.193). We found a three-way interaction among MIC*PE*Access (OR: 0.576; 95% CI: [0.367, 0.903]; p-value = 0.016): when MIC was present, SK tended to increase COVID testing when PE was not present. The study advances intervention science and takes the first step toward creating an efficient and effective multi-component intervention to increase COVID-19 testing rates in AABL frontline workers.

Racial/ethnic disparities in COVID-19 morbidity and mortality are serious in the United States, particularly among African American/Black and Latine (AABL) populations. Staying up-to-date on COVID-19 vaccination is essential for mitigating risk, but AABL vaccination rates are low. The present qualitative study explores perspectives on COVID-19 among AABL persons at high-risk for exposure to the SARS-CoV- 2 virus: frontline essential workers engaged in public-facing professions (e.g., retail). From a larger study of AABL frontline essential workers not up-to-date on COVID-19 vaccination, N = 50 participants were purposively sampled for maximum variability. Participants engaged in semi-structured qualitative interviews in English or Spanish that were audio-recorded, professionally transcribed, and translated into English as needed. Data were analyzed using a directed content analysis approach that was both inductive and theory-driven. Participants were 37 years old, on average, and most (65%) were men. Approximately half (56%) were Latine/Hispanic and 44% were African American/Black. Occupations included food preparation (40%), retail (28%), construction (12%), in-home health care (8%), and building maintenance and personal services (12%). Approximately a third (38%) had received ≥ 1 COVID-19 vaccine dose. We found COVID-19 vaccination perspectives were grounded in a larger context of medical and institutional distrust and past/ongoing systemic racism. In this context, results were organized into the following themes: general perspectives on COVID-19; barriers/facilitators related to race/ethnicity, social class, and community; specific aspects of the COVID-19 vaccine as barriers; mandates, incentives, and pressures to be vaccinated; and mixed effects of public health initiatives. Overall, participants were knowledgeable about COVID-19. Social norms reduced vaccine intentions but altruism and community/family concern could motivate it. Aspects of the public health response (e.g., advertisement campaigns targeting AABL populations) increased distrust and reduced vaccination willingness. However, at least some ambivalence about vaccination was common (participants would consider it). Yet there was a large gap between considering and receiving vaccination. Thus, barriers to COVID-19 vaccination for AABL frontline essential workers operate at multiple levels of influence, but are addressable. The present study yields recommendations to improve vaccination, including increasing the trustworthiness of systems and institutions, reducing systemic/structural barriers, harnessing social forces, and engaging AABL communities in program planning.

BACKGROUND:Black sexual minority men and Black transgender women (BSMM/BTW) experience disproportionate levels of HIV/STI-related risk factors as well as police harassment (PH). PH is linked to psychiatric risk and could play a role in substance use, sexual risk behavior, and HIV/STI risk. METHODS:We used data from the HIV Prevention Trials Network 061(HPTN 061) study to examine associations between PH and HIV/STI-related outcomes. Using PH exposure measured at baseline and 6-month study visits, we examined an ordinal exposure (PH reported at both visits, PH reported at either visit, versus PH reported at neither baseline nor 6 months) and a binary exposure of persistent PH reported at both visits (yes versus no). We estimate risk ratios (RR) for associations between PH and depression, use of alcohol and methamphetamine, multiple partnerships, condomless sex, and syphilis. RESULTS:Persistent PH (binary) was associated with a 20% or greater increase in the risk of depression (RR, 1.26 (1.07, 1.47)) and multiple partnerships (RR, 1.20 (1.05, 1.39)). There was evidence that ordinal PH was associated with elevated risk of alcohol use (RR, 1.17 (1.00, 1.36)); the point estimate for the association between persistent PH and alcohol use was similar but the imprecision was greater (RR, 1.16 (0.95, 1.42)). CONCLUSION/CONCLUSIONS:PH may influence not only mental health but also behavioral risks that contribute to HIV/STI among BSMM/BTW, highlighting the potential wide-ranging and downstream effects of PH on health. Further research is required to confirm associations and elucidate pathways through which PH may influence HIV/STI among BSMM/BTW.

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.