Faculty Bibliography

OBJECTIVE:We aimed to determine the effectiveness of various preexposure prophylaxis (PrEP) prescription strategies for African-American women impacted by mass incarceration within an urban setting. DESIGN/METHODS:An agent-based model was utilized to evaluate prevention strategies in an efficient, ethical manner. By defining agents, their characteristics and relationships, we assessed population-level effects of PrEP on HIV incidence. METHODS:We tested hypothetical PrEP prescription strategies within a simulation representing the African-American population of Philadelphia, Pennsylvania. Four strategies were evaluated: PrEP for women meeting CDC indicators regarding partner characteristics, PrEP for women with a recently incarcerated male partner, PrEP for women with a recently released male partner and couples-based PrEP at time of release. Interventions occurred alongside scale-up of HAART. We evaluated reductions in HIV transmissions, the number of persons on PrEP needed to avert one HIV transmission (NNT) and the resulting proportions of people on PrEP. RESULTS:Scenarios prescribing PrEP based on criminal justice system involvement reduced HIV transmissions. The NNT ranged from 147 (couples-based scenario) to 300 (recently released scenario). The percentage of the female population covered by PrEP at any one time ranged from 0.14% (couples-based) to 10.8% (CDC-based). CDC-guideline scenarios were consistently less efficient compared to the justice-involved interventions. CONCLUSION/CONCLUSIONS:Expanding PrEP for African-American women and their male partners affected by incarceration should be considered in national HIV prevention goals and correctional facilities leveraged as intervention sites. Partner characteristics in the current CDC indications may be more effective and efficient if guidelines considered criminal justice involvement.

PURPOSE/OBJECTIVE:To assess cross-population linkages in HIV/AIDS epidemics, we tested the hypothesis that the number of newly diagnosed AIDS cases among Black people who inject drugs (PWID) was positively related to the natural log of the rate of newly diagnosed HIV infections among Black non-PWID heterosexuals in 84 large U.S. metropolitan statistical areas (MSAs) in 2008-2016. METHODS:We estimated a multilevel model centering the time-varying continuous exposures at baseline between the independent (Black PWID AIDS rates) and dependent (HIV diagnoses rate among Black heterosexuals) variables. RESULTS:At MSA level, baseline (standardized β = 0.12) Black PWID AIDS rates and change in these rates over time (standardized β = 0.11) were positively associated with the log of new HIV diagnoses rates among Black heterosexuals. Thus, MSAs with Black PWID AIDS rates that were 1 standard deviation= higher at baseline also had rates of newly diagnosed HIV infections among Black non-PWID heterosexuals that were 10.3% higher. A 1 standard deviation increase in independent variable over time corresponded to a 7.8% increase in dependent variable. CONCLUSIONS:Black PWID AIDS rates may predict HIV rates among non-PWID Black heterosexuals. Effective HIV programming may be predicated, in part, on addressing intertwining of HIV epidemics across populations.

BACKGROUND:The COVID-19 pandemic poses significant challenges to people with opioid use disorder (OUD). As localities enforce lockdowns and pass emergency OUD treatment regulations, questions arise about how these changes will affect access and retention in care. In this study, we explore the influence of COVID-19 on access to, experiences with, and motivations for OUD treatment through a qualitative analysis of public discussion forums on Reddit. METHODS:We collected data from Reddit, a free and international online platform dedicated to public discussions and user-generated content. We extracted 1000 of the most recent posts uploaded between March 5th and May 13th, 2020 from each of the two most popular opioid subreddits "r/Opiates" and "r/OpiatesRecovery" (total 2000). We reviewed posts for relevance to COVID-19 and opioid use and coded content using a hybrid inductive-deductive approach. Thematic analysis identified common themes related to study questions of interest. RESULTS:Of 2000 posts reviewed, 300 (15%) discussed topics related to the intersection of opioid use and COVID-19. Five major themes related to OUD treatment were identified: Concern about closure of OUD treatment services; transition to telehealth and virtual care; methadone treatment requirements and increased exposure to COVID-19; reactions to changing regulations on medications for OUD; and influences of the pandemic on treatment motivation and progress. CONCLUSION/CONCLUSIONS:In the face of unprecedented challenges due to COVID-19, reactions of Reddit opioid forum users ranged from increased distress in accessing and sustaining treatment, to encouragement surrounding new modes of treatment and opportunities to engage in care. New and less restrictive avenues for treatment were welcomed by many, but questions remain about how new norms and policy changes will be sustained beyond this pandemic and impact OUD treatment access and outcomes long-term.

Drug use involves social interactions. Therefore, norms in the proximal environment of people who inject drugs (PWID) can favor behaviors that may result in HIV transmission. This work aimed at studying drug injection-related norms and their potential association with risky behaviors among PWID in Athens, Greece, in the context of economic recession and political activism that followed the fiscal crisis and soon after a recent HIV outbreak had leveled off. The Transmission Reduction Intervention Project (TRIP) was a social network-based approach (June 2013 to July 2015) that involved two groups of PWID seeds-with recent HIV infection and with long-term HIV infection and one control group of HIV-negative PWID. Network contacts of seeds were also enrolled. TRIP participants answered a questionnaire that included items on injection-related norms and behaviors. TRIP recruited 320 PWID (HIV positive, 44.4%). TRIP participants, especially those without HIV, often recalled or perceived as normative among their partners and in their networks some behaviors that can lead to HIV transmission. TRIP participants who recalled that they were encouraged by their regular drug partners to use an unclean syringe were almost twice as likely to report that they share syringes [odds ratio (OR) = 2.03; 95% confidence interval (CI) = 1.86-2.21], or give syringes to someone else (OR = 1.70; 95% CI = 1.42-2.04) as those who did not recall such an encouragement. Associations were modified by HIV status. HIV negatives, who were reportedly encouraged to share nonsyringe injecting equipment, were almost 4.5 times as likely to share that material as HIV-negative participants who were not encouraged (OR = 4.59, 95% CI = 4.12-5.11). Further research is needed on the multiple determinants (social, economic, and political) of norms in the social environments of PWID. Since peer norms are associated with risky behaviors, interventions should be developed to encourage norms and peer pressure against the sharing of injection equipment.

PURPOSE/OBJECTIVE:The challenges of producing adequate estimates of HIV prevalence among men who have sex with men (MSM) are well known. No one, to our knowledge, has published annual estimates of HIV prevalence among MSM over an extended period and across a wide range of geographic areas. METHODS:This article applies multilevel modeling to data integrated from numerous sources to estimate and validate trajectories of HIV prevalence among MSM from 1992 to 2013 for 86 of the largest metropolitan statistical areas in the United States. RESULTS:Our estimates indicate that HIV prevalence among MSM increased, from an across-metropolitan statistical area mean of 11% in 1992 to 20% in 2013 (S.D. = 3.5%). Our estimates by racial/ethnic subgroups of MSM suggest higher mean HIV prevalence among black and Hispanic/Latino MSM than among white MSM across all years and geographic regions. CONCLUSIONS:The increases found in HIV prevalence among all MSM are likely primarily attributable to decreases in mortality and perhaps also to increasing HIV incidence among racial/ethnic minority MSM. Future research is needed to confirm this. If true, health care initiatives should focus on targeted HIV prevention efforts among racial/ethnic minority MSM and on training providers to address cross-cutting health challenges of increased longevity among HIV-positive MSM.

Stigma is a known barrier to treating substance use disorders and dramatically diminishes the quality of life of people who use drugs (PWUD) nonmedically. Stigma against PWUD may be especially pronounced in rural areas due to their decreased anonymity and residents' limited access, or resistance, to "neutralizing" information on factors associated with drug use. Stigma often manifests in the attitudes of professionals whom stigmatized individuals regularly interact with and often materially impact. We analyzed interviews conducted between July 2018 and February 2019 with professional stakeholders in rural southern Illinois who interact with PWUD, specifically those who use opioids nonmedically or who inject drugs (n = 30). We further analyzed interview data from a complementary PWUD sample (n = 22). Interviews addressed perspectives around nonmedical drug use and treatment/harm reduction, with analysis centered around the Framework Integrating Normative Influences on Stigma and its focus on micro, meso and macro level stigmatization processes. Stakeholder participants included professionals from local law enforcement, courts, healthcare organizations, emergency management services, and faith-based and social services organizations. Most stakeholders, particularly law enforcement, negatively perceived PWUD and nonmedical drug use in general, questioned the character, agency and extrinsic value of PWUD, and used labels (e.g. "addict," "abuser," etc.) that may be regarded as stigmatizing. Further, most respondents, including PWUD, characterized their communities as largely unaware or dismissive of the bio-medical and sociocultural explanations for opioid use, drug injection and towards harm reduction services (e.g., syringe exchanges) and naloxone, which were frequently framed as undeserved usages of taxpayer funds. In conclusion, rural stigma against PWUD manifested and was framed as a substantial issue, notably activating at micro, meso and macro levels. Stigma prevention efforts in these communities should aim to improve public knowledge on the intricate factors contributing to opioid use and drug injection and harm reduction programming's moral and fiscal value.

This paper presents a framework that may help explain the interactions among capitalism, infectious disease, and environmental change in the world and in the Mediterranean region. Capitalism and the longevity of national governments require continued investment and economic growth. This disrupts the environment, most urgently in terms of climate change, which is expected to single out the Mediterranean region for droughts and heat and to lead to mass migrations of people and animals. Capitalism also disrupts the habitats of fauna, and creates factory farming and markets for the sale of animals from local ecologies that are being "opened up" for profitable use-all of which leads to increased interaction between potential vectors of infectious diseases and humans. Capitalist globalization has encouraged widespread international and other travel of people and goods, which can carry infectious people or animal vectors across long distances very rapidly. In sum, capitalism requires development, which creates environmental and infectious disease crises. Solving this problem will require profound political and economic change. In the immediate term, public health and medical institutions need to be protected against the pressures of austerity.

Introduction: Although a substantial body of research documents a relationship between traumatic stress in childhood and the initiation of substance use later in the life course, only limited research has examined potential linkages between adverse childhood experiences (ACEs) and the initiation of non-medical prescription opioid use and other opioid use behaviors. The present study contributes to this growing body of work by investigating the association of childhood trauma with early initiation of a series of opioid use behaviors. Methods: New York City young adults (n = 539) ages 18-29 who reported non-medical use of prescription opioids or heroin use in the past 30 days were recruited using Respondent-Driven Sampling in 2014-16. Ten ACEs were assessed via self-report with the ACE Questionnaire. Associations between number of ACEs and self-reported ages of initiating seven opioid use behaviors (e.g., non-medical prescription opioid use, heroin use, heroin injection) were estimated with multivariable logistic regression. Results: Eighty nine percent of participants reported at least one ACE, and 46% reported four or more ACEs, a well-supported threshold indicating elevated risk for negative health consequences. Every increase of one trauma was associated with a 12-23% increase in odds of early initiation across the seven opioid use behaviors. Findings also document that the mean age at initiation increased with increasing risk severity across the behaviors, contributing to evidence of a trajectory from opioid pill misuse to opioid injection. Discussion: Increasing number of childhood traumas was associated with increased odds of earlier initiation of multiple opioid misuse behaviors. In light of prior research linking earlier initiation of substance use with increased substance use severity, present findings suggest the importance of ACEs as individual-level determinants of increased opioid use severity. Efforts to prevent onset and escalation of opioid use among at-risk youth may benefit from trauma prevention programs and trauma-focused screening and treatment, as well as increased attention to ameliorating upstream socio-structural drivers of childhood trauma.