Faculty Bibliography

BACKGROUND:Sexually transmitted infections (STIs) are important public health concerns among black men who have sex with men only (BMSMO), as well as those who have sex with both men and women (BMSMW). Sexually transmitted infections also increase risk of acquiring and HIV, which is also a critical concern. Compared with BMSMO, research shows that BMSMW experience elevated levels of HIV/STI vulnerability factors occurring at the intrapersonal, interpersonal, and social/structural levels. These factors may work independently, increasing one's risk of engaging in high-risk sexual behaviors, but often work in a synergistic and reinforcing manner. The synergism and reinforcement of any combination of these factors are known as a syndemic, which increases HIV/STI risk. METHODS:Data from the HIV Prevention Trials Network (HPTN) 061 study (n = 799) was used to conduct a latent profile analysis to identify unique combinations of risk factors that may form a syndemic and that may vary between BMSMO and BMSMW. We hypothesized that the convergence of syndemic factors would differ between groups and predict sexual risk and subsequent incident STI. RESULTS:For BMSMO who had a high sexual risk profile, the syndemic factors characterizing this group included perceived racism, incarceration, intimate partner violence, depression, and binge drinking. For BMSMW with a high sexual risk profile, the syndemic factors that characterized this group were incarceration, depression, and binge drinking. CONCLUSIONS:The current analysis highlights syndemic profiles that differentiated BMSMO and BMSMW from one another and supports the need for tailored interventions that address specific syndemic factors for both subpopulations of black men who have sex with men.

BACKGROUND AND AIMS/OBJECTIVE:While substance use can lead to incarceration, the disruptive effects of incarceration may lead to, or increase psychosocial vulnerability and substance use. Using causal inference methods, we measured longitudinal associations between incarceration and post-release substance use among Black men who have sex with men (BMSM), populations facing disproportionate risk of incarceration and substance use. METHODS:Using data from the HIV Prevention Trials Network (HPTN 061) study (N = 1553) we estimated associations between past 6-month incarceration and binge drinking, marijuana use, and stimulant use post release (at 12-month follow-up visit). Adjusted models used inverse probability weighting (IPW) to control for baseline (pre-incarceration) substance use and additional risk factors. RESULTS:There were 1133 participants present at the twelve-month follow-up visit. Participants were predominately non-Hispanic Blacks and unemployed. At baseline, 60.1 % reported a lifetime history of incarceration, 22.9 % were HIV positive and 13.7 % had a history of an STI infection. A total of 43 % reported a history of depression. In adjusted analyses with IPW, recent incarceration was associated with crack-cocaine (adjusted odds ratio (AOR): 1.53, 95 % confidence interval (CI): 1.03, 2.23) and methamphetamine use (AOR: 1.52, 95 % CI: 0.94-2.45). Controlling for pre-incarceration binge drinking, incarceration was associated with post-release binge drinking (AOR: 1.47, 95 % CI: 1.05, 2.04); in fully adjusted models the AOR was 1.14 (95 % CI: 0.81, 1.62). Incarceration was not associated with marijuana use. CONCLUSION/CONCLUSIONS:Findings underscore the need to provide substance use treatment in custody and post-release, and to consider alternatives to incarceration for substance using populations.

BACKGROUND:Exposure to incarceration is associated with increased risk of mortality, and HIV is cited as a leading cause of death. Yet, few studies have examined the association between incarceration and mortality among people with HIV (PWH), specifically whether and how increasing exposure to incarceration increases risk of mortality. We compared mortality by different incarceration exposures and HIV status. METHODS:We conducted a prospective cohort study of participants in the Veterans Aging Cohort Study (VACS) from January 2011 to August 2017 (N=5,367). The primary exposure was incarceration by three measures: 1) any (ever/never); 2) frequency; and 3) cumulative duration. Stratifying by HIV status and controlling for age, race, and gender, we used Cox Proportional Hazard models to estimate adjusted hazard ratios (AHRs) and 95% confidence intervals (CIs). RESULTS:Incarceration was associated with increased risk of mortality compared with those never incarcerated for PWH (AHR 1.37; 95% CI, 1.13-1.66) and those uninfected (AHR 1.24; 95% CI, 0.99-1.54), but the association was only statistically significant among PWH. Increasing frequency of incarceration was associated with higher risk of mortality in both groups: for PWH, AHRs 1.13, 1.45, and 1.64 for 1, 2-5; 6+ times, respectively; for uninfected, AHRs 0.98, 1.35, and 1.70 for 1, 2-5, and 6+ times, respectively. CONCLUSIONS:PWH were at increased risk for mortality following incarceration and repeated exposure to incarceration was associated with mortality in both groups in a dose-response fashion. This increased risk for mortality may be mitigated by improving transitional healthcare, especially HIV care, and reducing incarceration.

Importance/UNASSIGNED:Alcohol screening may be associated with health outcomes that cluster with alcohol use (ie, alcohol-clustering conditions), including depression, anxiety, and use of tobacco, marijuana, and illicit drugs. Objective/UNASSIGNED:To quantify the extent to which alcohol screening provides additional information regarding alcohol-clustering conditions and to compare 2 alcohol use screening tools commonly used for this purpose. Design, Setting, and Participants/UNASSIGNED:This longitudinal cohort study used data from the Veterans Aging Cohort Study. Data were collected at 8 Veterans Health Administration facilities from 2003 through 2012. A total of 7510 participants were enrolled, completed a baseline survey, and were followed up. Veterans with HIV were matched with controls without HIV by age, race, sex, and site of care. Data were analyzed from January 2019 to December 2019. Exposures/UNASSIGNED:The Alcohol Use Disorders Identification Test (AUDIT) and Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) were used to assess alcohol use, with 4 risk groups delineated for each test: score 0 to 7 (reference), score 8 to 15, score 16 to 19, and score 20 to 40 (maximum score) for the full AUDIT and score 0 to 3 (reference), score 4 to 5, score 6 to 7, and score 8 to 12 (maximum score) for the AUDIT-C. Main Outcomes and Measures/UNASSIGNED:Alcohol-clustering conditions, including self-reported symptoms of depression and anxiety and use of tobacco, marijuana, cocaine, other stimulants, opioids, and injection drugs. Results/UNASSIGNED:A total of 6431 US patients (6104 [95%] men; median age during survey years 2003-2004, 50 years [range, 28-86 years; interquartile range, 44-55 years]) receiving care in the Veterans Health Administration completed 1 or more follow-up surveys when the AUDIT was administered and were included in the present analyses. Of the male participants, 4271 (66%) were African American, 1498 (24%) were white, and 590 (9%) were Hispanic. The AUDIT and AUDIT-C scores were associated with each alcohol-clustering condition. In particular, an AUDIT score of 20 or higher (vs <8, the reference) was associated with symptoms of depression (odds ratio [OR], 8.37; 95% CI, 6.20-11.29) and anxiety (OR, 8.98; 95% CI, 6.39-12.60) and with self-reported use of tobacco (OR, 14.64; 95% CI, 8.94-23.98), marijuana (OR, 12.41; 95% CI, 8.61-17.90), crack or cocaine (OR, 39.47; 95% CI, 27.38-56.90), other stimulants (OR, 21.31; 95% CI, 12.73-35.67), and injection drugs (OR, 8.67; 95% CI, 5.32-14.13). An AUDIT score of 20 or higher yielded likelihood ratio (sensitivity / 1 - specificity) values greater than 3.5 for depression, anxiety, crack or cocaine use, and other stimulant use. Associations between AUDIT-C scores and alcohol-clustering conditions were more modest. Conclusions and Relevance/UNASSIGNED:Alcohol screening can inform decisions about further screening and diagnostic assessment for alcohol-clustering conditions, particularly for depression, anxiety, crack or cocaine use, and other stimulant use. Future studies using clinical diagnoses rather than screening tools to assess alcohol-clustering conditions may be warranted.

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.