Faculty Bibliography

OBJECTIVE:People who use drugs (PWUD) face increased risk of exposure to COVID-19, but also elevated risk associated from injection drug use. We describe factors underlying their increased risk and identify mechanisms for reducing or minimizing rates of COVID-19 transmission and other health outcomes. METHODS:Our commentary draws upon empirical data, governmental and other reports, and field-based unpublished data from our own studies to inform our conclusion and recommendations. RESULTS:Co-morbid health conditions (eg, diabetes), structural challenges (eg, homelessness, criminal justice involvement), stigma (eg, social devaluation, discrediting), and syndemic clustering of of overdose, HCV, and HIV among PWUD are exacerbated by COVID-19. CONCLUSIONS:Beyond the many challenges all people face to remain safe and healthy during the COVID-19 pandemic, PWUD face additional barriers to remaining safe not only from COVID-19 but from negative health outcomes associated with their living environments, socioeconomic positions, and injection drug use. Collaborative efforts among governmental agencies, health providers, SSPs, CBOs, and other agencies providing services to PWUD is essential to the development of programs and services to meet the many needs of PWUD, which have been particularly accentuated during the COVID-19 pandemic.

Intimate partner violence (IPV) significantly increases HIV risk among MSM. Pre-exposure prophylaxis (PrEP) may provide MSM experiencing IPV an option for self-protection from HIV without requiring condom negotiation or compromising safety. This study examined relationships among various forms of IPV (physical, emotional, monitoring, controlling, and forced sex) and PrEP use among 863 MSM participating in a cross-sectional, internet-based survey. Participants reported IPV rates during the prior 6 months that were consistent with prior research (physical violence, 23.3%; emotional violence, 36.3%; monitoring, 45.1%; controlling, 25.3%; forced sex, 20.0%). Forced sex and emotional IPV were negatively associated with PrEP use in our sample; in contrast, controlling was positively associated with PrEP use. We suggest clinical IPV screenings among MSM seeking PrEP, as well as PrEP-focused interventions that explicitly address IPV.

Exchange sex is a behavior associated with HIV transmission risk among men who have sex with men (MSM). Few studies have examined exchange sex among HIV-positive MSM. We utilize a syndemic framework to account for co-occurring psychosocial problems that suggest the presence of intertwining epidemics (i.e., syndemics), which have not been examined within the context of exchange sex among HIV-positive MSM. In 2015, MSM were recruited via online sexual networking Web site and app advertisements for Sex Positive!^[+], a video-based online intervention that aimed to improve health outcomes for men living with HIV. Participants completed surveys every three months for a year. Surveys covered demographics, drug use, exchange sex, intimate partner violence (IPV), and past 2-week depressive symptoms. We conducted three logistic regression models to assess syndemic factors associated with exchange sex in the past 3 months. Of the 722 HIV-positive MSM included in the sample, 59 (8%) reported exchange sex in the past 3 months at 12-month follow-up. HIV-positive MSM who had more syndemic factors had greater odds of exchange sex. Exchange sex was associated with being African-American/Black, age 18-29 years, past and present experiences with IPV, stimulant use, polysubstance use, and depressive symptoms. Exchange sex was associated with multiple psychosocial factors, indicating exchange sex may be part of a syndemic involving substance use, depression, HIV, and IPV. Interventions should address the social and behavioral circumstances that perpetuate environments that can foster multiple negative health outcomes.

BACKGROUND:People who inject drugs (PWID) are a medically and socially vulnerable population with a high incidence of overdose, mental illness, and infections like HIV and hepatitis C. Existing literature describes social and economic correlations to increased health risk, including stigma. Injection drug use stigma has been identified as a major contributor to healthcare disparities for PWID. However, data on this topic, particularly in terms of the interface between enacted, anticipated, and internalized stigma, is still limited. To fill this gap, we examined perspectives from PWID whose stigmatizing experiences impacted their views of the healthcare system and syringe service programs (SSPs) and influenced their decisions regarding future medical care. METHODS:Semi-structured interviews conducted with 32 self-identified PWID in New York City. Interviews were audio recorded and transcribed. Interview transcripts were coded using a grounded theory approach by three trained coders and key themes were identified as they emerged. RESULTS:A total of 25 participants (78.1%) reported at least one instance of stigma related to healthcare system engagement. Twenty-three participants (71.9%) reported some form of enacted stigma with healthcare, 19 participants (59.4%) described anticipated stigma with healthcare, and 20 participants (62.5%) reported positive experiences at SSPs. Participants attributed healthcare stigma to their drug injection use status and overwhelmingly felt distrustful of, and frustrated with, medical providers and other healthcare staff at hospitals and local clinics. PWID did not report internalized stigma, in part due to the availability of non-stigmatizing medical care at SSPs. CONCLUSIONS:Stigmatizing experiences of PWID in formal healthcare settings contributed to negative attitudes toward seeking healthcare in the future. Many participants describe SSPs as accessible sites to receive high-quality medical care, which may curb the manifestation of internalized stigma derived from negative experiences in the broader healthcare system. Our findings align with those reported in the literature and reveal the potentially important role of SSPs. With the goal of limiting stigmatizing interactions and their consequences on PWID health, we recommend that future research include explorations of mechanisms by which PWID make decisions in stigmatizing healthcare settings, as well as improving medical care availability at SSPs.

BACKGROUND:Male persons who inject drugs (male PWID) are at heightened risk for HIV, particularly if they also have sex with men. Pre-exposure prophylaxis (PrEP) could aid in HIV prevention for this population, but PrEP awareness within different sexual identities among male PWID is not well-understood. We report factors associated with greater awareness among male PWID to identify efficient means of awareness dissemination. METHODS:Data from the 2015 National HIV Behavioral Surveillance (NHBS) system cycle on injection drug use collected in New York City (NYC) were used. Bivariable analyses, using chi-squared statistics, were conducted to examine correlates of awareness of PrEP with socio-demographic, behavioral, and health care variables. Log-linked Poisson regression with robust standard errors was used to estimate adjusted prevalence ratios and determine differences in awareness of PrEP. RESULTS:Among a sample of 332 male PWID (i.e., PWID who identified as male, not transgender) we find awareness of PrEP to be low (23%) among male PWID despite 68% reporting condomless vaginal/anal sex and 32% reporting injection equipment sharing in the last twelve months. Multivariable analysis found greater PrEP awareness associated with gay or bisexual identity (aPR: 2.77, 95% CI: 1.81-4.24) and having a conversation about HIV prevention at a syringe exchange program (SEP) (aPR: 2.71, 95% CI: 1.87-3.94) to be associated with increased PrEP awareness. CONCLUSION:We found low rates of PrEP awareness among male PWID. However, our findings provide insight into information diffusion that can be utilized to increase PrEP awareness among male PWID and among all PWID. We suggest that gay and bisexual social networks and syringe exchange programs are diffusing PrEP awareness among male PWID and can be harnessed to increase PrEP awareness among male PWID.

Stimulant use is associated with higher HIV viral load (VL) and sexual HIV transmission risk among men who have sex with men (MSM) living with HIV. There is little research on willingness of drug users living with HIV to fully participate in studies, especially those involving self-collection of biomarker data. This study presents findings from an at-home dried blood spot collection study measuring laboratory-quantified VL among U.S. HIV-positive MSM who reported high-risk sexual behavior and/or suboptimal antiretroviral therapy (ART) adherence to assess the association between drug-use behavior and (1) ability to complete a study protocol and (2) VL outcomes. Among recruited participants (n = 766), 35% reported stimulant drug use (amphetamines, cocaine, crack, crystal meth, ecstasy, or a combination of stimulant drugs), 39% reported using other drugs (heroin, marijuana, prescription opioids, and others), and 27% reported no drug use in the past 3 months. In all, 61% of enrolled participants completed the study protocol. Stimulant drug users were less likely (ARR 0.84; 95% CI 0.72-0.98) to complete the protocol than other drug users. Furthermore, other drug users were significantly less likely than non-drug users (ARR 0.52; 95% CI 0.28-0.97) to have an HIV VL result ≥ 1500 copies/mL. This study provides important estimates regarding the likelihood of participation in biomedical research activities among HIV-positive MSM with varying drug-use behaviors, showing that it is feasible to conduct such biomedical studies with drug-using MSM who report high-risk sexual behavior and struggle with their ART adherence.

Background: Increased drug use has disproportionately impacted rural areas across the U.S. People who use drugs are at risk of overdose and other medical complications, including infectious diseases. Understanding barriers to healthcare access for this often stigmatized population is key to reducing morbidity and mortality, particularly in rural settings where resources may be limited. Methods: We conducted 20 semi-structured interviews with people who use drugs, including 17 who inject drugs, in rural southern Illinois between June 2018 and February 2019. Interviews were analyzed using a modified grounded theory approach where themes are coded and organized as they emerge from the data. Results: Participants reported breaches of trust by healthcare providers, often involving law enforcement and Emergency Medical Services, that dissuaded them from accessing medical care. Participants described experiences of mistreatment in emergency departments, with one account of forced catheterization. They further recounted disclosures of protected health information by healthcare providers, including communicating drug test results to law enforcement and sharing details of counseling sessions with community members without consent. Participants also described a hesitancy common among people who use drugs to call emergency medical services for an overdose due to fear of arrest. Conclusion: Breaches of trust by healthcare providers in rural communities discouraged people who use drugs from accessing medical care until absolutely necessary, if at all. These experiences may worsen healthcare outcomes and further stigmatize this marginalized community. Structural changes including reforming and clarifying law enforcement's role in Emergency Departments as well as instituting diversion policies during arrests may help rebuild trust in these communities. Other possible areas for intervention include stigma training and harm reduction education for emergency medicine providers, as well as developing and implementing referral systems between Emergency Departments and local harm reduction providers and medically assisted drug treatment programs.

Pre-exposure prophylaxis (PrEP) for HIV prevention is indicated for people who inject drugs (PWID), yet most studies do not focus on PWID. This study examines factors associated with PrEP awareness and willingness, and identifies perceived barriers to PrEP among PWID. Methods: PWID were interviewed in Los Angeles and San Francisco, CA from 2016 to 2018. We analyzed data from self-reported HIV-negative participants who had injected drugs within the past 6 months (n = 469). Questions on PrEP included awareness, willingness, barriers, and uptake. Multiple logistic regression models of factors associated with awareness of, and willingness to, take PrEP were developed. Descriptive statistics on perceived PrEP barriers are reported. Results: Among HIV-negative PWID, 40% were aware of PrEP, 59% reported willingness to take PrEP, and 2% were currently taking PrEP. In multivariable analysis, PrEP awareness was associated with study site and sexual minority status, higher educational attainment, and HIV testing in the last 6 months. Willingness to take PrEP was associated with self-reported risk (paying sex partner in the last 6 months, sharing drug paraphernalia, and being injected by another PWID) and perceived HIV risk. The most common perceived barriers to PrEP were copays, concerns about increased HIV or sexually transmitted risk with PrEP, and concerns about reduction of medication efficacy without daily use. Conclusion: PrEP awareness among PWID remains inadequate. Willingness to take PrEP was moderate and was most desired by PWID who engaged in high-risk behaviors. Interventions to increase PrEP awareness and willingness, and to facilitate PrEP uptake among PWID are needed.