Faculty Bibliography

In New York City, over 90% of women newly diagnosed with human immunodeficiency virus (HIV) are Black and Latina; a quarter of these infections occur among 30-39 year-olds. A survey was administered to 343 Black and Puerto Rican women (2014-2016) to examine two HIV infection risk factors: relationship exclusivity and having experienced childhood sexual abuse (CSA). A majority of male partners (69.7%) had at least one risk for HIV transmission. Women in non-exclusive sexual relationships (nESRs) had higher-risk partners, but engaged in safer sex practices than those in ESRs. Two-thirds of women in ESRs (64.8%) reported unprotected vaginal intercourse, although 33.5% had partners with a history of concurrent relationships. Among women in nESRs, having experienced CSA was a strong risk factor for HIV infection. Black and Latina women's vulnerability to HIV infection is significant, even when in exclusive relationships. Safer sex counseling should be integrated in primary care.

BACKGROUND:Epidemiologic reports available on synthetic cannabinoids (SCs) have focused on sociodemographics, indicating high prevalence of SC use predominantly among white, relatively affluent, males. However, there is emerging evidence suggesting high SC prevalence among socioeconomically disadvantaged, racial/ethnic minority males. OBJECTIVES/OBJECTIVE:The purpose of this study is to investigate the risk correlates of SC use among psychosocial vulnerable communities. METHOD/METHODS:The sample of 100 participants was recruited from two harm reduction-focused, community-based organizations in the South Bronx and East Harlem neighborhoods in New York City. Consented individuals 18 years and older underwent a 30- minute survey ascertaining sociodemographics, psychosocial characteristics, SC and polydrug use characteristics, and mental health history. RESULTS:The study population was majority male (61%), Latino (56%), commonly diagnosed with psychiatric illness (67%), and with a mean age of 45.4. Those reporting SC use (74%) were more likely to be male, homeless, and report polydrug use. After adjustment, being male (AOR = 5.64), homelessness (AOR = 4.88) along with cocaine (AOR = 5.63) and opiate use (AOR = 31.1) were independently associated with SC use. The most common reasons for using SC were affordability, inability to detect SC in drug tests, and perceived physical and emotional benefits. Conclusion/importance: This work is significant in expanding the populations thought to be impacted by and understanding social disparities related to SC use. Further investigation is needed to assess the relationship between concomitant use of SC and other drug, particularly opiates. This may suggest that the sequelae of one drug may enhance or alleviate the effects of the other.

Despite treatment advances that have improved the health and life expectancy of HIV-positive people and contribute to the prevention of HIV transmission, HIV stigma is still frequently experienced by HIV-infected individuals and those close to them. This study investigated the types of HIV-related stigma experienced by HIV-negative adults in serodiscordant heterosexual relationships when their partner's HIV-positive status was revealed to family and friends and their strategies to manage such stigma. In-depth interviews were conducted in New York City with 56 men and 44 women who were HIV negative and had been in a relationship for at least six months with an HIV-positive partner of the opposite sex. Those who had disclosed the HIV status of their partner to family or friends experienced four main types of stigmatizing behaviours: distancing (avoidance of the participant or his/her partner for fear of infection), depreciation of the partner (being told their partner is not worthy of them), violation of privacy (people spreading the information that the partner is HIV positive), or accusations (being told that it was wrong to be in a relationship with HIV-positive people or to try to conceive with them). Participants described four main ways of managing actual or anticipated stigma: secrecy (not disclosing the HIV status of their partner to anyone), avoidance (breaking ties with people who held stigmatizing views), seeking support from their partner or the HIV-positive community (e.g., HIV-related organizations or their partner's family or friends), or education (informing family or friends about HIV treatment and prevention). Findings show that HIV-related "courtesy" stigma is frequently experienced by HIV-negative people in serodiscordant relationships but often can be managed. Offering support to individuals in serodiscordant relationships can improve the quality of life of HIV-positive people and their HIV-negative partners and potentially reduce HIV stigma.

HIV-related 'conspiracy beliefs' include ideas about the genocidal origin of HIV and the nature and purpose of HIV-related medications. These ideas have been widely documented as affecting myriad health behaviours and outcomes, including birth control use and HIV testing. Most HIV-related research has quantitatively explored this phenomenon, and further qualitative research is necessary to better understand the complexity of these beliefs as articulated by those who endorse them. Moreover, public health in general has over-emphasised the role of the Tuskegee Syphilis Study in explaining mistrust, rather than focus on ongoing social inequalities. Twenty-seven semi-structured interviews were conducted with low-income Black and Latinx people living with HIV who were currently, or had been recently, disengaged from HIV medical care. Beliefs about the role and intentions of the government and pharmaceutical industry in the epidemic highlighted the racism and classism experienced by participants. Notably, however, HIV care providers were not perceived as part of the government-pharmaceutical collusion. Interventions should focus on fostering positive beliefs about HIV medication and building trust between HIV care providers and populations that have experienced ongoing social and economic exclusion. Replacing the phrase 'conspiracy beliefs' with more descriptive terms, such as HIV-related beliefs, could avoid discrediting people's lived experiences.

The reproductive desires of HIV-positive men have been investigated far less than those of HIV-positive women, especially in the US. This qualitative study of a sample of 94 HIV-positive men in New York City who were in a relationship with a woman of reproductive age examined their reasons for wanting a child as well as the conditions under which they would feel ready to attempt conception. Participants felt a child would make them feel normal, give meaning to their lives, or make others in their life happy. Although they reported HIV-related concerns (i.e., horizontal or vertical transmission, reinfection, or shortened life expectancy), participants mostly discussed factors unrelated to HIV (e.g., finances, housing, incarceration, substance abuse, or relationships) as deterrents to acting on their desire to having a child. When providing information on safer conception, healthcare providers should be aware of the broad desires and factors informing HIV-positive men's reproductive goals.

Many low-income people of color living with HIV are not virally suppressed. More research is needed to understand how socially marginalized, disengaged, or inconsistently engaged people living with HIV (PLWH) contend with antiretroviral therapy (ART)-related challenges, particularly in the context of interactions with HIV care providers. Twenty-seven semi-structured interviews were conducted with low-income Black and Hispanic PLWH in the New York City area who were currently, or recently, disengaged from outpatient HIV health care at the time of the interview. Participants valued patient-centered health care in which they felt genuinely heard and cared for by their HIV clinicians. This desire was particularly pronounced in the context of wanting to change one's ART regimen. Participant emphasis on wanting to manage ART-related challenges with their providers suggests that HIV providers have an instrumental role in helping their patients feel able to manage their HIV.

For about 30 years, soon after the onset of the AIDS epidemic, sexual-health messaging has emphasized personal responsibility for using condoms to protect from acquiring or transmitting HIV or other sexually transmitted infections. Those who did not use condoms during casual sexual encounters may therefore feel compelled to offer to others aware of their behavior what sociologists have called "accounts," an impression-management strategy to avoid unfavorable judgment. We analyzed accounts-excuses and justifications-from qualitative interviews with 150 adults who had unprotected sex in the past 3 months with at least two different partners met online (ages 18-50, mean: 33.7, equally divided among black, Hispanic, and white men and women, over half were college educated and the median yearly household income range was $50-$75,000). Many participants made excuses that aimed to defer responsibility for unprotected sex: they claimed that consistently practicing safer sex was impossible, that they got carried away by sexual passion, that they were inebriated, that they were influenced by emotional or psychological problems, or they put fault on their partners. Participants also provided justifications, claiming that unsafe sex had been acceptable because the risks taken were likely minimal or negotiated with their partner. Understanding the accounts heterosexual adults offer to excuse and justify condomless sex with partners met online can be helpful in developing prevention messages that debunk these explanations for their behavior.

Heterosexuals' use of the Internet for meeting romantic or sexual partners is rapidly increasing, raising concerns about the Internet's potential to facilitate encounters that place individuals at risk for acquiring HIV or other sexually transmitted infections (STIs). For example, online sharing of personal information and self-revelations can foster virtual intimacy, promoting a false sense of familiarity that might accelerate progression to unprotected sex. Therefore, it is critical to understand how those who meet sexual partners online attempt to assess the possible risk of acquiring HIV or STIs posed by having unprotected sex with a new partner and decide whether to use a condom. To investigate this issue, in-depth interviews were conducted with a diverse sample of heterosexual male and female participants from large metropolitan cities who had had unprotected vaginal or anal sex with at least two partners met online in the past 3 months. With few exceptions, participants relied on faulty strategies and heuristics to estimate these risks; yet, most engaged in unprotected sex at their first meeting or very soon afterward. While some seemed to try to make a genuine effort to arrive at a reliable assessment of the HIV risk posed, most appeared to be looking for a way to justify their desire and intention to have unprotected sex. The findings suggest the need for more HIV and sexual health education targeted at heterosexuals, especially for those who go online to meet partners.

Nurses are often first to identify and manage a patient leaving against medical advice (AMA), and so they are critical contributors to the development of strategies to address this problem. We studied AMA discharge in order to help develop useful interventions. We performed a cross-sectional analysis of 55,938 discharges from a single urban hospital for the years 2002-2003 and 2012-2013. AMA discharge rates were higher for HIV-infected patients than for patients with alcohol-related disorders or sickle cell anemia in both time periods, even after adjustment for age, race, sex, insurance status, and household income. For HIV infection, 25% of AMA discharges occurred in patients with multiple AMA discharges and 30-day readmission rates were higher after an AMA discharge: odds ratio 1.57 (95% confidence interval 1.01 to 2.43, p = .046). Team-based and nursing interventions that incorporate the treatment-based values and preferences of HIV-infected patients with prior AMA discharges may improve linkage to care and reduce readmissions.

The phenomenon of leaving the hospital against medical advice (AMA) despite being quite common and associated with significant deleterious health outcomes remains inadequately understood and addressed. Researchers have identified certain patient characteristics as predictors of AMA discharges, but the patients' reasons for these events have not been comprehensively explored. Moreover, because the medical authority model dominates this research area, providers' experiences of AMA discharges remain unstudied. We examined the AMA discharge from a patient-centered perspective by analyzing the content of notes providers generate to record such events. We analyzed providers' notes for all inpatients with a primary HIV diagnosis (N = 33) that, in 2012, left an urban hospital AMA. Applying the Scott and Lyman accounts framework, we identified that the notes constituted records of providers' and patients' excuses and justifications for failing to meet the expectations of a provider offering patient-centered care and a compliant patient receiving care. Alongside the patients' reasons for leaving AMA, the notes also revealed the providers' reasons for honoring or discrediting the patients' accounts. The style of the accounts and the professional status of the notes' authors enabled us to contextualize the production and sharing of AMA notes in the hospital hierarchy. Conceptualizing AMA notes as dyadic accounts elicited specific factors that challenge the patient-provider relationship, and generated insights on how to strengthen it, and thus decrease the rates of AMA discharges and their associated health effects.