Faculty Bibliography

The jail-involved population-people with a history of arrest in the previous year-has high rates of illness, which leads to high costs for society. A significant percentage of jail-involved people are estimated to become newly eligible for coverage through the Affordable Care Act's expansion of Medicaid, including coverage of substance abuse treatment and mental health care. In this article we explore the need to break down the current policy silos between health care and criminal justice, to benefit both sectors and reduce unnecessary costs resulting from lack of coordination. To draw attention to the hidden costs of the current system, we review three case studies, from Washington State, Los Angeles County in California, and New York City. Each case study addresses different aspects of care needed by or provided to the jail-involved population, including mental health and substance abuse, emergency care, and coordination of care transitions. Ultimately, bending the cost curve for health care and criminal justice will require greater integration of the two systems.

PURPOSE: Relatively little is known about the prevalence of traumatic brain injury (TBI) among adolescents who come into contact with the criminal justice system. METHODS: We undertook screening for TBI among newly admitted adolescents in the New York City jail system using a validated TBI screening tool. A convenience sample of 300 male and 84 female screenings was examined. RESULTS: Screening revealed that 50% of male and 49% of female adolescents enter jail with a history of TBI. Incidence of TBI was assessed using patient health records, and revealed an incidence of 3,107 TBI per 100,000 person-years. CONCLUSIONS: Elevated prevalence and incidence of TBI among incarcerated adolescents may relate to criminal justice involvement as well as friction in jail. Given the large representation of violence as a cause of TBI among our patients, we have begun focus groups with them to elicit meaningful strategies for living with and avoiding TBI.

OBJECTIVES: We sought to better understand acts of self-harm among inmates in correctional institutions. METHODS: We analyzed data from medical records on 244 699 incarcerations in the New York City jail system from January 1, 2010, through January 31, 2013. RESULTS: In 1303 (0.05%) of these incarcerations, 2182 acts of self-harm were committed, (103 potentially fatal and 7 fatal). Although only 7.3% of admissions included any solitary confinement, 53.3% of acts of self-harm and 45.0% of acts of potentially fatal self-harm occurred within this group. After we controlled for gender, age, race/ethnicity, serious mental illness, and length of stay, we found self-harm to be associated significantly with being in solitary confinement at least once, serious mental illness, being aged 18 years or younger, and being Latino or White, regardless of gender. CONCLUSIONS: These self-harm predictors are consistent with our clinical impressions as jail health service managers. Because of this concern, the New York City jail system has modified its practices to direct inmates with mental illness who violate jail rules to more clinical settings and eliminate solitary confinement for those with serious mental illness.

Analysis of the politics of HIV programme scale-up requires critical attention to the role of the state, since the state formulates HIV policies, provides resources for the HIV response and negotiates donor involvement in HIV programmes. However, conceptual and methodological approaches to analysing states' responses to HIV remain underdeveloped. Research suggests that differences in states' successes in HIV programme scale-up reflect their levels of 'political commitment' to responding to HIV. Few empirical measures of political commitment exist, and those that do, notably the AIDS Program Effort Index (API), employ ad hoc scoring approaches to combine information from different variables into an index of commitment. The indices are thus difficult to interpret and may not have empirically useful meaning. In this paper, we apply exploratory factor analysis to examine whether, and how, selected variables that comprise the API score reflect previously theorised dimensions of political commitment. We investigate how variables associated with each of the factors identified in the analyses correspond to these theorised dimensions as well as to API categories. Finally, we discuss potential uses--such as political benchmarking and accountability--and challenges of factor analysis as a means to identify and measure states' political commitment to respond to HIV.

OBJECTIVE: In the context of continued high rates of condomless anal intercourse and HIV-1 infection, young men who have sex with men (YMSM) need additional effective and desirable HIV prevention tools. This study reports on the willingness of a racially-ethnically diverse cohort of YMSM to use a new biomedical prevention approach, a long-acting injectable pre-exposure prophylaxis (LAI-PrEP) agent. METHODS: A cross-sectional study conducted between June-August 2013 recruited participants from an ongoing cohort study of YMSM in NYC. Participants included 197 YMSM, of whom 72.6% (n = 143) identified as men of color. Two outcomes were measured through computer-assisted self-interviews: 1) willingness to use long-acting injectable PrEP and 2) preference for route of administration of PrEP. In addition, concerns about perceived impacts of PrEP on health and risk behavior, access to health services, and stigma were investigated. RESULTS: Over 80% (n = 159/197, p<0.001) of participants stated they would be willing to use LAI-PrEP. With regards to preference for mode of delivery 79.2% (n = 156/197, p<0.001) stated they would prefer an injection administered every three months over a daily pill or neither one. CONCLUSIONS: This study is the first to explore acceptability of LAI-PrEP in the US. A significant majority of participants expressed willingness to use LAI and the majority preferred LAI-PrEP. LAI-PrEP holds great promise in that it could circumvent the adherence challenges associated with daily dosing, especially if nested within appropriate psycho-behavioral support. Medical providers whose patients include YMSM at high risk for HIV infection should note the positive attitudes toward PrEP, and specifically LAI-PrEP.

Few studies have examined how social support network characteristics are related to perceived receipt of social support among male sexual minority youth. Using egocentric network data collected from a study of male sexual minority youth (n=592), multivariable logistic regression analyses examined distinct associations between individual and social network characteristics with receipt of (1) emotional and (2) material support. In multivariable models, frequent communication and having friends in one's network yielded a two-fold increase in the likelihood of receiving emotional support whereas frequent communication was associated with an almost three-fold higher likelihood of perceived material support. Finally, greater internalized homophobia and personal experiences of gay-related stigma were inversely associated with perceived receipt of emotional and material support, respectively. Understanding the evolving social context and social interactions of this new generation of male sexual minority youth is warranted in order to understand the broader, contextual factors associated with their overall health and well-being.

The prevalence of cigarette smoking and the relations between smoking and HIV clinical markers, HIV medication adherence, and opportunistic infections (OIs) were examined in a sample of 199 HIV-positive, gay, bisexual, and other men who have sex with men (MSM) aged 50 and older. Overall, 35.7% were current smokers, 35.7% were former smokers, and 28.6% were never smokers. In the final multivariable polytomous logistic regression model controlling for age, income, and illicit drug use, current smokers were less likely to report an undetectable viral load as compared to never and former smokers. Relative to never smokers, former smokers were more likely to report respiratory OIs, and current smokers were more likely to report gastrointestinal OIs. This study demonstrates high prevalence of cigarette smoking among aging, HIV-positive MSM and provides additional evidence for a relationship between smoking and poorer HIV clinical markers. Targeted and tailored smoking cessation programs within the context of HIV care services are warranted.