Faculty Bibliography

INTRODUCTION/BACKGROUND:Little data exists on the effectiveness of HIV prevention interventions among people who inject drugs (PWID) in Africa. We used empirical data from Kenya to fill this evidence gap. METHODS:Six rounds of bio-behavioural surveys using respondent-driven-sampling were conducted among PWID in Nairobi and Coastal Kenya over 2012-2015. Dried blood spot samples were tested for HIV and HIV viral load, and HIV incidence was estimated through linking participants between rounds. Regression analyses evaluated whether self-reported usage of opioid agonist therapy (OAT) or needle and syringe programmes (NSP) in last year were associated with reduced injecting risk behaviours, increased ART uptake and viral suppression, and reduced risk of HIV acquisition. RESULTS:Overall, 4897 PWID participated in the study, with 3903 participating in >1 round. Over the rounds, coverage increased from zero to 80-86 % for NSP and zero to 10-20 % for OAT. The proportion of people living with HIV (PLHIV) that were virally suppressed increased from 7-14 % to 39-55 %. Accessing NSP and OAT was associated with reduced syringe sharing at last injection (NSP adjusted odds ratio (aOR)=0.31; 95 %CI:0.24-0.40; OAT aOR=0.046; 95 %CI:0.034-0.061) and OAT was associated with reduced injecting frequency (adjusted rate ratio=0.21; 95 %CI:0.12-0.36). Using OAT was associated with increased ART coverage (aOR=2.76; 95 %CI:1.50-5.06) and viral suppression (aOR=2.99; 95 %CI:1.78-5.03) among PLHIV, while NSP was not. HIV incidence decreased from 6.10 (95 %CI:3.56-9.77) to 1.49 (95 %CI:0.79-2.54) per 100 person-years between the first and second half of the study. Accessing NSP was associated with lower HIV incidence (adjusted hazard ratio=0.25; 95 %CI:0.087-0.58). CONCLUSIONS:This study provides strong evidence for the benefits of NSP and OAT on varied HIV outcomes among PWID in Africa.

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.

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.

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.

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.

INTRODUCTION/BACKGROUND:The United States is facing an opioid use disorder (OUD) epidemic, marked by unprecedented overdose death rates. In New York State, synthetic opioids significantly contribute to the increasing overdose deaths, disproportionately impacting Black and Latinx communities. There is an urgent need to address issues related to equitable access to and the quality of care provided by substance use disorder (SUD) treatment programs. In light of this, the Quality Measurement and Management Research Center (QM2-RC) brought together an academic-government partnership to develop a person-centered quality measurement system and to assess its impact on a statewide treatment system that serves approximately 180,000 individuals per year. METHODS AND ANALYSIS/METHODS:The QM2-RC encompasses three interconnected projects (Project 1, 2, and 3) aimed at developing a quality management strategy and evaluating its impact on system performance across New York State. This report specifically focuses on Project 3, which involves a stepped-wedge trial with 35 clinics receiving a quality management intervention that includes performance coaching. This intervention will be compared to a treatment-as-usual (TAU) condition for clinics not participating in the trial. Administrative data will be utilized to monitor outcomes over four years. The coaching intervention, guided by the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) model, emphasizes interpreting quality measures and applying insights to enhance care. Coaches will provide support on data utilization, patient-centered care, harm reduction strategies, and the use of patient monitoring tools. The trial aims to evaluate clinic staff and leadership attitudes, experiences, and behaviors through surveys, semi-structured interviews, and external facilitator notes. Primary clinic outcomes will be assessed through adverse events, decreased clinic rates of substance use related emergency department visits and hospitalizations as well as mortality among patients within the first 12 months after admission to treatment after adjusting for individual and community level characteristics. This study is being developed over a multi-year period and will be informed by a mixed-methods approach incorporating multiple data sources, qualitative interviews, patient and clinic surveys. The study is being conducted in partnership with New York State Office of Addiction Services and Supports (OASAS) and will be informed by input from patient, providers, health insurers, family members and local governing units. DISCUSSION/CONCLUSIONS:Project 3 of the QM2 study specifically targets key barriers in measuring the quality of SUD treatment, including technological limitations, unvalidated measures, workforce data literacy, and concerns about fairness in assessing clinical complexity. Through the implementation of a stepped-wedge trial involving 35 clinics, the project aims to develop new quality measures, offer performance feedback, and engage clinic leadership and staff in efforts to improve practices. The ultimate goal of Project 3 is to overcome these barriers, promote person-centered care, and improve SUD treatment practices across New York State.

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.