Faculty Bibliography

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.

BACKGROUND: HIV prevalence remains disproportionately high among youth, especially among young men who have sex with men, young people with substance use disorders, and recently incarcerated youth. However, youth may not report behavioral risks because they fear stigma or legal consequences. While routine HIV screening programs have increased testing, current programs are not designed to identify, or provide prevention services to, high-risk patients who test HIV negative. AIMS: To examine the feasibility and preliminary efficacy of: a tablet-based screening designed to facilitate HIV risk reporting and testing among a sample of young urban emergency department (ED) patients; and a text message-based follow up protocol for patients who test HIV-negative and report increased behavioral risk. METHODS: 100 ED patients aged 18 - 24, who declined HIV tests offered at triage, completed a tablet-based intervention that included a risk screening, an educational video, and offered participants HIV tests. If patients accepted testing and reported increased risk, the tablets offered follow-up text messages. RESULTS: 30 participants accepted HIV tests following the intervention and 21 participants, identified by custom software as high-risk, agreed to receive text messages. Two thirds (66.7%) of text recipients responded to questions at week 6, more than half (57.1%) responded at week 8, one (4.76%) re-tested after week 12. CONCLUSION: Results indicate our intervention provides a feasible way to facilitate risk reporting, increase HIV testing, and maintain ongoing contact with hard-to-reach youth via tablet computers and text messages.

Annual HIV testing is recommended for high-risk populations in the United States, to identify HIV infections early and provide timely linkage to treatment. However, heterosexuals at high risk for HIV, due to their residence in urban areas of high poverty and elevated HIV prevalence, test for HIV less frequently than other risk groups, and late diagnosis of HIV is common. Yet the factors impeding HIV testing in this group, which is predominantly African American/Black and Latino/Hispanic, are poorly understood. The present study addresses this gap. Using a systematic community-based sampling method, venue-based sampling (VBS), we estimate rates of lifetime and recent (past year) HIV testing among high-risk heterosexuals (HRH), and explore a set of putative multi-level barriers to and facilitators of recent testing, by gender. Participants were 338 HRH African American/Black and Latino/Hispanic adults recruited using VBS, who completed a computerized structured assessment battery guided by the Theory of Triadic Influence, comprised of reliable/valid measures on socio-demographic characteristics, HIV testing history, and multi-level barriers to HIV testing. Logistic regression analysis was used to identify factors associated with HIV testing within the past year. Most HRH had tested at least once (94%), and more than half had tested within the past year (58%), but only 37% tested annually. In both men and women, the odds of recent testing were similar and associated with structural factors (better access to testing) and sexually transmitted infection (STI) testing and diagnosis. Thus VBS identified serious gaps in rates of annual HIV testing among HRH. Improvements in access to high-quality HIV testing and leveraging of STI testing are needed to increase the proportion of HRH testing annually for HIV. Such improvements could increase early detection of HIV, improve the long-term health of individuals, and reduce HIV transmission by increasing rates of viral suppression.

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: 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.

OBJECTIVE: We investigated the relationships between self-reported discrimination (SRD) and mental and physical health (self-reported physical health conditions and direct, physiologic measures [BMI, waist-to-hip ratio, and blood pressure]) among Sikh Asian Indians (AI), a group that may be particularly discriminated against because of physical manifestations of their faith, including a tendency to wear turbans or ethnic clothing. METHODS: Sikh AIs (N = 196) were recruited from Sikh gurdwaras in Queens, New York. Data were collected on SRD, social support, and self-reported health, along with multiple direct physiological measures for cardiovascular health. RESULTS: Participants who wore turbans/scarves reported higher levels of discrimination than those who did not wear turbans/scarves. As hypothesized, multiple regression analysis supported that discrimination is significantly associated with poorer self-reported mental (B = -.53, p < .001) and physical health (B = -.16, p = .04) while controlling for socioeconomic, acculturation, and social support factors. The study did not support an association between SRD and physiologic measures (elevated BMI, waist-to-hip ratio, and blood pressure). CONCLUSION: Consistent with previous discrimination and health reports, this study demonstrated an inverse relationship between discrimination and health among Sikh AIs, an understudied yet high-risk minority population. Community-based efforts are also needed to reduce the occurrence or buffer the effects of discrimination experienced by Sikh AIs. (PsycINFO Database Record

OBJECTIVES: We sought to determine whether contextual factors shape injection drug use among Black adolescents and adults. METHODS: For this longitudinal study of 95 US metropolitan statistical areas (MSAs), we drew annual MSA-specific estimates of the prevalence of injection drug use (IDU) among Black adolescents and adults in 1993 through 2007 from 3 surveillance databases. We used existing administrative data to measure MSA-level socioeconomic status; criminal justice activities; expenditures on social welfare, health, and policing; and histories of Black uprisings (1960-1969) and urban renewal funding (1949-1974). We regressed Black IDU prevalence on these predictors by using hierarchical linear models. RESULTS: Black IDU prevalence was lower in MSAs with declining Black high-school dropout rates, a history of Black uprisings, higher percentages of Black residents, and, in MSAs where 1992 White income was high, higher 1992 Black income. Incarceration rates were unrelated. CONCLUSIONS: Contextual factors shape patterns of drug use among Black individuals. Structural interventions, especially those that improve Black socioeconomic security and political strength, may help reduce IDU among Black adolescents and adults.

BACKGROUND: Ecstasy (MDMA) in the US is commonly adulterated with other drugs, but research has not focused on purity of ecstasy since the phenomenon of "Molly" (ecstasy marketed as pure MDMA) arose in the US. METHODS: We piloted a rapid electronic survey in 2015 to assess use of novel psychoactive substances (NPS) and other drugs among 679 nightclub/festival-attending young adults (age 18-25) in New York City. A quarter (26.1%) of the sample provided a hair sample to be analyzed for the presence of select synthetic cathinones ("bath salts") and some other NPS. Samples were analyzed using fully validated UHPLC-MS/MS methods. To examine consistency of self-report, analyses focused on the 48 participants with an analyzable hair sample who reported lifetime ecstasy/MDMA/Molly use. RESULTS: Half (50.0%) of the hair samples contained MDMA, 47.9% contained butylone, and 10.4% contained methylone. Of those who reported no lifetime use of "bath salts", stimulant NPS, or unknown pills or powders, about four out of ten (41.2%) tested positive for butylone, methylone, alpha-PVP, 5/6-APB, or 4-FA. Racial minorities were more likely to test positive for butylone or test positive for NPS after reporting no lifetime use. Frequent nightclub/festival attendance was the strongest predictor of testing positive for MDMA, butylone, or methylone. DISCUSSION: Results suggest that many ecstasy-using nightclub/festival attendees may be unintentionally using "bath salts" or other NPS. Prevention and harm reduction education is needed for this population and "drug checking" (e.g., pill testing) may be beneficial for those rejecting abstinence.

BACKGROUND: Patients undergoing hematopoietic cell transplantation (HCT) for hematological malignancies experience a number of challenges during treatment. There is growing evidence that malglycemia (hyperglycemia, hypoglycemia, and/or increased glycemic variability) contributes to HCT-related complications, even in patients without preexisting diabetes. The purpose of this pilot study was to investigate factors influencing glycemic status and associated infection occurrences in nondiabetic autologous HCT recipients. METHODS: Oncology patients without preexisting diabetes treated with autologous HCT at a National Cancer Institute-designated cancer center were followed from admission through discharge or 28 days post-HCT. Patients had morning fasting laboratory tests. Descriptive statistics and Cox proportional hazards models were used to examine associations between BG levels and risk for infection while adjusting for baseline covariates including age, body mass index (BMI), cumulative glucocorticoid dose, and diagnosis. RESULTS: The sample included 28 female and 25 male predominately non-Hispanic White patients (mean age 55.7 years, SD = 11.32). Blood glucose (BG) range was 35-325 mg/dl. Twenty-three patients incurred at least one infection. BMI >/= 25 kg/m2 was associated with high BG and infections. In the multivariate Cox model, an increase of 1 interquartile range in BG 2 days before infection was associated with a moderately increased risk of infection (hazard ratio = 1.44, p = .008). CONCLUSIONS: Understanding the contributors to and consequences of malglycemic events can lead to better protocols for identifying patients at greater risk for infection. Further investigation is warranted for interventions to mitigate BG events for improved outcomes.