Faculty Bibliography

BACKGROUND: African American/Black and Hispanic persons living with HIV (AABH-PLWH) are under-represented in AIDS clinical trials (ACTs) in the United States. Barriers AABH-PLWH experience to ACTs are multi-faceted, including distrust of medical research, low levels of knowledge, unsupportive social norms, lack of referral, and challenges navigating ACT systems. In past research we found a multi-component peer-driven intervention was efficacious in boosting rates of screening for/enrollment into ACTs. The present qualitative study seeks to understand AABH-PLWH's perspectives on which specific intervention features or components had utility. Interventions features explored included structural elements (e.g., small group sessions, individual sessions on the ACT research unit); approaches (e.g., Motivational Interviewing); and specific components (e.g., small-group discussion of historical and cultural factors reducing participation among AABH-PLWH). METHODS: A total of 37 AABH-PLWH (mean age 50.6 years, SD=7.5 years; 48.6% female; 62.2% African American/Black, 27.0% Hispanic) were purposively selected from a larger study for in-depth interviews, which were audio-recorded, transcribed verbatim, and analyzed using systematic content analysis. RESULTS: We found the intervention improved knowledge and positive attitudes toward ACTs, and triggered social-level facilitators such as altruism and more positive social norms. Discussions of cultural/historical barriers to ACTs associated with race/ethnicity had utility. Holding a session on the ACT research unit reduced fear and increased motivation. Results highlighted the value of Motivational Interviewing, and several components were perceived as less useful (e.g., involving social network members in ACT decisions). CONCLUSION: Findings can inform future intervention designs to address racial/ethnic disparities in ACTs and have implications for trials of other conditions where racial/ethnic disparities persist.

After HIV diagnosis, heterosexuals in high-poverty urban areas evidence delays in linkage to care and antiretroviral therapy initiation compared to other groups. Yet barriers to/facilitators of HIV care among these high-risk heterosexuals are understudied. Under the theory of triadic influence, putative barriers to HIV care engagement include individual/attitudinal-level (e.g., fear, medical distrust), social-level (e.g., stigma), and structural-level influences (e.g., poor access). Participants were African-American/Black and Hispanic adults found newly diagnosed with HIV (N = 25) as part of a community-based HIV testing study with heterosexuals in a high-poverty, high-HIV-incidence urban area. A sequential explanatory mixed-methods design was used. We described linkage to HIV care and clinical outcomes [CD4 counts, viral load (VL) levels] over 1 year, and then addressed qualitative research questions about the experience of receiving a new HIV diagnosis, its effects on timely engagement in HIV care, and other barriers and facilitators. Participants were assessed five times, receiving a structured interview battery, laboratory tests, data extraction from the medical record, a post-test counseling session, and in-person/phone contacts to foster linkage to care. Participants were randomly selected for qualitative interviews (N = 15/25) that were recorded and transcribed, then analyzed using systematic content analysis. Participants were 50 years old, on average (SD = 7.2 years), mostly male (80%), primarily African-American/Black (88%), and low socioeconomic status. At the first follow-up, rates of engagement in care were high (78%), but viral suppression was modest (39%). Rates improved by the final follow-up (96% engaged, 62% virally suppressed). Two-thirds (69%) were adequately retained in care over 1 year. Qualitative results revealed multi-faceted responses to receiving an HIV diagnosis. Problems accepting and internalizing one's HIV status were common. Reaching acceptance of one's HIV-infected status was frequently a protracted and circuitous process, but acceptance is vital for engagement in HIV care. Fear of stigma and loss of important relationships were potent barriers to acceptance. Thus, partially as a result of difficulties accepting HIV status, delays in achieving an undetectable VL are common in this population, with serious potential negative consequences for individual and public health. Interventions to foster acceptance of HIV status are needed.

Emergency departments (EDs) frequently serve people who have limited, if any, additional interactions with health care, yet many ED patients are not offered HIV testing, and those who are frequently decline. ED staff (n = 13) at a high volume urban ED (technicians, nurses, physicians, and administrators) were interviewed to elicit their perspectives on the feasibility and acceptability of a tablet-based intervention designed to increase HIV test rates among patients who initially decline testing. Content-based thematic analysis of semi-structured interviews indicated overall support for interventions to increase HIV testing, but a lack of available staff resources emerged as a potential barrier to widespread implementation. Also, some ED staff questioned whether it was appropriate to shift responsibility for public health services, such as HIV testing, to the ED instead of a primary care setting. Although tablet-based interventions have been shown effective in high volume ED settings and can potentially increase HIV test rates among hard-to-reach populations, additional effort is now required to better integrate this type of intervention into existing workflows.

Substance use problems tend to co-occur with risk factors that are especially prevalent in urban communities with high rates of poverty. The present study draws on Syndemics Theory to understand profiles of risk and resilience and their associations with substance use problems in a population at risk for adverse outcomes. African-American/Black and Hispanic heterosexual adults (N = 2,853) were recruited by respondent-driven sampling from an urban area with elevated poverty rates, and completed a structured assessment battery covering sociodemographics, syndemic factors (that is, multiple, co-occurring risk factors), and substance use. More than one-third of participants (36%) met criteria for either an alcohol or a drug problem in the past year. Latent class analysis identified profiles of risk and resilience, separately for women and men, which were associated with the probability of a substance use problem. Almost a third of women (27%) and 38% of men had lower risk profiles-patterns of resilience not apparent in other types of analyses. Profiles with more risk and fewer resilience factors were associated with an increased probability of substance use problems, but profiles with fewer risk and more resilience factors had rates of substance use problems that were very similar to the general adult population. Relative to the lowest risk profile, profiles with the most risk and fewest resilience factors were associated with increased odds of a substance use problem for both women [adjusted odds ratio (aOR) = 8.50; 95% CI: 3.85-18.74] and men (aOR = 11.68; 95% CI: 6.91-19.74). Addressing syndemic factors in substance use treatment and prevention may yield improved outcomes.

OBJECTIVE:We compared the impact and costs of HIV prevention strategies focusing on youth (15-24 year-old persons) versus on adults (15+ year-old persons), in a high-HIV burden context of a large generalized epidemic. DESIGN/METHODS:Compartmental age-structured mathematical model of HIV transmission in Nyanza, Kenya. INTERVENTIONS/METHODS:The interventions focused on youth were high coverage HIV testing (80% of youth), treatment at diagnosis (TasP, i.e., immediate start of antiretroviral therapy [ART]) and 10% increased condom usage for HIV-positive diagnosed youth, male circumcision for HIV-negative young men, pre-exposure prophylaxis (PrEP) for high-risk HIV-negative females (ages 20-24 years), and cash transfer for in-school HIV-negative girls (ages 15-19 years). Permutations of these were compared to adult-focused HIV testing coverage with condoms and TasP. RESULTS:The youth-focused strategy with ART treatment at diagnosis and condom use without adding interventions for HIV-negative youth performed better than the adult-focused strategy with adult testing reaching 50-60% coverage and TasP/condoms. Over the long term, the youth-focused strategy approached the performance of 70% adult testing and TasP/condoms. When high coverage male circumcision also is added to the youth-focused strategy, the combined intervention outperformed the adult-focused strategy with 70% testing, for at least 35 years by averting 94,000 more infections, averting 5.0 million more disability-adjusted life years (DALYs), and saving US$46.0 million over this period. The addition of prevention interventions beyond circumcision to the youth-focused strategy would be more beneficial if HIV care costs are high, or when program delivery costs are relatively high for programs encompassing HIV testing coverage exceeding 70%, TasP and condoms to HIV-infected adults compared to combination prevention programs among youth. CONCLUSION/CONCLUSIONS:For at least the next three decades, focusing in high burden settings on high coverage HIV testing, ART treatment upon diagnosis, condoms and male circumcision among youth may outperform adult-focused ART treatment upon diagnosis programs, unless the adult testing coverage in these programs reaches very high levels (>70% of all adults reached) at similar program costs. Our results indicate the potential importance of age-targeting for HIV prevention in the current era of 'test and start, ending AIDS' goals to ameliorate the HIV epidemic globally.

BACKGROUND: Chronic inflammation, as defined by persistent immune activation (IA) is associated with adverse clinical outcomes. People who inject drugs (PWIDs) have evidence of persistent IA. Here, in a cohort of HCV+ and HCV- infection drug users (IDU), we sought to dissect out the contribution of chronic hepatitis C infection (HCV, common in PWID) from the effects of drug injection itself. METHODS: Four groups of study volunteers were recruited- Group1- active PWID, Group 2- individuals who ceased injecting for 1-2 months, Group 3- individuals who ceased injecting for 3-4 months, and Group 4- healthy volunteers. Soluble and cell associated markers of immune activation were quantified. (https://clinicaltrials.gov/ct2/show/NCT01831284) RESULTS: HCV viremic PWID have elevated levels of IA when compared to healthy volunteers. Cessation of IDU results in a decline in IA in the absence of HCV viremia, while HCV-viremic, former IDUs continue to harbor elevated levels of IA as defined by sCD14, TNF-alpha and the presence of CD38+HLA-DR+ CD4+ and CD8+ T cells. CONCLUSIONS: IA, a well-defined surrogate of poor clinical outcome, elevated in PWID can regress to normal levels in former IDUs who are HCV-aviremic. Therefore, enhanced harm reduction efforts should incorporate aggressive treatment of HCV infection.

BACKGROUND: Novel psychoactive substances (NPSs) continue to emerge in the United States and worldwide. Few epidemiological studies have examined the prevalence and correlates of use. OBJECTIVE: We examined the extent of NPS use in a high-risk population-attendees of electronic dance music (EDM) parties at nightclubs and festivals. METHODS: We surveyed 682 adults (age 18-25) entering EDM events at nightclubs and festivals in New York City (NYC) in 2015. A variation of time-space sampling was used. We examined the prevalence of self-reported use of 196 NPS and correlates of any NPS use. RESULTS: Over a third (35.1%) of participants reported lifetime use of any NPS. Self-reported use of synthetic cannabinoids was most prevalent (16.3%), followed by psychedelic phenethylamines (14.7%; 2C series: 10.3%, 2-(4-iodo-2,5-dimethoxyphenyl)-N-[(2-methoxyphenyl)methyl]ethanamine [NBOMe] series: 9.0%, Dox series: 3.5%), synthetic cathinones ("bath salts", 6.9%), other psychedelics (6.6%), tryptamines (5.1%), and dissociatives (4.3%). 2C-I was the most prevalent 2C series drug (5.1%); methylone was the most prevalent synthetic cathinone (3.3%), 2-MeO-ketamine was the most prevalent dissociative (3.7%), and 1P-lysergic acid diethylamide (LSD) (2.9%) was the most prevalent non-phenethylamine psychedelic. Risk factors for NPS use included Ecstasy/MDMA/Molly, LSD, and ketamine use; identifying as bisexual (compared to heterosexual), reporting higher frequency of nightclub/festival attendance, and being surveyed outside of a festival (compared to those surveyed outside of nightclubs). DISCUSSION: NPS use is prevalent in the nightclub and festival scenes in NYC. Since individuals in these scenes-especially frequent attendees-are at high risk for use, prevention and harm reduction services need to be geared toward this population.

OBJECTIVE: The purpose of this article is to examine sociodemographic and health behavior factors associated with dietary intake as measured by the healthy eating index (HEI-2010) for persons with and without diabetes (T2D). DESIGN: A secondary data analysis of three NHANES data cycles spanning 2007-2012. Multiple linear regression assessed racial/ethnic differences in HEI-2010 scores in those without T2D, with T2D, and with undiagnosed T2D. PARTICIPANTS: The sample included non-pregnant adults aged >/=20 years who had two days of reliable dietary recall data. OUTCOME MEASURES: Total scores for the HEI-2010. RESULTS: For those without T2D, there was a significant association between race/ethnicity and HEI score, with non-Hispanic Blacks achieving significantly lower scores than their non-Hispanic White counterparts. Differences in HEI-2010 score were also associated with age, sex, smoking status and time spent in the United States. Racial/ethnic differences in dietary patterns were present, but not significant in those with undiagnosed or diagnosed T2D. CONCLUSIONS: Racial/ethnic disparities in dietary patterns are present in individuals without T2D, but differences are not statistically significant in those with undiagnosed or diagnosed T2D. Non-Hispanic Blacks without T2D received significantly lower HEI-2010 scores than non-Hispanic Whites. Further research is necessary to determine whether or not similarities in dietary intake across racial/ethnic groups with T2D will be reflected in diabetes-related health outcomes in this population.

BACKGROUND: Nonmedical opioid use has become a major public health concern due to increases in treatment admissions, overdoses, and deaths. Use has also been linked to heroin initiation. Reliable data on nonmedical opioid use are needed to continue to inform prevention. OBJECTIVE: To determine the prevalence and correlates of discordant self-report of nonmedical use of opioids in a national sample. METHODS: Utilizing a nationally representative sample of 31,149 American high school seniors in the Monitoring the Future study (2009-2013), discordant responses between self-reported 12-month nonmedical opioid use and self-reported 12-month nonmedical Vicodin and OxyContin use (reporting Vicodin/OxyContin use, but not reporting "opioid" use) were assessed. We also used multivariable logistic regression to determine the characteristics of students who were most likely to provide a discordant response. RESULTS: 37.1% of those reporting nonmedical Vicodin use and 28.2% of those reporting nonmedical OxyContin use did not report overall nonmedical opioid use. Prevalence of nonmedical opioid use (8.3%) would increase when factoring in Vicodin, OxyContin, or both, by 2.8%, 1.3%, and 3.3%, respectively. Females were more likely to provide a discordant response to Vicodin and highly religious students were more likely to provide a discordant response regarding OxyContin use. Those who reported cocaine or nonmedical tranquilizer use were at consistently low odds for discordant responses. Nonmedical amphetamine users were at low odds for providing a discordant Vicodin response. CONCLUSION: Prevalence of nonmedical opioid use may be underreported on some surveys, particularly among specific subpopulations. Further research on the effect of question order and skip-patterns (e.g., "gate" questions) is needed. Reliable data on nonmedical opioid use are needed to continue to accurately inform prevention.