Faculty Bibliography

BACKGROUND:Although periods of HIV antiretroviral therapy (ART) discontinuation have deleterious health effects, ART is not always sustained. Yet, little is known about factors that contribute to such ART non-persistence among long-term HIV survivors. The present study applied a convergent parallel mixed-methods design to explore the phenomena of stopping/starting and sustaining ART, focusing on low-socioeconomic status African American or Black and Latino persons living with HIV (PLWH) who face the greatest challenges. METHODS:Participants (N = 512) had poor engagement in HIV care and detectable HIV viral load. All received structured assessments and N = 48 were randomly selected for in-depth interviews. Quantitative analysis using negative binomial regression uncovered associations among multi-level factors and the number of times ART was stopped/started and the longest duration of sustained ART. Qualitative data were analyzed using a directed content analysis approach and results were integrated. RESULTS:Participants were diagnosed 18.2 years ago on average (SD = 8.6), started ART a median five times (Q1 = 3, Q3 = 10), and the median longest duration of sustained ART was 18 months (Q1 = 6, Q3 = 36). Factors associated with higher rates of stops/starts were male sex, transgender identity, cannabis use at moderate-to-high-risk levels, and ART- and care-related stigma. Factors associated with lower rates of stops/starts were older age, more years since diagnosis, motivation for care, and lifetime injection drug use (IDU). Factors associated with longer durations of sustained ART were Latino/Hispanic ethnicity, motivation for ART and care, and recent IDU. Factors associated with a shorter duration were African American/Black race, alcohol use at moderate-to-high-risk levels, and social support. Qualitative results uncovered a convergence of intersecting risk factors for stopping/starting ART and challenges inherent in managing HIV over decades in the context of poverty. These included unstable housing, which contributed to social isolation, mental health distress, and substance use concerns, the latter prompting selling ("diverting") ART. Primarily complementary quantitative and qualitative findings described mechanisms by which risk/protective factors operated and ways PLWH successfully restart and/or sustain ART. CONCLUSIONS:The field focuses substantially on ART adherence, but greater attention to reducing the frequency of ART non-persistence is needed, along with creating social/structural conditions favorable for sustained ART.

The mental health impact of exposure to police harassment is understudied, particularly among Black men who have sex with men (BMSM), a group at elevated risk of exposure to such discrimination. This study aimed to identify the associations among BMSM between recent police harassment and psychosocial vulnerability, psychological distress, and depression measured six months later. Data come from the HIV Prevention Trials Network (HPTN) 061 Study, a cohort study of BMSM recruited in 6 U.S. cities (Atlanta, GA, Boston, MA, Los Angeles, CA, New York, NY, San Francisco, CA, and Washington DC). Participants completed baseline, 6-month follow-up, and 12-month follow-up interviews. A convenience sample of 1553 BMSM was recruited between July 2009 and October 2010 of whom 1155 returned for a follow-up interview 12 months later. Accounting for previous police interaction, poverty, psychopathology, drug use, and alcohol use, we estimated associations between recent police harassment reported at the 6 month follow-up interview and 12 month outcomes including psychosocial vulnerability (elevated racial/sexual identity incongruence), psychological distress (being distressed by experiences of racism and/or homophobia), and depression. About 60% of men reported experiencing police harassment between the baseline and 6-month interview due to their race and/or sexuality. Adjusted analyses suggested police harassment was independently associated with a 10.81 (95% CI: 7.97, 13.66) point increase and 8.68 (95% CI: 6.06, 11.30) point increase in distress due to experienced racism and distress due to experienced homophobia scores, respectively. Police harassment perceived to be dually motivated predicted disproportionate levels of distress. Police harassment is prevalent and associated with negative influences on psychosocial vulnerability and psychological distress among BMSM. Reducing exposure to police harassment may improve the psychosocial health of BMSM.

The COVID-19 pandemic has great potential to disrupt the lives of persons living with HIV (PLWH). The present convergent parallel design mixed-methods study explored the early effects of COVID-19 on African American/Black or Latino (AABL) long-term survivors of HIV in a pandemic epicenter, New York City. A total of 96 AABL PLWH were recruited from a larger study of PLWH with non-suppressed HIV viral load. They engaged in structured assessments focused on knowledge, testing, trust in information sources, and potential emotional, social, and behavioral impacts. Twenty-six of these participants were randomly selected for in-depth semi-structured interviews. Participants were mostly men (64%), African American/Black (75%), and had lived with HIV for 17 years, on average (SD=9 years). Quantitative results revealed high levels of concern about and the adoption of recommended COVID-19 prevention recommendations. HIV care visits were commonly canceled but, overall, engagement in HIV care and antiretroviral therapy use were not seriously disrupted. Trust in local sources of information was higher than trust in various federal sources. Qualitative findings complemented and enriched quantitative results and provided a multifaceted description of both risk factors (e.g., phones/internet access were inadequate for some forms of telehealth) and resilience (e.g., "hustling" for food supplies). Participants drew a direct line between structural racism and the disproportional adverse effects of COVID-19 on communities of color, and their knowledge gleaned from the HIV pandemic was applied to COVID-19. Implications for future crisis preparedness are provided, including how the National HIV/AIDS Strategy can serve as a model to prevent COVID-19 from becoming another pandemic of the poor.

PURPOSE/OBJECTIVE:To improve testing coverage, it is imperative to determine adolescent girls and young women (AGYW) preferences about HIV testing modality and where they prefer receiving services. METHODS:Participants were enrolled between May 2017 and April 2018 from three sites in Homa Bay County, Nyanza region, western Kenya. We explored two recruitment approaches (home-based vs. mobile-event based) and three HIV testing options (oral self-test, staff-administered, or referral to health facility). Exact logistic regression compared yield of newly diagnosed HIV and high-risk HIV-negatives from the recruitment and testing option strategies. RESULTS:A total of 1,198 participants were enrolled, 1,046 (87.3%) at home and 152 (12.7%) at mobile events. Most participants (928, 77.5%) chose staff-aided testing either at home or at a mobile event; 268 (22.4%) chose self-testing; and only 2 (.2%) chose facility referral. Prevalence of newly diagnosed HIV-positives was 2.7% (32/1,198) and 36.8% (429/1,166) of HIV-negative AGYW were identified as high risk. We identified more newly diagnosed HIV infection among AGYW recruited at mobile events than at home (OR = 3.11; 95% CI: 1.33-6.74; p = .02). High-risk status was related to neither recruitment strategy nor testing modality. Older age was associated with increased odds of selecting an oral self-test (OR = 1.85; 95% CI: 1.06-3.22). CONCLUSIONS:More than one-third of AGYW were at elevated risk of HIV infection, and those unaware of their HIV infection were more likely to be identified at a mobile outreach. Though self-testing was not the dominant preferred strategy, self-tests were performed accurately and with high confidence. These findings can help inform efficient identification of undiagnosed HIV infection and high risk for seroconversion among AGYW in similar settings.

Black men who have sex with men (BMSM) have disproportionate HIV/STI acquisition risk. Incarceration may increase exposure to violence and exacerbate psychosocial vulnerabilities, including internalized homophobia, which are associated with HIV/STI acquisition risk. Using data from HIV Prevention Trials Network 061 (N = 1553), we estimated adjusted prevalence ratios (APR) and 95% confidence intervals (CIs) for associations between lifetime burden of incarceration and HIV/STI risk outcomes. We measured associations between incarceration and HIV/STI risk outcomes with hypothesized mediators of recent violence victimization and internalized homophobia. Compared to those never incarcerated, those with 3-9 or ≥ 10 incarcerations had approximately 10% higher prevalence of multiple partnerships. Incarceration burden was associated with selling sex (1-2 incarcerations: APR: 1.52, 95% CI 1.14-2.03; 3-9: APR: 1.77, 95% CI 1.35-2.33; ≥ 10: APR: 1.85, 95% CI 1.37-2.51) and buying sex (≥ 10 incarcerations APR: 1.80, 95% CI 1.18-2.75). Compared to never incarcerated, 1-2 incarcerations appeared to be associated with current chlamydia (APR: 1.47, 95% CI 0.98-2.20) and 3-9 incarcerations appeared to be associated with current syphilis (APR: 1.46, 95% CI 0.92-2.30). Incarceration was independently associated with violence, which in turn was a correlate of transactional sex. Longitudinal research is warranted to clarify the role of incarceration in violence and HIV/STI risk in this population.

Research Objective: Studies have found that race/ethnicity concordance between patients and providers improves medication adherence among patients with hypertension and single CVD outcomes (eg, blood pressure control). Our objective was to examine the association of patient-physician race/ethnicity concordance on adherence to the Million Hearts "ABCS" CVD guidelines: (A) aspirin when indicated, (B) blood pressure control, (C) cholesterol management, and (S) smoking screening and cessation. To the best of our knowledge, this is the first study to examine the impact of race/ ethnicity concordance on guideline adherence to multiple CVD outcome measures.
Study Design: This study was part of HealthyHearts NYC, a stepped-wedge cluster randomized controlled trial funded through AHRQ's EvidenceNOW initiative to test the effectiveness of practice facilitation on helping primary care practices adhere to CVD guidelines. The main outcomes were the Million Hearts' ABCS measures. Two additional measures were created: (a) proportion of patients who use tobacco who received a cessation intervention (smokers counseled) and (b) a composite measure that assessed the proportion of patients meeting treatment targets for A, B, and C (ABC composite). Practice-level outcome data were extracted for thirteen quarters from practices' electronic health record (EHR) systems, encompassing the control, intervention, and follow-up periods of the intervention. Patient-physician race/ethnicity concordance was calculated using patient race/ethnicity data extracted from the practices' EHR and physician race/ethnicity data collected via a Provider Survey. The concordance measure was calculated as the proportion of patients with the same race/ethnicity as the physician, for example, if practice is led by an Asian physician, and patients are 33% non-Hispanic white, 5% non-Hispanic black, 5% Hispanic, and 57% Asian, the concordance is 0.57. Population Studied: 211 small primary care practices in NYC. Principal Findings: 57.7% of Hispanic, 53.6% of black, 73.6% of Asian, 74.2% of non-Hispanic white, and 24.1% of Hawaiian/Pacific Islander patients had the same race/ethnicity as their physicians. 44.7% of physicians had the same race/ethnicity as at least 70% of their patients. Patient-physician race/ethnicity concordance was associated with adherence to four of our six outcome measures: aspirin (IRR = 1.08, 95% CI: 1.03-1.14, P < .001); blood pressure (IRR = 1.09, 95% CI: 1.07-1.12, P < .001); smoking screening and cessation (IRR = 1.06, 95% CI: 1.04-1.08, P < .001); and ABC composite (IRR = 1.42, 95% CI: 1.33-1.52, P < 0.001). We did not find an association for race/ethnicity concordance with Cholesterol and Smokers Counseled.
Conclusion(s): Increasing opportunities for patient-physician race/ ethnicity concordance may improve adherence to CVD guidelines. The largest improvement was observed in the ABC Composite measure, suggesting that patient-physician race/ethnicity concordance is particularly important for managing medically complex patients who have multiple chronic diseases. Implications for Policy or Practice: Health policy should fund programs that support the recruitment and retention of a wide diversity of students and faculty to increase the level of concordance in patient-clinician encounters. Policy makers may also want to consider legislation to help support or protect small practices that predominantly serve communities of color, where a large proportion of the physicians may be racially/ ethnically concordant with the patient population. Medical education programs should incorporate patient-physician communication training to minimize gaps potentially created by race/ethnicity discordance

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.