Faculty Bibliography

Background:A "seek-test-treat" intervention (ARISTOTLE) was implemented in response to an outbreak of human immunodeficiency virus (HIV) infection among persons who inject drugs (PWID) in Athens. We assess trends in HIV incidence, prevalence, risk behaviors and access to prevention/treatment. Methods:Methods included behavioral data collection, provision of injection equipment, HIV testing, linkage to opioid substitution treatment (OST) programs and HIV care during 5 rounds of respondent-driven sampling (2012-2013). HIV incidence was estimated from observed seroconversions. Results:Estimated coverage of the target population was 88% (71%-100%; 7113 questionnaires/blood samples from 3320 PWID). The prevalence of HIV infection was 16.5%. The incidence per 100 person-years decreased from 7.8 (95% confidence interval, 4.6-13.1) (2012) to 1.7 (0.55-5.31) (2013; P for trend = .001). Risk factors for seroconversion were frequency of injection, homelessness, and history of imprisonment. Injection at least once daily declined from 45.2% to 18.8% (P < .001) and from 36.8% to 26.0% (P = .007) for sharing syringes, and the proportion of undiagnosed HIV infection declined from 84.3% to 15.0% (P < .001). Current OST increased from 12.2% to 27.7% (P < .001), and 48.4% of unlinked seropositive participants were linked to HIV care through 2013. Repeat participants reported higher rates of adequate syringe coverage, linkage to HIV care and OST. Conclusions:Multiple evidence-based interventions delivered through rapid recruitment in a large proportion of the population of PWID are likely to have helped mitigate this HIV outbreak.

BACKGROUND:Housing instability has been associated with poor health outcomes among people who inject drugs (PWID). This study investigates the associations of local-level housing and economic conditions with homelessness among a large sample of PWID, which is an underexplored topic to date. METHODS:PWID in this cross-sectional study were recruited from 19 large cities in the USA as part of National HIV Behavioral Surveillance. PWID provided self-reported information on demographics, behaviours and life events. Homelessness was defined as residing on the street, in a shelter, in a single room occupancy hotel, or in a car or temporarily residing with friends or relatives any time in the past year. Data on county-level rental housing unaffordability and demand for assisted housing units, and ZIP code-level gentrification (eg, index of percent increases in non-Hispanic white residents, household income, gross rent from 1990 to 2009) and economic deprivation were collected from the US Census Bureau and Department of Housing and Urban Development. Multilevel models evaluated the associations of local economic and housing characteristics with homelessness. RESULTS:Sixty percent (5394/8992) of the participants reported homelessness in the past year. The multivariable model demonstrated that PWID living in ZIP codes with higher levels of gentrification had higher odds of homelessness in the past year (gentrification: adjusted OR=1.11, 95% CI=1.04 to 1.17). CONCLUSIONS:Additional research is needed to determine the mechanisms through which gentrification increases homelessness among PWID to develop appropriate community-level interventions.

OBJECTIVES:To examine whether racial/ethnic disparities persist at the "end of the HIV epidemic" (prevalence of untreated HIV infection < 5%; HIV incidence < 0.5 per 100 person-years) among persons who inject drugs (PWID) in New York City. METHODS:We recruited 2404 PWID entering New York City substance use treatment in 2001 to 2005 and 2011 to 2015. We conducted a structured interview, and testing for HIV and herpes simplex virus 2 (HSV-2; a biomarker for high sexual risk). We estimated incidence by using newly diagnosed cases of HIV. Disparity analyses compared HIV, untreated HIV, HIV-HSV-2 coinfection, HIV monoinfection, and estimated HIV incidence among Whites, African Americans, and Latinos. RESULTS:By 2011 to 2015, Whites, African Americans, and Latino/as met both criteria of our operational "end-of-the-epidemic" definition. All comparisons that included HIV-HSV-2-coinfected persons had statistically significant higher rates of HIV among racial/ethnic minorities. No comparisons limited to HIV monoinfected persons were significant. CONCLUSIONS:"End-of-the-epidemic" criteria were met among White, African American, and Latino/a PWID in New York City, but elimination of disparities may require a greater focus on PWID with high sexual risk.

BACKGROUND:Assaultive violence events are associated with increased risk for adverse psychiatric outcomes, including post-traumatic stress (PTS), depression, and generalized anxiety. Prior research has indicated that economic, legal, and social stressors that could follow assaultive events may explain the increased risk for adverse psychiatric outcomes, yet longitudinal studies have not adequately examined this pathway. In the current study, we aimed to address this limitation. METHODS:Participants (N = 1360) were part of a longitudinal population-based study of adults living in Detroit. At three waves, participants indicated their exposure to assaultive violence and economic, legal, and social stressors, and completed inventories of PTS, depression, and generalized anxiety. Longitudinal mediation models were used to test the hypothesized pathway from assaultive violence to each psychiatric outcome. RESULTS:The hypothesized models evidenced good fit with the data and, in each, the paths from Wave 1 (W1) assaultive violence to W2 stressors, and from W2 stressors to W3 symptoms were significant (range of Standardized Estimates: 0.09-0.15, all p < 0.01). Additionally, the indirect paths from W1 assaultive violence to W3 symptoms were significant (range of Standardized Estimates: 0.01-0.02, all p < 0.05). CONCLUSIONS:The findings illustrate that the economic, legal, and social stressors that could follow assaultive violence increase risk for a range of psychiatric symptoms. Although future research is needed, the results suggest that investment in interventions that prevent and mitigate assaultive violence survivors' exposure to such stressors may be an effective way to prevent mental illness in the aftermath of violent assaults.

The pathways through which neighborhood poverty can affect resident depression are still unknown. We investigated mechanisms through which neighborhood poverty may influence depression among older adults. Participants were drawn from the New York City Neighborhood and Mental Health in the Elderly Study II, a 3-wave study of adults aged 65-75 (n=3,497) at baseline. Neighborhood poverty and homicide were associated with depressive symptoms at follow-up waves (RR:1.20, 95%CI: 1.05, 1.36; RR: 1.09, 95%CI: 1.02, 1.17, respectively). Homicide accounted for 30% of the effect of neighborhood poverty on depressive symptoms. Neighborhood exposure to violence may be a key mechanism through which neighborhood poverty influences depression among older adults.

Neighborhood physical disorder-the visual indications of neighborhood deterioration-may inhibit outdoor physical activity, particularly among older adults. However, few previous studies of the association between neighborhood disorder and physical activity have focused on this sensitive population group, and most have been cross-sectional. We examined the relationship between neighborhood physical disorder and physical activity, measured using the Physical Activity Scale for the Elderly (PASE), in a three-wave longitudinal study of 3497 New York City residents aged 65-75 at baseline weighted to be representative of the older adult population of New York City. We used longitudinal mixed linear regression controlling for a number of individual and neighborhood factors to estimate the association of disorder with PASE score at baseline and change in PASE score over 2 years. There were too few subjects to assess the effect of changes in disorder on activity levels. In multivariable mixed regression models accounting for individual and neighborhood factors; for missing data and for loss to follow-up, each standard deviation increase in neighborhood disorder was associated with an estimated 2.0 units (95% CI 0.3, 3.6) lower PASE score at baseline, or the equivalent of about 6 min of walking per day. However, physical disorder was not related to changes in PASE score over 2 years of follow-up. In this ethnically and socioeconomically diverse population of urban older adults, residents of more disordered neighborhoods were on average less active at baseline. Physical disorder was not associated with changes in overall physical activity over time.

BACKGROUND:Recently, social movements across the world have demanded reforms to education systems and other institutions. Although such movements have affected large numbers of people across multiple countries, we know little about the impacts they have had on population health. We focus on one example: the massive strikes and collective occupation of secondary schools across Chile, which occurred contemporaneously with a large increase in marijuana use among students in this age group. We aimed to evaluate the causal effects that the 2011 Chilean school strikes had on adolescent substance use, including the initiation of marijuana use and the use of alcohol and marijuana. METHODS:School-level, aggregated panel design using data from the National Drug Surveys among Secondary Students from 2005 to 2015 for students in grades 9-12. We used a fixed-effects difference-in-difference model to estimate the effect of school occupations on prevalence of self-reported indicators of drug use. RESULTS:Reported marijuana use doubled between 2009 and 2013 among Chilean adolescents. After controlling for secular trends in outcomes and for school characteristics, there was no evidence of increased marijuana initiation, alcohol and marijuana use, or of an increase in heavy use among adolescents being directly attributable to school strikes and occupations in 2011. CONCLUSIONS:The 2011 Occupy school movement in Chile had no detectable causal effect on substance use among Chilean adolescents. The increase in marijuana use from 2009 to 2013 seems to be part of broader social changes occurring among the school-age population.