Faculty Bibliography

OBJECTIVE: African-American/Black and Latino/Hispanic persons living with HIV/AIDS (i.e., "PLHA of color") are under-represented in HIV/AIDS medical studies (HAMS). A crucial entry point into HAMS is screening, but PLHA of color face serious barriers to screening compared to Whites. Recently we evaluated a social/behavioral intervention that substantially increased rates of HAMS screening among PLHA of color. Yet very little is known about the actual screening experience for these under-represented subgroups. Thus, the objectives of the present study were to explore participants' motivations for and experiences of HAMS screening. METHODS: A total of 186 participants in the larger study's intervention arm were screened for HAMS, 35 of whom also participated in qualitative interviews. Participants engaged in a structured interview about the screening experience at 4- and 12- months post-baseline (14 items, Cronbach's alpha=0.72). Further, from a qualitative data set we purposively selected a set of three case studies to contextualize and enrich quantitative findings on screening experiences. RESULTS: The screening experience was overwhelmingly positive. Almost all participants reported being treated with dignity and respect, did not feel they were being treated like a "guinea pig," and experienced a high level of trust in the setting and the screener, with no gender or racial/ethnic differences, and no differences based on whether participants were found eligible for HAMS during screening. A number of areas where screening could be improved were also identified. CONCLUSIONS: Despite the complex barriers PLHA of color experience to screening for HAMS, the experience of screening was positive. Moreover, HAMS screening experiences were positive regardless of gender, race/ethnicity, or HAMS eligibility. HAMS screening can therefore be a productive learning experience that may reduce patient concerns about participating in HAMS. As such, fostering screening among PLHA of color can be an important component of reducing racial/ethnic disparities in HAMS.

Advances in bioelectrical impedance analysis (BIA) permit the assessment of lymphedema by directly measuring lymph fluid changes. The objective of the study was to examine the reliability, sensitivity, and specificity of cross-sectional assessment of BIA in detecting lymphedema in a large metropolitan clinical setting. BIA was used to measure lymph fluid changes. Limb volume by sequential circumferential tape measurement was used to validate the presence of lymphedema. Data were collected from 250 women, including healthy female adults, breast cancer survivors with lymphedema, and those at risk for lymphedema. Reliability, sensitivity, specificity and area under the ROC curve were estimated. BIA ratio, as indicated by L-Dex ratio, was highly reliable among healthy women (ICC=0.99; 95% CI = 0.99 - 0.99), survivors at-risk for lymphedema (ICC=0.99; 95% CI = 0.99 - 0.99), and all women (ICC=0.85; 95% CI = 0.81 - 0.87); reliability was acceptable for survivors with lymphedema (ICC=0.69; 95% CI = 0.54 to 0.80). The L-Dex ratio with a diagnostic cutoff of >+7.1 discriminated between at-risk breast cancer survivors and those with lymphedema with 80% sensitivity and 90% specificity (AUC=0.86). BIA ratio was significantly correlated with limb volume by sequential circumferential tape measurement. Cross-sectional assessment of BIA may have a role in clinical practice by adding confidence in detecting lymphedema. It is important to note that using a cutoff of L-Dex ratio >+7.1 still misses 20% of true lymphedema cases, it is important for clinicians to integrate other assessment methods (such as self-report, clinical observation, or perometry) to ensure the accurate detection of lymphedema.

OBJECTIVE: The objective of the study is to determine whether Alcoholics Anonymous (AA) participation leads to reduced drinking and problems related to drinking within Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity), an existing national alcoholism treatment data set. METHOD: The method used is structural equation modeling of panel data with cross-lagged partial regression coefficients. The main advantage of this technique for the analysis of AA outcomes is that potential reciprocal causation between AA participation and drinking behavior can be explicitly modeled through the specification of finite causal lags. RESULTS: For the outpatient subsample (n = 952), the results strongly support the hypothesis that AA attendance leads to increases in alcohol abstinence and reduces drinking/ problems, whereas a causal effect in the reverse direction is unsupported. For the aftercare subsample (n = 774), the results are not as clear but also suggest that AA attendance leads to better outcomes. CONCLUSIONS: Although randomized controlled trials are the surest means of establishing causal relations between interventions and outcomes, such trials are rare in AA research for practical reasons. The current study successfully exploited the multiple data waves in Project MATCH to examine evidence of causality between AA participation and drinking outcomes. The study obtained unique statistical results supporting the effectiveness of AA primarily in the context of primary outpatient treatment for alcoholism.

African-American and Latino/Hispanic persons living with HIV/AIDS are underrepresented in AIDS clinical trials (ACTs). The aim of this paper was to uncover factors, either unmodifiable or not directly targeted for change, that predicted screening for ACTs during an efficacious peer-driven intervention (N = 540 total; N = 351 in an intervention arm, N = 189 control). This paper focused on participants assigned to an intervention arm, 56 % of whom were screened for ACTs. We found a decreased odds of screening was associated with closer proximity to the screening site, gay/lesbian orientation, lower mental health symptoms, current injection drug use, more recent HIV diagnosis, lack of prior screening experience, and failure to attend all intervention sessions, but there were no gender or racial/ethnic differences. Efforts to reduce racial/ethnic disparities in ACTs can be enhanced by attending to these specific factors, which may interfere with programmatic efforts to increase African-American and Latino/Hispanic representation in ACTs.

Although experiencing childhood sexual abuse (CSA) puts youth at risk for involvement in relationship violence, research is limited on the potential pathways from CSA to subsequent dating aggression. The current study examined prospective pathways from externalizing behavior problems and stigmatization (abuse-specific shame and self-blame attributions) to anger and dating aggression. One hundred sixty youth (73% female, 69% ethnic/racial minorities) with confirmed CSA histories were interviewed at the time of abuse discovery (T1, when they were 8-15 years of age), and again 1 and 6 years later (T2 and T3). Externalizing behavior and abuse-specific stigmatization were assessed at T1 and T2. Anger and dating aggression were assessed at T3. The structural equation model findings supported the proposed relations from stigmatization following the abuse to subsequent dating aggression through anger. Only externalizing behavior at T1 was related to later dating aggression, and externalizing was not related to subsequent anger. This longitudinal research suggests that clinical interventions for victims of CSA be sensitive to the different pathways by which youth come to experience destructive conflict behavior in their romantic relationships.

BACKGROUND: People who inject drugs (PWID) have increased risk of morbidity and mortality. We update and present estimates and trends of the prevalence of current PWID and PWID subpopulations in 96 US metropolitan statistical areas (MSAs) for 1992-2007. Current estimates of PWID and PWID subpopulations will help target services and help to understand long-term health trends among PWID populations. METHODOLOGY: We calculated the number of PWID in the US annually from 1992-2007 and apportioned estimates to MSAs using multiplier methods. We used four types of data indicating drug injection to allocate national annual totals to MSAs, creating four distinct series of component estimates of PWID in each MSA and year. The four component estimates are averaged to create the best estimate of PWID for each MSA and year. We estimated PWID prevalence rates for three subpopulations defined by gender, age, and race/ethnicity. We evaluated trends using multi-level polynomial models. RESULTS: PWID per 10,000 persons aged 15-64 years varied across MSAs from 31 to 345 in 1992 (median 104.4) to 34 to 324 in 2007 (median 91.5). Trend analysis indicates that this rate declined during the early period and then was relatively stable in 2002-2007. Overall prevalence rates for non-Hispanic black PWID increased in 2005 as compared to other racial/ethnic groups. Hispanic prevalence, in contrast, declined across time. Importantly, results show a worrisome trend in young PWID prevalence since HAART was initiated - the mean prevalence was 90 to 100 per 10,000 youth in 1992-1996, but increased to >120 PWID per 10,000 youth in 2006-2007. CONCLUSIONS: Overall, PWID rates remained constant since 2002, but increased for two subpopulations: non-Hispanic black PWID and young PWID. Estimates of PWID are important for planning and evaluating public health programs to reduce harm among PWID and for understanding related trends in social and health outcomes.

We investigated the impact of cognitive behavioral therapy and mindfulness training (CBT/MT) on attentional task performance in incarcerated adolescents. Attention is a cognitive system necessary for managing cognitive demands and regulating emotions. Yet persistent and intensive demands, such as those experienced during high-stress intervals like incarceration and the events leading to incarceration, may deplete attention resulting in cognitive failures, emotional disturbances, and impulsive behavior. We hypothesized that CBT/MT may mitigate these deleterious effects of high stress and protect against degradation in attention over the high-stress interval of incarceration. Using a quasi-experimental, group randomized controlled trial design, we randomly assigned dormitories of incarcerated youth, ages 16-18, to a CBT/MT intervention (youth n = 147) or an active control intervention (youth n = 117). Both arms received approximately 750 min of intervention in a small-group setting over a 3-5 week period. Youth in the CBT/MT arm also logged the amount of out-of-session time spent practicing MT exercises. The Attention Network Test was used to index attentional task performance at baseline and 4 months post-baseline. Overall, task performance degraded over time in all participants. The magnitude of performance degradation was significantly less in the CBT/MT vs. control arm. Further, within the CBT/MT arm, performance degraded over time in those with no outside-of-class practice time, but remained stable over time in those who practiced mindfulness exercises outside of the session meetings. Thus, these findings suggest that sufficient CBT/MT practice may protect against functional attentional impairments associated with high-stress intervals.

OBJECTIVE: Sublingual buprenorphine/naloxone (Bup/Nx) is approved for addiction treatment and may be useful for pain management, particularly in opioid-treated patients with pain with nonadherence behaviors. The transition of opioid-treated patients with pain to buprenorphine carries the risk of precipitated withdrawal and increased pain. This study convened pain and addiction specialists to develop and pilot a clinical protocol for safe transitioning to Bup/Nx. DESIGN: The protocol was revised three times based on outside expert review and pilot study observations. The pilot was conducted with a prospective cohort of 12 patients with moderate to severe chronic pain, who were receiving long-term opioid therapy with any full m-agonist drug, and had exhibited one or more aberrant drug-related behaviors. Patients were followed up for 3-6 months with the expectation that they would experience few adverse events (AEs) and report lower pain severity. RESULTS: The three patients on the highest baseline opioid dose (equivalent to 303-450 mg of oral morphine) and the three on the lowest doses (