Faculty Bibliography

CONTEXT/BACKGROUND:Receptive anal intercourse (RAI), which has become increasingly common among U.S. heterosexual women, is associated with STDs, including HIV, when it is unprotected and coercive. Childhood traumatic experiences may increase sexual risk behavior, but the relationship between childhood trauma and RAI among women has not been examined. METHODS:Data from 4,876 female participants in Waves 1 (1994-1995), 3 (2001-2002) and 4 (2007-2008) of the National Longitudinal Study of Adolescent to Adult Health were used to examine associations between nine self-reported childhood traumas (neglect; emotional, physical and sexual abuse; parental binge drinking and incarceration; and witnessing, being threatened with and experiencing violence) and RAI during adulthood using modified Poisson regression analysis. Whether depression, low self-esteem, drug use, relationship characteristics or sex trade involvement mediated the relationship between trauma and RAI was also explored. RESULTS:Forty percent of the sample reported having engaged in receptive anal intercourse. After adjustment for sociodemographic characteristics, eight of the nine childhood traumas were associated with increased risk of RAI (adjusted prevalence ratios, 1.2-1.5); the strongest association was with experience of violence. Each unit increase in the number of traumas yielded a 16% increase in RAI prevalence. In mediation analyses, only drug use and relationship factors slightly attenuated the association between childhood trauma and RAI (1.2 for each). CONCLUSIONS:Women with a history of childhood trauma may be at increased risk of engaging in RAI, highlighting the importance of screening and trauma-informed education in sexual health settings. Pathways linking childhood trauma and RAI among women are complex and warrant further research.

OBJECTIVE/UNASSIGNED:We sought to quantify the extent to which a depression screening instrument commonly used in primary care settings provides additional information regarding pain interference symptoms, anxiety, and substance use. METHODS/UNASSIGNED:Veterans Aging Cohort Study (VACS) data collected from 2003 through 2015 was used to calculate odds ratios (OR) for associations between positive depression screening result cutoffs and clustering conditions. We assessed the test performance characteristics (likelihood ratio value, positive predictive value, and the percentage of individuals correctly classified) of a positive Patient Health Questionnaire (PHQ-9 & PHQ-2) depression screen for the identification of pain interference symptoms, anxiety, and substance use. RESULTS/UNASSIGNED:A total 7731 participants were included in the analyses. The median age was 50 years. The PHQ-9 threshold of ≥20 was strongly associated with pain interference symptoms (OR 21.6, 95% CI 17.5-26.7) and anxiety (OR 72.1, 95% CI 52.8-99.0) and yielded likelihood ratio values of 7.5 for pain interference symptoms and 21.8 for anxiety and positive predictive values (PPV) of 84% and 95%, respectively. A PHQ-9 score of ≥10 still showed significant associations with pain interference symptoms (OR 6.1, 95% CI 5.4-6.9) and symptoms of anxiety (OR 11.3, 95% CI 9.7-13.1) and yet yielded lower likelihood ratio values (4.36 & 8.24, respectively). The PHQ-9 was less strongly associated with various forms of substance use. CONCLUSION/UNASSIGNED:Depression screening provides substantial additional information regarding the likelihood of pain interference symptoms and anxiety and should trigger diagnostic assessments for these other conditions.

BACKGROUND:Despite evidence of socio-demographic disparities in outcomes of COVID-19, little is known about characteristics and clinical outcomes of patients admitted to public hospitals during the COVID-19 outbreak. OBJECTIVE:To assess demographics, comorbid conditions, and clinical factors associated with critical illness and mortality among patients diagnosed with COVID-19 at a public hospital in New York City (NYC) during the first month of the COVID-19 outbreak. DESIGN/METHODS:Retrospective chart review of patients diagnosed with COVID-19 admitted to NYC Health + Hospitals / Bellevue Hospital from March 9th to April 8th, 2020. RESULTS:A total of 337 patients were diagnosed with COVID-19 during the study period. Primary analyses were conducted among those requiring supplemental oxygen (n = 270); half of these patients (135) were admitted to the intensive care unit (ICU). A majority were male (67.4%) and the median age was 58 years. Approximately one-third (32.6%) of hypoxic patients managed outside the ICU required non-rebreather or non-invasive ventilation. Requirement of renal replacement therapy occurred in 42.3% of ICU patients without baseline end-stage renal disease. Overall, 30-day mortality among hypoxic patients was 28.9% (53.3% in the ICU, 4.4% outside the ICU). In adjusted analyses, risk factors associated with mortality included dementia (adjusted risk ratio (aRR) 2.11 95%CI 1.50-2.96), age 65 or older (aRR 1.97, 95%CI 1.31-2.95), obesity (aRR 1.37, 95%CI 1.07-1.74), and male sex (aRR 1.32, 95%CI 1.04-1.70). CONCLUSION/CONCLUSIONS:COVID-19 demonstrated severe morbidity and mortality in critically ill patients. Modifications in care delivery outside the ICU allowed the hospital to effectively care for a surge of critically ill and severely hypoxic patients.

OBJECTIVE:With nearly 11 million people in the United States arrested in 2015, the need to identify antecedent risk factors driving criminal justice involvement (CJI) and possible mitigating factors is crucial. This study examines the relation between childhood trauma and CJI in adolescence and adulthood and assesses how this relation is moderated by mentoring during young adulthood. METHODS:The analysis included 3 waves of data-adolescents, young adults, and adults-collected from 1995 to 2008 from 12,288 adolescents who participated in the National Longitudinal Study of Adolescent to Adult Health, a nationally representative study of adolescents in grades 7 to 12. Logistic regression was used to examine how having a close mentor in adolescence moderated the relation between criminal justice involvement and 9 childhood traumatic events: (1) neglect, (2) emotional abuse, (3) physical abuse, (4) sexual abuse, (5) parental incarceration, (6) parental binge drinking, (7) witnessed violence, (8) threatened with violence, and (9) experienced violence. RESULTS:Cumulative exposure to childhood trauma was associated with CJI in adolescence (adjusted odds ratios [AORs] ranging from 2.24 to 25.98) and adulthood (AOR range, 1.82-6.69), and parental incarceration was consistently one of the, if not the, most strongly associated with each form of CJI; the strength of these associations was weakened for those who reported a close mentor compared to those who did not. CONCLUSIONS:This study advances the literature regarding trauma and CJI, highlighting the role of social support and mentorship as protective factors for youth who experience childhood trauma. Interventions aimed at protecting vulnerable children from the harms of trauma should be the next priority.

Background Racial/ethnic and sexual minorities face elevated risk of policing and detainment. Dual minority status is linked to disproportionate incarceration; among black men who have sex with men (BMSM) in the HIV Prevention Trials Network (HPTN) study, 60% had been incarcerated. Incarceration disrupts networks and increases partnership exchange and STI. We lack understanding of the impact of incarceration on STI risk among BMSM. Methods We used data from HPTN 061 (N=1553) conducted in Atlanta, Boston, New York, Los Angeles, San Francisco, and Washington DC to measure longitudinal associations between incarceration within six months and twelve-month risk of multiple partnerships and biologically-confirmed STI gonorrhea, chlamydia, syphilis). Using inverse probability of treatment weighted (IPTW) regression to account for preincarceration poverty, psychopathology, drug use, and STI risk, we estimated risk ratios (RRs) and 95% confidence intervals (CIs) for associations between incarceration and outcomes and assessed differences by city. Results Approximately 14% had been incarcerated in the past six months. Controlling for site, incarceration predicted multiple partnerships (RR: 1.20, 95% CI: 1.06-1.36) and incident STI (RR: 1.08, 95% CI: 1.00-1.16). Associations with multiple partnerships and STI differed by city (joint test of interaction, p value <0.05). Incarceration was most strongly associated with multiple partnerships (RR: 1.69, 95% CI: 1.38-2.04) and STI (RR: 1.31, 95% CI: 1.04-1.64) in Washington DC. In other cities, STI RRs ranged from 0.95 to 1.08 and were not significant at the 0.05 level. Incarceration was associated with multiple partnerships in New York (RR: 1.25, 95% CI: 1.01-1.55) and Boston (RR: 1.31, 95% CI: 1.08- 1.58), while RRs ranged from 0.87 to 1.08 and were not significant in other cities. Conclusion Recent incarceration impacts STI risk among BMSM in Washington DC and the northeastern United States

Background/UNASSIGNED:The prevalence and risk of concurrent unhealthy drinking, cigarette use, and depression on mortality among persons living with HIV (PLWH) is unclear. This study applied a syndemic framework to assess whether these co-occurring conditions increase mortality and whether such risk is differential by HIV status. Methods/UNASSIGNED:We evaluated 6721 participants (49.8% PLWH) without baseline cancer from the Veterans Aging Cohort Study, a prospective, observational cohort of PLWH and matched uninfected veterans enrolled in 2002 and followed through 2015. Multivariable Cox proportional hazards regressions estimated risk of a syndemic score (number of conditions: that is, unhealthy drinking, cigarette use, and depressive symptoms) on all-cause mortality by HIV status, adjusting for demographic, health status, and HIV-related factors. Results/UNASSIGNED:= .013), after adjusting for health status and HIV disease progression. Among PLWH and uninfected participants, mortality risk persisted after adjustment for time-updated health status. Conclusions/UNASSIGNED:Syndemic unhealthy drinking, cigarette use, and depression are common and are associated with higher mortality risk among PLWH, underscoring the need to screen for and treat these conditions.

Background: Exposure to incarceration is associated with greater risk of mortality, especially following release from correctional facilities. Few studies have examined whether frequency of incarceration or amount of time spent incarcerated over one's lifetime is associated with increasing mortality. We used data from the Veterans Aging Cohort Study (VACS) to compare mortality by intensity of incarceration exposure among individuals with HIV.
Method(s): HIV+ participants who provided a response to incarceration questions in the VACS survey from January 2011 to August 2017 were included (N=2,718), and mortality data were available through August 2018. We calculated and compared mortality rates per 100 person years (pys) by three incarceration measures: 1) ever/never; 2) number of times over lifetime; and 3) length of time over lifetime. We then used Cox Proportional Hazard models to determine whether the three incarceration measures are associated with increased mortality adjusting for demographics (race, sex, age), and then also adjusting for social and health-related factors (education, smoking, HCV, social support, hazardous drinking, and homelessness, past year drug use, and mental health disorders).
Result(s): Participants' mean age was 56, ranging from 22 to 84; 66% were African-American, 19% white, and 9% Hispanic or other; 97% were male, 38% reported current cigarette smoking, 36% were HCV+, 55% reported exposure to incarceration. There were 465 mortality events over a mean follow-up time of 5.8 years. Unadjusted mortality rates increased with incarceration exposure for all three incarceration measures and were 2.7 per 100 person years (pys) for those never incarcerated vs 3.6 for those ever incarcerated. In models adjusted for demographics, ever incarceration was associated with an AHR of 1.36 [1.13-1.66]. Number of times incarcerated was associated with mortality in models adjusted for demographics with AHRs of: 1.1 [0.9-1.5], 1.45 [1.2-1.8], and 1.64 [1.2-2.2] for 1, 2-5; 6+ times, respectively. Length of time incarcerated was also associated with mortality in models adjusted for demographics with AHRs of: 1.1 [0.9-1.5], 1.4 [1.1-1.9]. 1.6 [1.2-2.2], and 1.6 [1.1-2.2] for < 1 month, 1 to 11 months, 1-5 years, and > 5 years, respectively. After further adjustment for social and health-related factors, the associations were no longer statistically significant.
Conclusion(s): Among individuals living with HIV, increasing exposure to incarceration (both frequency and total length of time spent incarcerated) was associated with increased mortality in unadjusted analyses and models adjusting for demographics. However, this association was not seen after additional adjustment for social and health-related factors, suggesting some covariates may be mediators or confounders

Post-release opioid-related overdose mortality is the leading cause of death among people released from jails or prisons (PRJP). Informed by the proximate determinants framework, this paper presents the Post-Release Opioid-Related Overdose Risk Model. It explores the underlying, intermediate, proximate and biological determinants which contribute to risk of post-release opioid-related overdose mortality. PRJP share the underlying exposure of incarceration and the increased prevalence of several moderators (chronic pain, HIV infection, trauma, race, and suicidality) of the risk of opioid-related overdose. Intermediate determinants following release from the criminal justice system include disruption of social networks, interruptions in medical care, poverty, and stigma which exacerbate underlying, and highly prevalent, substance use and mental health disorders. Subsequent proximate determinants include interruptions in substance use treatment, including access to medications for opioid use disorder, polypharmacy, polydrug use, insufficient naloxone access, and a return to solitary opioid use. This leads to the final biological determinant of reduced respiratory tolerance and finally opioid-related overdose mortality. Mitigating the risk of opioid-related overdose mortality among PRJP will require improved coordination across criminal justice, health, and community organizations to reduce barriers to social services, ensure access to health insurance, and reduce interruptions in care continuity and reduce stigma. Healthcare services and harm reduction strategies, such as safe injection sites, should be tailored to the needs of PRJP. Expanding access to opioid agonist therapy and naloxone around the post-release period could reduce overdose deaths. Programs are also needed to divert individuals with substance use disorder away from the criminal justice system and into treatment and social services, preventing incarceration exposure.

Objective:This study explored the relationships between participation in group sex and risk for HIV and other sexually transmissible infections (STIs). Methods: An anonymous online survey collected data from 580 gay and bisexual men using a mobile sex and dating application in Paris, France. Logistic regression analyses were conducted, which controlled for HIV status, HIV pre-exposure prophylaxis (PrEP) use and participants' sociodemographic characteristics. Results: Compared with men with no recent group sex experience, those reporting group sex in the 3 months before the survey (30.7% of the sample) were more likely to have had condomless receptive anal sex at least once in the same period [adjusted odds ratio (aOR)=1.6, 95% confidence interval (CI)=1.1-2.4, P = 0.02], condomless insertive anal sex (aOR=2.0, 95%CI: 2.4-8.7, P < 0.001) and substance use before or during sex (aOR=1.6, 95%CI: 1.1-2.3, P = 0.02). Even when controlling for condom use, men involved with group sex were more likely to be have been diagnosed with a bacterial STI in the previous year (aOR=2.1, 95%CI: 1.3-3.3, P = 0.002). Conclusions: Group sex remains a useful marker of risk among gay and bisexual men, but research is needed that moves beyond individual practice in order to assess the epidemiological networks comprising group sex and the risks they pose relevant to HIV and other STIs.

As a prevention strategy, HIV pre-exposure prophylaxis (PrEP) may benefit men who participate in group sex, but little is known about PrEP among this group internationally and virtually nothing is known of the European context. This study used an online survey of gay men living in Paris, France to assess associations between group sex and awareness of, use and interest in PrEP in its once-daily, episodic, injectable, and microbicidal forms. Men reporting recent (within 3 months) condomless group sex were much more likely to report once-daily PrEP use than men with no group sex experience (41.5% vs 7.7%, p < .001). Uptake was similarly low among men who had group sex with condoms (8.0%) and those with less-recent experience (6.43%). Overall, willingness to use PrEP-including its non-daily forms-was high among men reporting group sex, suggesting opportunities for outreach and implementation.