Faculty Bibliography

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.

BACKGROUND:Despite evidence that education and poverty act through distinct pathways to influence sexually transmitted infection (STI), few studies have examined the unique, independent associations of these socioeconomic vulnerabilities on sexual risk behaviors and STI among women. METHODS:From August-October 2013, women at an antenatal clinic in Gressier, Haiti, were interviewed and tested for Chlamydial infection, gonorrhea, and trichomoniasis (N=200). We measured low educational attainment as <9 years of schooling and currently living in poverty based on crowding, defined as >2 people sleeping in one room. We used logistic regression to estimate independent associations between each socioeconomic indicator and outcomes of sexual behaviors and STI. RESULTS:Approximately 29% of the sample had a current STI (chlamydia: 8.0%; gonorrhea: 3.0%; trichomoniasis: 20.5%), with 2.5% testing positive for more than one STI. Forty percent of the sample reported low educational attainment and 40% reported current poverty. Low educational attainment was associated with early risk behaviors, including twice the odds of earlier sexual debut (adjusted OR (AOR): 2.09, 95% CI: 1.14, 3.84). Poverty was associated with reporting the current main sexual partner to be non-monogamous (AOR: 2.01, 95% CI: 1.00, 4.01) and current STI (AOR=2.50, 95% CI: 1.26, 4.98). CONCLUSION/CONCLUSIONS:Education and poverty appear to independently influence STI behaviors and infection, with low education associated with early sexual risk and poverty associated with current risk and infection. Improving women's educational attainment may be important in improving risk awareness, thereby reducing risky sexual behaviors and preventing a trajectory of STI risk.

BACKGROUND:Black men who have sex with men (BMSM); some who also have sex with women (BMSMW), account for over 70% of new HIV infections in the US representing an elevated HIV risk in this group, also informing risks for HIV transmission to other BMSM and female sexual partners. SETTINGS/METHODS:We examined trajectories of self-reported substance use, HIV-related sexual risk behaviors and psychosocial vulnerabilities among BMSMW versus BMSM over a one-year study period. METHODS:We analyzed baseline, 6- and 12-month follow-up data from the HIV Prevention Trials Network (HPTN) "BROTHERS" Study (HPTN 061; n=1126). Categorizing participants by sexual partner type across three time points: (1) BMSMO: having male and no female partners across assessments and (2) BMSMW: having sex male and one or more female partners at least at one time point. Using generalized estimating equations (GEE) we estimated associations between being BMSMW (versus BMSMO) and changes in psychosocial vulnerability, substance use, and HIV-related sexual risk behaviors. RESULTS:GEE models controlling for sociodemographics, time-varying effects, and intervention status showed that BMSMW versus BMSMO had 50% increased odds of crack use, 71% increased odds of alcohol use during condomless anal intercourse (CAI), 51% greater odds of using drugs at last CAI, and twice the odds of receiving goods at last CAI. CONCLUSIONS:Findings show stable and comparatively elevated illicit drugs, alcohol and exchange sex during last CAI among BMSMW. Future intervention research should focus on ways to address changes in substance-related HIV transmission behaviors over time in this population of men.

Incarceration is strongly associated with post-release STI/HIV risk. One pathway linking incarceration and STI/HIV risk may be incarceration-related dissolution of protective network ties. Among African American men released from prison who were in committed partnerships with women at the time of incarceration (N = 207), we measured the association between committed partnership dissolution during incarceration and STI/HIV risk in the 4 weeks after release. Over one-quarter (28%) experienced incarceration-related partnership dissolution. In adjusted analyses, incarceration-related partnership dissolution was strongly associated with post-release binge drinking (adjusted odds ratio (AOR) 4.2, 95% confidence interval (CI); 1.4-15.5). Those who experienced incarceration-related partnership dissolution were much more likely to engage in multiple/concurrent partnerships or sex trade defined as buying or selling sex (64%) than those who returned to the partner (12%; AOR 20.1, 95% CI 3.4-175.6). Policies that promote maintenance of relationships during incarceration may be important for protecting health.

Low executive function (EF) and depression are each determinants of health. This study examined the synergy between deficits in EF (impaired cognitive flexibility; >75th percentile on the Wisconsin Card Sorting Test perseverative error score) and depressive symptoms (modified Centers for Epidemiologic Studies-Depression) and preincarceration well-being among incarcerated African American men ( N = 189). In adjusted analyses, having impaired EF and depression was strongly associated with pre-incarceration food insecurity (odds ratio [ OR] = 3.81, 95% confidence interval [CI] = [1.35, 10.77]), homelessness ( OR = 3.00, 95% CI [1.02, 8.80]), concern about bills ( OR = 3.76, 95% CI [1.42, 9.95]), low significant other support ( OR = 4.63, 95% CI [1.62, 13.24]), low friend support ( OR = 3.47, 95% CI [1.30, 9.26]), relationship difficulties ( OR = 2.86, 95% CI [1.05, 7.80]), and binge drinking ( OR = 3.62, 95% CI [1.22, 10.80]). Prison-based programs to treat depression and improve problem-solving may improve postrelease success.

BACKGROUND:We measured associations between parental incarceration and STI/HIV-related drug use and sex risk, assessing differences by race, age at first parental incarceration, and potential mediators of the relationship. METHODS:We used Waves I (adolescence), III (young adulthood), and IV (adulthood) of the National Longitudinal Study of Adolescent to Adult Health (n = 11,884) to measure associations between age of parental incarceration (never; <8; 8-17; ≥18 years old) and marijuana and cocaine use, multiple partnerships, and STI in adolescence and adulthood among white, Black, and Hispanic participants and assessed mediation by sexual and physical abuse, mental disorder symptoms, and drug use. RESULTS:By Wave IV, approximately one in six had experienced a parental incarceration; higher prevalence observed among black (26%) and Hispanic (20%) versus white (15%) respondents (p < 0.0001). Parental incarceration at any age was moderately to strongly associated with STI/HIV risk outcomes. In multivariable models, parental incarceration at age <8 years old (versus never) remained strongly associated with STI/HIV risk in both adolescence and adulthood, with strongest associations among non-whites. Among black participants, parental incarceration at <8 years old was associated with over double the odds of adulthood use of marijuana (adjusted odds ratio (AOR): 2.53, 95% confidence interval: 1.62, 3.95) and cocaine (AOR: 4.41, 95% CI: 2.05, 9.48). Delinquency, drug use, and mood disorders appeared to partially mediate the relationship. CONCLUSIONS:Children impacted by parental incarceration constitute priority populations for substance use and STI/HIV prevention and treatment. The unintended consequences of incarceration for children should be considered in decarceration discussions.