Faculty Bibliography

Background: In the US, nearly half of sexually transmitted infections (STIs) occur among 15-24-year-olds, and disproportionate rates of infections exist among blacks. Modifiable factors that drive STI transmission from adolescence into young adulthood should be identified, especially among this vulnerable population.Methods: The National Longitudinal Study of Adolescent Health (n=13123) was used to examine racial differences in the prevalence of adolescent inhalant use and unadjusted and adjusted longitudinal associations between inhalant use and adulthood STI risk.Results: Adolescent inhalant use was more commonly reported by whites than blacks. Inhalant use was an indicator of adulthood multiple partnerships among all groups except black females and was an especially strong indicator of 10 or more past year partnerships among men (white risk ratio (RR): 3.48, 95% confidence interval (CI): 1.46-8.32; black RR: 4.47, 95% CI: 1.34-14.90). Adolescent inhalant use was also predictive of adulthood STI among white women and black men, with black male inhalant users having more than twice the risk of a biologically-confirmed or self-reported STI in adulthood than non-users (RR: 2.35, 95% CI: 1.29-4.25).Conclusions: White adolescents and, more so, black male adolescents inhalant users experience disproportionate adulthood STI risk and, thus, constitute a priority population for STI prevention.

OBJECTIVE: Trauma processing is central to healthy recovery, but few studies examine how youth process experiences of child sexual abuse (CSA). The current study builds on our prior work identifying individual differences in CSA processing strategies (i.e., Constructive, Absorbed, Avoidant) to examine whether abuse stigmatization, PTSD symptoms, and negative reactions from others experienced during the year after abuse discovery were associated with subsequent CSA processing strategies. METHOD: Participants included 160 ethnically diverse youth (8-15 years, 73% female) with confirmed cases of CSA. Predictors were measured at abuse discovery (T1) and 1 year later (T2). Individual differences in CSA processing strategies were assessed 6 years after discovery (T3) from participants' abuse narratives. RESULTS: The persistence of abuse stigmatization from T1 to T2 significantly increased the odds of using either an Avoidant or Absorbed (vs. Constructive) strategy at T3. Higher levels of PTSD symptoms at T1 as well as their persistence from T1 to T2 each significantly increased the odds of having an Absorbed versus Constructive strategy. The persistence of perceived negative reactions from others from T1 to T2 increased the odds of an Absorbed versus Avoidant strategy. Effect sizes ranged from medium to large (M d = 0.636). CONCLUSIONS: Results further validate prior work identifying distinct CSA processing strategies and suggest the persistence of abuse-specific disruptions over the year after abuse discovery may be associated with subsequent problems processing CSA experiences.

BACKGROUND: Using Donabedian's structure-process-outcomes (SPO) framework, this descriptive, exploratory study examined the structure of a telemonitoring program in a population of patients with type 2 diabetes (T2D), the process of nurse-patient telephonic interactions, and patients' clinical outcomes. METHODS: Secondary data analysis was conducted using data from 581 patients who participated in a home telemonitoring program for 12 months. Three point-biserial and six Pearson correlations were estimated to determine how patient demographics related to clinical characteristics. Mixed model regressions were conducted predicting hemoglobin A1c (HbA1c), systolic blood pressure (SBP), and diastolic blood pressure (DBP) levels at 6, 9, and 12 months based on the frequency of contact in the earlier 3 months. Analysis of variances were conducted to assess if the frequency of contact was significantly different by change in HbA1c levels from 3 to 6, 6 to 9, and 9 to 12 months. RESULTS: Significant negative correlations were found between age and HbA1c (r=-0.10, P=0.015) and DBP (r=-0.16, P<0.001), a significant positive correlation was found between age and SBP (r=0.15, P=0.001). A significant correlation was found between sex and DBP (r pb=-0.11, P=0.015); female participants had lower DBP levels than males. Frequency of contact was not related to the change in clinical outcomes. However, the frequency of contact for the time period 3 to 6 months was associated with change in HbA1c for the 6- to 9- month period and frequency of contact during the 6- to 9- month period was associated with change in HbA1c from 9 to 12 months. CONCLUSION: Examination of the SPO measures in the telemonitoring environment assisted in understanding the effectiveness of this type of unique intervention and the need for further in-depth exploration of self-management techniques among individuals with T2D.

Drug use is associated with low uptake of HIV antiretroviral therapy (ART), an under-studied step in the HIV care continuum, and insufficient engagement in HIV primary care. However, the specific underlying mechanisms by which drug use impedes these HIV health outcomes are poorly understood. The present qualitative study addresses this gap in the literature, focusing on African-American/Black and Hispanic persons living with HIV (PLWH) who had delayed, declined, or discontinued ART and who also were generally poorly engaged in health care. Participants (N = 37) were purposively sampled from a larger study for maximum variation on HIV indices. They engaged in 1-2 h audio-recorded in-depth semi-structured interviews on HIV histories guided by a multilevel social-cognitive theory. Transcripts were analyzed using a systematic content analysis approach. Consistent with the existing literature, heavy substance use, but not casual or social use, impeded ART uptake, mainly by undermining confidence in medication management abilities and triggering depression. The confluence of African-American/Black or Hispanic race/ethnicity, poverty, and drug use was associated with high levels of perceived stigma and inferior treatment in health-care settings compared to their peers. Furthermore, providers were described as frequently assuming participants were selling their medications to buy drugs, which strained provider-patient relationships. High levels of medical distrust, common in this population, created fears of ART and of negative interactions between street drugs and ART, but participants could not easily discuss this concern with health-care providers. Barriers to ART initiation and HIV care were embedded in other structural- and social-level challenges, which disproportionately affect low-income African-American/Black and Hispanic PLWH (e.g., homelessness, violence). Yet, HIV management was cyclical. In collaboration with trusted providers and ancillary staff, participants commonly reduced substance use and initiated or reinitiated ART. The present study highlights a number of addressable barriers to ART initiation and engagement in HIV care for this vulnerable population, as well as gaps in current practice and potential junctures for intervention efforts.

BACKGROUND: The Centers for Disease Control and Prevention recommends persons at high risk for HIV infection in the United States receive annual HIV testing to foster early HIV diagnosis and timely linkage to health care. Heterosexuals make up a significant proportion of incident HIV infections (>25%) but test for HIV less frequently than those in other risk categories. Yet factors that promote or impede annual HIV testing among heterosexuals are poorly understood. The present study examines individual/attitudinal-, social-, and structural-level factors associated with past-year HIV testing among heterosexuals at high risk for HIV. METHODS: Participants were African-American/Black and Hispanic heterosexual adults (N = 2307) residing in an urban area with both high poverty and HIV prevalence rates. Participants were recruited by respondent-driven sampling in 2012-2015 and completed a computerized structured assessment battery covering background factors, multi-level putative facilitators of HIV testing, and HIV testing history. Separate logistic regression analysis for males and females identified factors associated with past-year HIV testing. RESULTS: Participants were mostly male (58%), African-American/Black (75%), and 39 years old on average (SD = 12.06 years). Lifetime homelessness (54%) and incarceration (62%) were common. Half reported past-year HIV testing (50%) and 37% engaged in regular, annual HIV testing. Facilitators of HIV testing common to both genders included sexually transmitted infection (STI) testing or STI diagnosis, peer norms supporting HIV testing, and HIV testing access. Among women, access to general medical care and extreme poverty further predicted HIV testing, while recent drug use reduced the odds of past-year HIV testing. Among men, past-year HIV testing was also associated with lifetime incarceration and substance use treatment. CONCLUSION: The present study identified gaps in rates of HIV testing among heterosexuals at high risk for HIV, and both common and gender-specific facilitators of HIV testing. Findings suggest a number of avenues for increasing HIV testing rates, including increasing the number and types of settings offering high-quality HIV testing; promoting STI as well as HIV testing; better integrating STI and HIV testing systems; implementing peer-driven social/behavioral intervention approaches to harness the positive influence of social networks and reduce unfavorable shared peer norms; and specialized approaches for women who use drugs.

OBJECTIVE: HIV infection in sub-Saharan Africa increasingly occurs among people who inject drugs (PWID). Kenya is one of the first to implement a national needle and syringe program (NSP). Our study undertook a baseline assessment as part of evaluating NSP in a seek, test, treat, and retain approach. METHODS: Participants enrolled May-December 2012 from 10 sites. Respondent-driven sampling was used to reach n=1,785 PWID for HIV-1 prevalence and viral load determination and survey data. RESULTS: Estimated HIV prevalence, adjusted for differential network size and recruitment relationships, was 14.5% in Nairobi (95% CI 10.8-18.2) and 20.5% in the Coast region (95% CI 17.3-23.6). Viral load (log10 transformed) in Nairobi ranged from 1.71 to 6.12 (median 4.41; IQR 3.51-4.94) and in the Coast from 1.71 to 5.88 (median 4.01; IQR 3.44-4.72). Using log10 viral load 2.6 as a threshold for HIV viral suppression, the percentage of HIV-infected participants with viral suppression was 4.2% in Nairobi and 4.6% in the Coast. Heroin was the most commonly injected drug in both regions, used by 93% of participants in the past month typically injecting 2-3 times/day. Receptive needle/syringe sharing at last injection was more common in Nairobi (23%) than the Coast (4%). Estimated incidence among new injectors was 2.5/100 person-years in Nairobi and 1.6/100 person-years in the Coast. CONCLUSION: The HIV epidemic is well-established among PWID in both Nairobi and Coast regions. Public health scale implementation of combination HIV prevention has the potential to greatly limit the epidemic in this vulnerable and bridging population.

BACKGROUND: Very brief single-item screening questions (SISQs) for alcohol and other drug use can facilitate screening in health care settings, but are not widely used. Self-administered versions of the SISQs could ease barriers to their implementation. OBJECTIVE: We sought to validate SISQs for self-administration in primary care patients. DESIGN: Participants completed SISQs for alcohol and drugs (illicit and prescription misuse) on touchscreen tablet computers. Self-reported reference standard measures of unhealthy use, and more specifically of risky consumption, problem use, and substance use disorders, were then administered by an interviewer, and saliva drug tests were collected. PARTICIPANTS: Adult patients aged 21-65 years were consecutively enrolled from two urban safety-net primary care clinics. MAIN MEASURES: The SISQs were compared against reference standards to determine sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) for alcohol and drug use. KEY RESULTS: Among the 459 participants, 22 % reported unhealthy alcohol use and 25 % reported drug use in the past year. The SISQ-alcohol had sensitivity of 73.3 % (95 % CI 65.3-80.3) and specificity of 84.7 % (95 % CI 80.2-88.5), AUC = 0.79 (95 % CI 0.75-0.83), for detecting unhealthy alcohol use, and sensitivity of 86.7 % (95 % CI 75.4-94.1) and specificity of 74.2 % (95 % CI 69.6-78.4), AUC = 0.80 (95 % CI 0.76-0.85), for alcohol use disorder. The SISQ-drug had sensitivity of 71.3 % (95 % CI 62.4-79.1) and specificity of 94.3 % (95 % CI 91.3-96.6), AUC = 0.83 (95 % CI 0.79-0.87), for detecting unhealthy drug use, and sensitivity of 85.1 (95 % CI 75.0-92.3) and specificity of 88.6 % (95 % CI 85.0-91.6), AUC = 0.87 (95 % CI 0.83-0.91), for drug use disorder. CONCLUSIONS: The self-administered SISQs are a valid approach to detecting unhealthy alcohol and other drug use in primary care patients. Although self-administered SISQs may be less accurate than the previously validated interviewer-administered versions, they are potentially easier to implement and more likely to retain their fidelity in real-world practice settings.

BACKGROUND: An estimated 14 % of the 1.2 million individuals living with HIV in the U.S. are unaware of their status. Yet this modest proportion of individuals with undiagnosed HIV is linked to 44-66 % of all new infections. Thus innovative intervention approaches are needed to seek out and test those with undiagnosed HIV, and link them to HIV treatment with high retention, an approach referred to as "Seek, Test, Treat, and Retain" (STTR). The present protocol describes a creative "hybrid" STTR approach that uses anonymous HIV testing followed by confidential care linkage, focused on heterosexuals at high risk (HHR) for HIV, who do not test as frequently as, and are diagnosed later, than other risk groups. METHODS/DESIGN: This is a single-arm exploratory intervention efficacy trial. The study has two phases: one to seek out and test HHR, and another to link those found infected to HIV treatment in a timely fashion, with high retention. We will recruit African American/Black and Latino adult HHR who reside in urban locations with high poverty and HIV prevalence. Participants will be recruited with respondent-driven sampling, a peer recruitment method. The "Seek and Test" phase is comprised of a brief, convenient, single-session, anonymous HIV counseling and testing session. The "Treat and Retain" component will engage those newly diagnosed with HIV into a confidential research phase and use a set of procedures called care navigation to link them to HIV primary care. Participants will be followed for 6 months with objective assessment of outcomes (using medical records and biomarkers). DISCUSSION: Undiagnosed HIV infection is a major public health problem. While anonymous HIV testing is an important part of the HIV testing portfolio, it does not typically include linkage to care. The present study has potential to produce an innovative, brief, cost-effective, and replicable STTR intervention, and thereby reduce racial/ethnic disparities in HIV/AIDS. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02421159 , Registered April 15, 2015.

OBJECTIVE: The epidemiology of the incidence of sexually transmitted hepatitis C virus (HCV) infection in HIV-positive MSM is only partially understood. In the presence of HIV, HCV infection is more likely to become chronic and liver fibrosis progression is accelerated. DESIGN: A systematic review and meta-analysis was used to synthesize data characterizing sexually transmitted HCV in HIV-positive MSM. METHODS: Electronic and other searches of medical literature (including unpublished reports) were conducted. Eligible studies reported on HCV seroconversion or on reinfection postsuccessful HCV treatment in HIV-positive MSM who were not injecting drugs. Pooled incidence rates were calculated using random-effects meta-analysis, and meta-regression was used to assess study-level moderators. Attributable risk measures were calculated from statistically significant associations between exposures and HCV seroconversion. RESULTS: More than 13 000 HIV-positive MSM in 17 studies were followed for more than 91 000 person-years between 1984 and 2012; the pooled seroconversion rate was 0.53/100 person-years. Calendar time was a significant moderator of HCV seroconversion, increasing from an estimated rate of 0.42/100 person-years in 1991 to 1.09/100 person-years in 2010, and 1.34/100 person-years in 2012. Reinfection postsuccessful HCV treatment (n = 2 studies) was 20 times higher than initial seroconversion rates. Among the seroconverters, a large proportion of infections were attributable to high-risk behaviours including mucosally traumatic sex and sex while high on methamphetamine. CONCLUSION: The high reinfection rates and the attributable risk analysis suggest the existence of a subset of HIV-positive MSM with recurring sexual exposure to HCV. Approaches to HCV control in this population will need to consider the changing epidemiology of HCV infection in MSM.

Nationally up to 60 % of persons living with HIV are neither taking antiretroviral therapy (ART) nor well engaged in HIV care, mainly racial/ethnic minorities. This study examined a new culturally targeted multi-component intervention to address emotional, attitudinal, and social/structural barriers to ART initiation and HIV care. Participants (N = 95) were African American/Black and Latino adults with CD4 < 500 cells/mm(3) not taking ART, randomized 1:1 to intervention or control arms, the latter receiving treatment as usual. Primary endpoints were adherence, evaluated via ART concentrations in hair samples, and HIV viral load suppression. The intervention was feasible and acceptable. Eight months post-baseline, intervention participants tended to be more likely to evidence "good" (that is, 7 days/week) adherence (60 vs. 26.7 %; p = 0.087; OR = 3.95), and had lower viral load levels than controls (t(22) = 2.29, p = 0.032; OR = 5.20), both large effect sizes. This highly promising intervention merits further study.