Faculty Bibliography

BACKGROUND:Sub-Saharan Africa has a large population of people with hepatitis C virus (HCV) infection, yet little is known about HCV among people who inject drugs this region. We assessed the prevalence of HCV mono-infection and HIV-HCV co-infection, and the estimated incidence, genotypes, and risk behaviours associated with HCV among people who inject drugs in Kenya. METHODS:People aged 18 years or older who were living in Nairobi, coastal Kenya, or western Kenya, had a history of injection drug use, and had used any illicit drugs in the past 12 months were recruited at needle and syringe programme sites using respondent-driven sampling. Participants were screened for the presence of an anti-HCV antibody. Those who were anti-HCV positive underwent confirmatory HCV RNA testing, and those with detectable HCV RNA were genotyped. Participants were interviewed regarding parenteral risk behaviours and exposure to services received at the needle and syringe programme sites. We examined correlates of HCV infection and HIV-HCV co-infection using bivariate and multivariate regression, and estimated HCV incidence. FINDINGS/RESULTS:Of 2188 enrolled participants, 291 (13%) were anti-HCV positive: 183 (22%) of 842 participants in coastal Kenya, 105 (13%) of 817 in Nairobi, and three (1%) of 529 in western Kenya. 284 anti-HCV-positive participants underwent successful HCV RNA testing, of whom 230 (81%) were viraemic. Estimated incidence rates of anti-HCV positivity per 100 person-years were 6·31 in coastal Kenya, 3·19 in Nairobi, and 0·22 in western Kenya. HCV incidence rate was greater in coastal Kenya compared with Nairobi (incidence rate ratio 1·97 [95% CI 1·35-2·93], p=0·0001) and the western region (28·17 [7·55-236·58], p<0·0001). In the coastal region, history of incarceration, more years injecting, more injections in the past month, and receptive cooker sharing were associated with increased risk of HCV, while female sex, more years injecting, more injections in the past month, and regular use of a syringe with a detachable needle were associated with HCV risk in Nairobi. HCV prevalence among HIV-positive participants was 50% (66 of 131 participants) in coastal Kenya, 35% (42 of 121) in Nairobi, and 4% (one of 23) in western Kenya. Risk factors for HIV-HCV co-infection were similar to those observed for HCV mono-infection. The prevailing genotypes were 1a (51%), 4a (47%), and mixed (2%; three 1a/4a and one 1a/2b). INTERPRETATION/CONCLUSIONS:HCV prevalence, estimated incidence, and risk behaviours among people who inject drugs in Kenya vary with region, with the highest estimated incidence observed in coastal Kenya. These findings should be used to inform focused strategies to reduce HCV transmission, such as expansion of needle and syringe programmes, upscaling of opioid agonist therapy, and treatment as prevention in regions affected by injection drug use and HCV. FUNDING/BACKGROUND:National Institute on Drug Abuse.

Introduction/UNASSIGNED:Smoking prevalence is high in Viet Nam, yet tobacco dependence treatment (TDT) is not widely available. Methods/UNASSIGNED:We conducted a quasi-experimental study that compared the effectiveness of health care provider advice and assistance (ARM 1) vs. ARM 1 plus village health worker (VHW) counseling (ARM 2) on abstinence at 6-month follow-up. This study was embedded in a larger two-arm cluster randomized controlled trial (RCT) conducted in 26 community health centers (CHCs) in Viet Nam. Subjects (N=1,318) were adult patients who visited any participating CHC during the parent RCT intervention period and were self-identified as current tobacco users (cigarettes and/or waterpipe). Results/UNASSIGNED:At 6-month follow-up, abstinences rates in ARM 2 were significantly higher than ARM 1 (25.7% vs. 10.5%; p<.001). In multivariate analyses smokers in ARM 2 were almost three times more likely to quit compared with those in ARM 1 (adjusted odds ratio [AOR]=2.96, 95% confidence interval [CI]=1.78-4.92). Compared to cigarette-only smokers, waterpipe-only smokers (AOR=0.4, 95% CI=0.26-0.62) and dual users (AOR=0.62, 95% CI=0.45-0.86) were less likely to achieve abstinence, however the addition of VHW counseling (ARM 2) was associated with higher quit rates compared with ARM 1 alone for all smoker types. Conclusion/UNASSIGNED:A team approach in TDT programs that offers a referral system for health care providers to refer smokers to VHW-led cessation counseling is a promising and potentially scalable model for increasing access to evidence-based TDT and increasing quit rates in LMICs. TDT programs may need to adapt interventions to improve outcomes for waterpipe users.

BACKGROUND:Little is known about the risk and addiction perceptions of e-cigarettes among Asian populations. We examined e-cigarette perceptions among young adults in Hong Kong and the association between the perceptions and e-cigarette use patterns. METHODS:An online survey was administered to a convenience sample of Hong Kong residents aged 18-35 (N = 1186). Measures of e-cigarette perceptions included perceived harm and addictiveness of e-cigarettes, perceived harm of secondhand e-cigarette aerosol, and perceived popularity of e-cigarette use among peers. Separate multinomial logistic regression models were conducted to examine the associations between the four perceptions and former and current use of e-cigarettes relative to never use, controlling for demographics and current cigarette smoking status. Interactions of e-cigarette perceptions and current cigarette smoking were assessed in all models. Among current e-cigarette users, bivariate exact logistic regression models were used to examine the relationships between each of the perceptions and frequent e-cigarette use (≥3 days in past 30-day vs. 1-2 days). Among participants who had never used e-cigarettes, separate multivariable logistic regression models were conducted to examine the associations between e-cigarette perceptions and susceptibility to e-cigarette use. RESULTS:Overall, 97.2% of participants were aware of e-cigarettes, and 16.1% had tried e-cigarettes (11.3% former users; 4.8% current users). Young adults perceived e-cigarettes (and aerosol) as less harmful, less addictive, and less popular than cigarettes. Current cigarette smokers reported significantly lower perceived harmfulness and addictiveness of e-cigarettes, lower perceived harmfulness of e-cigarette aerosol, and higher perceived popularity than nonsmokers. The lower degree of harm and addiction perceptions, and higher levels of popularity perceptions were associated with greater odds of e-cigarette use, and these relationships were generally stronger among nonsmokers compared to current cigarette smokers. E-cigarette perceptions were not associated with frequent e-cigarette use. Perceiving e-cigarettes (and aerosol) as less harmful and less addictive were associated with greater susceptibility to e-cigarette use. Compared to nonsmokers, current smokers were more likely to report e-cigarette use and susceptibility. CONCLUSIONS:Continued monitoring of e-cigarette use and perceptions is needed. Educational programs should emphasize the potential harmful and addictive properties of e-cigarettes and the risks of secondhand exposure to e-cigarette aerosol.

OBJECTIVE:To characterize the prevalence of tobacco, alcohol, and drug use and the acceptability of screening in university health centers. PARTICIPANTS/METHODS:Five hundred and two consecutively recruited students presenting for primary care visits in February and August, 2015, in two health centers. METHODS:Participants completed anonymous substance use questionnaires in the waiting area, and had the option of sharing results with their medical provider. We examined screening rates, prevalence, and predictors of sharing results. RESULTS:Past-year use was 31.5% for tobacco, 67.1% for alcohol (>4 drinks/day), 38.6% for illicit drugs, and 9.2% for prescription drugs (nonmedical use). A minority (43.8%) shared screening results. Sharing was lowest among those with moderate-high risk use of tobacco (OR =0.37, 95% CI 0.20-0.69), alcohol (OR =0.48, 95% CI 0.25-0.90), or illicit drugs (OR =0.38, 95% CI 0.20-0.73). CONCLUSIONS:Screening can be integrated into university health services, but students with active substance use may be uncomfortable discussing it with medical providers.

BACKGROUND:Drug use is prevalent among electronic dance music (EDM) party attendees, but research is needed to determine the extent of adverse drug-related outcomes in this population in order to better inform prevention and harm reduction efforts. METHOD/METHODS:1029 adults were surveyed entering EDM parties in New York City in 2018. Those reporting past-year use of a drug were asked if they experienced a harmful or very unpleasant effect after use in which they were concerned about their immediate safety. They were also asked about co-use of other drugs and whether they sought help. RESULTS:We estimate that a third (33.5%) of EDM party attendees have experienced a drug-related adverse effect in the past year. Two-thirds (67.8%) of adverse effects involved use of alcohol. Relative to use, adverse effects most commonly resulted from use of opioids (e.g., prescription opioid misuse, 41.2%) or alcohol (33.9%). Among those reporting an adverse effect, concomitant use of other drugs was common, particularly among users of LSD (56.5%), ketamine (56.3%), cocaine (55.7%), and ecstasy/MDMA/Molly (47.7%). Adverse effects resulting from synthetic cathinone ("bath salt") use were most likely to result in a hospital visit (57.1%). CONCLUSION/CONCLUSIONS:Adverse effects from drug use are common among those in the EDM party scene and polydrug use appears to be a common risk factor. More research is needed, however, to determine the extent of event-specific adverse outcomes. Results can inform prevention and harm reduction efforts in this population.

Runaway and homeless youth (RHY) are dependent on the specialized settings that locate, engage, and serve them. Yet, little research has focused on the features of effective settings for RHY. The present qualitative study, grounded in the Youth Program Quality Assessment model, explored characteristics of higher quality organizations for RHY and gaps that remain from staff and RHY perspectives. A total of 29 diverse settings serving RHY in New York State were randomly selected for participation, and ranked on a quantitative program quality index. Within settings, we conducted in-depth semi-structured interviews with program administrators (N=30) and other staff (N=24). Focus group interviews were conducted with RHY (N=13 focus groups; N=84 RHY). Data were analyzed using a systematic content analysis approach that was both theory-driven and inductive, comparing higher to lower quality settings. We found all settings provided vital services and experienced challenges, but higher quality settings ameliorated challenges through 1) a youth-centered program philosophy equally understood by staff and RHY; 2) developmentally appropriate relationships between staff and RHY that promoted autonomy; 3) a focus on short- and long-term goals within anticipated crises; and 4) ongoing internal quality assessment procedures. Within lower-quality settings we found 1) difficulties retaining effective staff and 2) a primary focus on basic services and managing crises, but less attention to emotional support, exacerbated by 3) funding and other challenges emerging from the larger environment. The present study extends the literature on organizations for RHY by identifying characteristics of higher quality settings, and challenges that remain.

BACKGROUND:The highest rates of new HIV infections are observed in African Americans and Hispanics/Latinos (ethnic minority) adolescents and young adults (youth). HIV-infected ethnic minority youth are less likely to initiate and maintain adherence to antiretroviral treatment (ART) and medical care, as compared with their adult counterparts. OBJECTIVE:The objective of this research protocol was to describe our proposed methods for testing a peer-led mobile health cognitive behavioral intervention, delivered via remote videoconferencing and smartphones with HIV-infected ethnic minority youth, Adherence Connection for Counseling, Education, and Support (ACCESS). Our secondary aim was to obtain initial estimates of the biobehavioral impact of ACCESS on HIV virologic outcomes and self-reported ART adherence, beliefs and knowledge about ART treatment, adherence self-efficacy, and health care utilization (retention in care). METHODS:An exploratory, sequential mixed-methods study design will be used with conceptual determinants of adherence behavior informed by the information-motivation-behavioral skills model. HIV-infected ethnic minority youth aged 16 to 29 years with a detectable HIV serum viral load of more than 200 copies/ml (N=25) will be recruited. Qualitative pretesting will be conducted, including semistructured, in-depth, individual interviews with a convenience sample meeting the study inclusion criteria. Preliminary analysis of qualitative data will be used to inform and tailor the ACCESS intervention. Testing and implementation will include a one-group pre-posttest pilot, delivered by a trained successful peer health coach who lives with HIV and is well-engaged in HIV care and taking ART. A total of 5 peer-led remote videoconferencing sessions will be delivered using study-funded smartphones and targeting adherence information (HIV knowledge), motivation (beliefs and perceptions), and behavioral skills (self-efficacy). Participant satisfaction will be assessed with poststudy focus groups and quantitative survey methodology. Bivariate analyses will be computed to compare pre- and postintervention changes in HIV biomarkers, self-reported ART adherence, beliefs and knowledge about ART, adherence self-efficacy, and retention in care. RESULTS:As of December 2018, we are in the data analysis phase of this pilot and anticipate completion with dissemination of final study findings by spring/summer 2019. The major outcomes will include intervention feasibility, acceptability, and preliminary evidence of impact on serum HIV RNA quantitative viral load (primary adherence outcome variable). Self-reported ART adherence and retention in care will be assessed as secondary outcomes. Findings from the qualitative pretesting will contribute to an improved understanding of adherence behavior. CONCLUSIONS:Should the ACCESS intervention prove feasible and acceptable, this research protocol will contribute to a shift in existent HIV research paradigms by offering a blueprint for technology-enabled peer-led interventions and models. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)/UNASSIGNED:DERR1-10.2196/12543.

BACKGROUND:Electronic dance music (EDM) parties at nightclubs and festivals are high-risk scenes for drug use. Although intention to use drugs (such as ecstasy) has been shown to be the most proximal determinant of use, little is known regarding the extent to which drug use is unplanned in this high-risk scene. METHODS:We surveyed 954 adults entering EDM parties in New York City in 2017 and asked about planned drug use that night. A quarter (n = 236) completed the optional online follow-up survey which asked about drug use during their outing. We examined prevalence and correlates of planned and unplanned use. RESULTS:A fifth (21.0%) of attendees reported planning to use a specific drug the night of the party and over a third (35.4%) reported using a drug later that night. A quarter (26.6%) used in an unplanned manner. Unplanned marijuana use was most common (10.7%), followed by unplanned use of ecstasy (7.3%), cocaine (4.7%), amphetamine (1.4%), LSD (1.3%), and MDA (1.1%). Unplanned initiation of ecstasy and PMA also occurred. Unplanned drug use was more likely to occur among those recruited outside of nightclubs compared to festivals. Non-heterosexual participants and those with a college degree or higher were also more likely to engage in unplanned marijuana use compared to heterosexual and less educated participants, respectively. CONCLUSIONS:Unplanned drug use is common at EDM parties. Results can inform prevention and harm reduction in these scenes as unplanned use may exacerbate potential adverse outcomes related to drug use and often extreme party environments.