Faculty Bibliography

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.

Three quarters of new HIV infections in the US are among men who have sex with men (MSM). In other populations, incarceration is a social determinant of elevations in viral load and HIV-related substance use and sex risk behavior. There has been limited research on incarceration and these HIV transmission risk determinants in HIV-positive MSM. We used the Veterans Aging Cohort Study (VACS) 2011-2012 follow-up survey to measure associations between past year and prior (more than one year ago) incarceration and HIV viral load and substance use and sex risk behavior among HIV-positive MSM (N = 532). Approximately 40% had ever been incarcerated, including 9% in the past year. In analyses adjusting for sociodemographic factors, past year and prior incarceration were strongly associated with detectable viral load (HIV-1 RNA >500 copies/mL) (past year adjusted odds ratio (AOR): 3.50 95% confidence interval (CI): 1.59, 7.71; prior AOR: 2.48 95% CI: 1.44, 4.29) and past 12 month injection drug use (AORs > 6), multiple sex partnerships (AORs > 1.8), and condomless sex in the context of substance use (AORs > 3). Past year incarceration also was strongly associated with alcohol and non-injection drug use (AOR > 2.5). Less than one in five HIV-positive MSM recently released from incarceration took advantage of a jail/prison re-entry health care program available to veterans. We need to reach HIV-positive MSM leaving jails and prisons to improve linkage to care and clinical outcomes and reduce transmission risk upon release.

BACKGROUND:Research demonstrates strong associations between adverse childhood experiences (ACEs) and non-medical prescription opioid use (NMPO), but pathways are not understood, hindering prevention and treatment responses. METHODS:We assessed hypothesized mediators of the association between ACEs and NMPO in a nationally-representative U.S. SAMPLE/METHODS:National Longitudinal Study of Adolescent to Adult Health data (N = 12,288) yielded an ordinal exposure comprising nine ACEs (neglect; emotional, physical, sexual abuse; parental incarceration and binge drinking; witnessed, threatened with, experienced violence) and a binary lifetime NMPO outcome. Nine potential mediators measured in adolescence and/or adulthood included depression, anxiety, suicidality, delinquency, impulsivity, and risk-taking. We estimated adjusted odds ratios (AOR) and 95% confidence intervals (CI) for sex-stratified associations of: ACEs and mediators; mediators and NMPO; and ACEs and NMPO adjusting for mediators individually and simultaneously. RESULTS:All associations of ACEs and mediators were statistically significant and similar by sex. All mediators had statistically significant associations with NMPO (except one depression measurement for each sex). Delinquency was strongly associated with ACEs and NMPO and was the strongest individual mediator. Every ACE increase was associated with increased NMPO odds of 32% for males and 27% for females. Adjusting for all mediators, odds of NMPO were attenuated partially for males [AOR = 1.18 (95% CI:1.07, 1.31)] and somewhat more for females [AOR = 1.11 (95% CI:1.00, 1.25)]. CONCLUSIONS:Internalizing and externalizing factors partially explained the pathway from ACEs to NMPO. Substance abuse may be more difficult to treat with co-occurring psychopathologies and maladaptive behaviors, highlighting the need to address trauma early in life.

BACKGROUND:Incarceration and HIV disproportionately impact African American communities. The mass incarceration of African American men is hypothesized to increase HIV acquisition risk for African American women. Interventions optimizing HIV care engagement and minimizing sexual risk behaviors for men living with HIV post-incarceration may decrease HIV incidence. METHODS:Using an agent-based model, we simulated a sexual and injection drug using network representing the African American population of Philadelphia. We compared intervention strategies for men living with HIV post-incarceration by the number of averted HIV transmissions to women within the community. Three interventions were evaluated: a 90-90-90 scenario scaling up HIV testing, ART provision, and ART adherence; a behavioral intervention decreasing sexual risk behaviors; and a combination intervention involving both. RESULTS:The status quo scenario projected 2,836 HIV transmissions to women over twenty years. HIV transmissions to women decreased by 29% with the 90-90-90 intervention, 23% with the behavioral intervention, and 37% with both. The number of men living with HIV receiving the intervention needed in order to prevent a single HIV transmission ranged between 6 and 10. CONCLUSION:Interventions to improve care engagement and decrease sexual risk behaviors post-incarceration for men living with HIV have the potential to decrease HIV incidence within African American heterosexual networks.

BACKGROUND:The United States has the highest incarceration rate in the world. Incarceration can increase HIV risk behaviors for individuals involved with the criminal justice system and may be a driver of HIV acquisition within the community. METHODS:We used an agent-based model to simulate HIV transmission in a sexual-contact network representing heterosexual African American men and women in Philadelphia to identify factors influencing the impact of male mass incarceration on HIV acquisition in women. The model was calibrated using surveillance data and assumed incarceration increased the number of sexual contacts and decreased HIV care engagement for men post-release. Incarceration of a partner increased the number of sexual contacts for women. We compared a counterfactual scenario with no incarceration to scenarios varying key parameters to determine what factors drove HIV acquisition in women. RESULTS:Setting the duration of male high-risk sexual behavior to two years post-release increased the number of HIV transmissions to women by more than 20%. Decreasing post-release HIV care engagement and increasing HIV acquisition risk attributable to sexually transmitted infections (STIs) also increased the number of HIV transmissions to women. Changing the duration of risk behavior for women, the proportion of women engaging in higher risk behavior, and the relative risk of incarceration for HIV-infected men had minimal impact. CONCLUSION/CONCLUSIONS:The mass incarceration of African American men can increase HIV acquisition in African American women on a population-level through factors including post-release high-risk behaviors, disruption of HIV care engagement among formerly incarcerated men, and increased STI prevalence. These findings suggest that the most influential points of intervention may be programs seeking to reduce male risk behaviors and promote HIV care engagement post-release, as well as STI testing and treatment programs for recently incarcerated men, as well as women with incarcerated partners.

BACKGROUND:While previous research has documented the impact of violence on substance use, none has looked longitudinally across the lifespan to measure independent effects of direct and indirect violence exposure. OBJECTIVE:To examine independent associations between adolescent experiences of violence and subsequent substance use in adolescence and adulthood in the United States. METHOD/METHODS:Using the National Longitudinal Study of Adolescent to Adult Health (N = 12,288), we examined being shot or stabbed ("experienced"), being threatened with a knife or gun ("threatened"), and seeing someone either shot or stabbed ("witnessed") during adolescence (Wave I) as correlates of substance use in adolescence and adulthood (Wave IV) via logistic regression. RESULTS:Violence exposure was a significant correlate of drug use in adolescence and several associations remained significant in adulthood. Witnessing violence had the highest point estimates in the adjusted models in adolescence for each substance use outcome (e.g., Cocaine-Adjusted Odds Ratios [AOR] = 2.59, 95% confidence interval [CI] = 1.21, 5.54). However, the point estimates for threatened with violence or experienced violence were highest in three out of the four drug outcomes in adulthood (e.g., Threatened with violence: Binge drinking-AOR = 1.41, 95% CI = 1.08, 1.83). Conclusion/Importance: Adolescent exposure to witnessing violence had stronger effects on substance use in adolescence, while experiencing and being threatened with violence in adolescence had stronger effects on substance use in adulthood. Violence prevention efforts targeted toward adolescents may lead to a reduction in substance use throughout the life-course, and clinicians and policy makers should be aware of the downstream effects of violence experienced in adolescence.