The impact of socio-environmental factors on doxycycline post-exposure prophylaxis awareness in the US: a cross-sectional study

Background We investigated awareness and use of doxycycline post-exposure prophylaxis (doxyPEP) in the US. DoxyPEP has preventative benefits for bacterial STIs among people assigned male at birth. We considered how individual, interpersonal and social determinants of health, such as state-level LGBTQ equality, impact doxyPEP awareness. Methods We conducted an online snapshot cross-sectional survey in June 2023. Survey questions included demographics, sexual and substance use behaviours, and socio-environmental factors, and provided a short explanation of doxyPEP, with questions regarding prior awareness and use. Results Among a racially diverse sample of 196 participants (median age 33 years), 94% identified as cisgender men, 26% were aware of doxyPEP, whereas only 14 (7%) had ever used it. Factors significantly associated with awareness included being college educated (OR 2.50, 95% CI 1.09-5.74), a past year bacterial STI (OR 4.20, 95% CI 1.97-8.89), having discussed HIV pre-exposure prophylaxis with a health care provider (OR 3.88, 95% CI 1.99-7.57) and having taken HIV pre-exposure prophylaxis (OR 2.29, 95% CI 1.11-4.70). Socio-environmental factors associated with doxyPEP awareness included living in a large urban city (OR 2.14, 95% CI 1.12-4.10) and living in a state with higher levels of LGBTQ policy equality (OR 2.18, 95% CI 1.07-4.44). Conclusions Considering the disproportionate impact of bacterial STIs on men who have sex with men, especially those living in lower LGBTQ equality regions, such as the Southern US, our study emphasises how socio-environmental factors may limit awareness and uptake of novel biomedical approaches that have the potential to prevent morbidity and enhance sexual health.

Stigma Related to the Non-Medical Use and Diversion of Prescription Stimulant Drugs: Should We Care

BACKGROUND

Non-medical use (NMU) and diversion of prescription stimulants are prevalent on college campuses. Diversion represents a primary source of acquisition for NMU among young adults. This study examined relationships between stigmatizing beliefs related to NMU and diversion of stimulant medications and engagement in these behaviors, as well as how such perceptions are associated with indicators of psychological distress among those who engage in these behaviors.

METHODS

Young adults (N = 384) were recruited from a large US university to participate in this cross-sectional electronic survey-based study. Relationships between stigma variables and NMU and diversion were assessed. Among those who engage in NMU and diversion, we tested relationships between stigma variables and indicators of psychological distress, using validated instruments.

RESULTS

Perceived social and personal stigmatic beliefs did not significantly predict NMU. However, perceived social and personal stigma of diversion significantly reduced diversion likelihood. For NMU, associations were found between stigma variables and indicators of psychological distress. Markedly, we found that as stigmatic perceptions of NMU increased, so did depressive, anxiolytic, and suicidal symptomatology among those who engage in NMU.

CONCLUSIONS

Stigmatization does not deter NMU; however, stigmatization is positively associated with psychological harm among those who engage in NMU. Interventions should be developed to reduce stigmatization in order to improve psychological health among those who engage in NMU. Stigmatic perceptions of diversion were not predictive of psychological harm, though they are negatively associated with diversion behavior.

Gabapentin Use Among Individuals Initiating Buprenorphine Treatment for Opioid Use Disorder

Importance

Gabapentin prescriptions have drastically increased in the US due to off-label prescribing in settings such as opioid use disorder (OUD) treatment to manage a range of comorbid conditions and withdrawal symptoms, despite a lack of evidence.

Objective

To assess the purpose and associated risks of off-label gabapentin use in OUD treatment.

Design, Setting, and Participants

This retrospective recurrent-event case-control study with a crossover design used administrative claims data from MarketScan Commercial and Multi-State Medicaid databases from January 1, 2006, to December 31, 2016. Individuals aged 12 to 64 years with an OUD diagnosis and filling buprenorphine prescriptions were included in the primary analysis conducted from July 1, 2022, through June 1, 2023. Unit of observation was the person-day.

Exposures

Days covered by filled gabapentin prescriptions.

Main Outcomes and Measures

Primary outcomes were receipt of gabapentin in the 90 days after initiation of buprenorphine treatment and drug-related poisoning. Drug-related poisonings were defined using codes from International Classification of Diseases, Ninth Revision, and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision.

Results

A total of 109 407 patients were included in the analysis (mean [SD] age, 34.0 [11.2] years; 60 112 [54.9%] male). Among the 29 967 patients with Medicaid coverage, 299 (1.0%) were Hispanic, 1330 (4.4%) were non-Hispanic Black, 23 112 (77.1%) were non-Hispanic White, and 3399 (11.3%) were other. Gabapentin was significantly less likely to be prescribed to Black or Hispanic patients, and more likely to be prescribed to female patients, those with co-occurring substance use or mood disorders, and those with comorbid physical conditions such as neuropathic pain. Nearly one-third of persons who received gabapentin (4336 [31.1%]) had at least 1 drug-related poisoning after initiating buprenorphine treatment, compared with 13 856 (14.5%) among persons who did not receive gabapentin. Adjusted analyses showed that days of gabapentin use were not associated with hospitalization for drug-related poisoning (odds ratio, 0.98 [95% CI, 0.85-1.13]). Drug-related poisoning risks did not vary based on dosage.

Conclusions and Relevance

Gabapentin is prescribed in the context of a myriad of comorbid conditions. Even though persons receiving gabapentin are more likely to have admissions for drug-related poisoning, these data suggest that gabapentin is not associated with an increased risk of drug-related poisoning alongside buprenorphine in adjusted analyses. More data on the safety profile of gabapentin in OUD settings are needed.

Associations Between Kratom-Related State Policy Environments and Kratom Use in a Nationally Representative Population in the United States

Limited research has resulted in conflicting views on the risks versus benefits associated with kratom use. Despite no federal policy in the United States, individual states have implemented diverging policies through kratom bans, and legalization and regulation through Kratom Consumer Protection Acts (KCPAs). The Survey of Non-Medical Use of Prescription Drugs (NMURx) Program employs nationally-representative, repeated cross-sectional surveys on drug use. In 2021, weighted prevalence of past-12 month kratom use was compared across three state legal frameworks: no overarching state policy, KCPAs, and state bans. There was lower estimated prevalence of kratom use in banned states (prevalence: 0.75% (0.44, 1.06) relative to states with a KCPA (1.20% (0.89, 1.51)), and relative to states with no policies (1.04% (0.94, 1.13), though odds of use were not significantly associated with policy type. Kratom use was significantly associated with medicated treatment for opioid use disorder. While there were observed differences in the prevalence of past-12 month kratom use by state policy type, low uptake mitigated meaningful distinctions by limiting statistical precision, and potentially confounding effects, such as accessibility online. Future kratom-related policy decisions should be informed through evidence-based research.

Young Adult Nightclub Participants Who Attend Adult Entertainment Clubs: Sexual Risk and Substance Use Behaviors

This secondary analysis of cross-sectional baseline data from an intervention trial study examines demographics, sexually transmitted infection (STI) history, substance use and sexual risk behaviors among young adult nightclub participants who do (n = 79) and do not (n = 419) frequent "strip" or adult entertainment clubs (AECs) in Miami, Florida. AEC patrons were older, and more likely to identify as Black race and report STI history. Compared to those who do not, AEC patrons also reported greater recent (past 90-day) frequencies of alcohol and ecstasy use, higher numbers of recent sex partners and were more likely to report recently being high during sex a majority of the time. Increased HIV/STI prevention efforts among young adult AEC patrons appear warranted.

Associations of Transactional Sex and Sexually Transmitted Infections Among Treatment-Seeking Individuals With Opioid Use Disorder

INTRODUCTION

Coinciding with the rise in opioid use across the U.S., the rates of sexually transmitted infections have reached historically high levels, underscoring the need to understand multiple pathways of disease spread. Although prevention is often focused on injection-related behaviors, this study sought to identify the prevalence and associations of a little understood pathway, transactional sex, among individuals with opioid use disorder, including associations of transactional sex with the prevalence of sexually transmitted infection diagnoses.

METHODS

Data were sourced from a nationwide opioid surveillance program of treatment-seeking individuals with opioid use disorder utilizing a serial, cross-sectional survey of 4,366 new entrants to 1 of 99 substance use treatment programs for opioid use disorder in 37 states from October 2018 to June 2021.

RESULTS

A quarter of the sample (24.9%) self-reported a lifetime history of transactional sex for drugs, with rates highest for sexual (56.6%) and gender (53.8%) minority, female (33.4%), Latinx (30.4%), and Black (29.6%) subgroupings. Lifetime diagnoses of all specific sexually transmitted infections analyzed were significantly higher (p<0.001) among those reporting transactional sex, particularly syphilis (14.3% vs 4.4%) and HIV (4.0 vs 0.9%). Financial hardship, trauma, and psychiatric disorder were significantly associated with transactional sex engagement.

CONCLUSIONS

Transactional sex is relatively common among patients with opioid use disorder, particularly among sexual/gender minorities, which was associated with a greater lifetime prevalence of all sexually transmitted infections assessed. Sexually transmitted infection testing remains at low levels within substance use treatment programs, occurring in just 26.3% of programs; sexual health screenings and sexually transmitted infection prevention/testing need to be prioritized and integrated into opioid use disorder patient care.

Understanding motivations and use typologies of gabapentin with opioid agonist medications

BACKGROUND

Prior research suggests a potential relationship between the nonmedical use of gabapentin and use of opioid agonist medications (OAMs), buprenorphine and methadone. However, this research has been limited in scope and understanding despite increases in gabapentin prescribing in opioid use disorder (OUD) treatment settings and increased detection in opioid overdose fatalities.

METHODS

Data were analyzed for 346 participants of a follow-up program to an ongoing national opioid surveillance program of new entrants to treatment for opioid use disorder. Data were sourced from a cross-sectional online survey distributed in July/August 2021.

RESULTS

Lifetime exposure to gabapentin was reported by 60.0 % of the sample, while lifetime history of nonmedical use was reported by 43.2 %. Of those nonmedically using gabapentin, 50.0 % did so while also on a dosage of either buprenorphine or methadone, with 28.4 % engaged in concurrent nonmedical use of both gabapentin and OATs. Motivations for concurrent nonmedical use included high-seeking (38.6 %), self-management of pain/physical symptoms (33.3 %), and self-management of OUD (22.2 %).

CONCLUSIONS

Gabapentin exposure in treatment-seeking persons with OUD appears to be quite common, and use, both medically and nonmedically, frequently occurs alongside OAMs. Motivations for concurrent nonmedical use of gabapentin and OATs mirrors motivations for off-label prescribing by healthcare providers, but may also serve as a form of self-management of OUD when OAM regimens are interrupted, insufficiently prescribed or prescribed at insufficient dosages. Further research should seek to understand the risks versus benefits of gabapentin in OAM treatment settings.

Nonmedical use of gabapentin and opioid agonist medications in treatment-seeking individuals with opioid use disorder

BACKGROUND

As prescriptions for gabapentin have increased in recent years, nonmedical use and risk of adverse outcomes (e.g., hospitalizations and overdose) have been identified, particularly in association with opioids, including opioid agonist medications (OAMs) buprenorphine and methadone. However, there is a lack of systematic, nationwide data assessing the relationship between the nonmedical use of gabapentin and OAMs.

METHODS

Data were sourced from two nationwide opioid surveillance programs of treatment-seeking individuals with opioid use disorder (OUD). Both programs utilized an identical serial, cross sectional survey of 12,792 new entrants to one of 163 substance use treatment programs for OUD in 46 states and the District of Columbia from January 2019 to December 2020.

RESULTS

Past month nonmedical use of gabapentin was endorsed by 9.3% of the sample. Of those using gabapentin nonmedically, 64.1% also endorsed nonmedical use of an OAM, including concomitant use of methadone (35.3%), and buprenorphine (49.0%). Concomitant nonmedical use of gabapentin and OAMs was more prevalent (versus nonmedical use of gabapentin alone) in the Southern region, among those living in a street dwelling, those with chronic pain and healthcare professionals.

CONCLUSIONS

Nonmedical use of gabapentin in people with OUD appears to frequently coincide with nonmedical use of OAMs. As prescriptions and off-label use of gabapentin increase, provider education should include the risks of concomitant gabapentin and OAM use, particularly amongst buprenorphine prescribers. Future research should investigate motivations (e.g., OUD self-management) for nonmedical use of gabapentin and OAMs within the context of OUD treatment access and retention.

Increasing rates of buprenorphine diversion in the United States, 2002 to 2019

PURPOSE

Recent reports suggest that buprenorphine is being diverted and used non-medically. However, no apparent studies have reported national-level data on buprenorphine diversion.

METHODS

Case report data were drawn from a quarterly survey of prescription drug diversion completed by a national sample of law enforcement and regulatory agencies who engage in drug diversion investigations. Quarterly rates of buprenorphine diversion per 100 000 population and 100 000 prescriptions dispensed were calculated for the period 2002 through 2019. Population-based diversion rates were also calculated by U.S. region.

RESULTS

In total, 9670 cases of diverted buprenorphine were reported across all 50 states and the District of Columbia during the study period. Buprenorphine diversion rates, per 100 000 population, were characterized by an accelerating increase over time; increases in diversion rates from 1st quarter 2002 through 4th quarter 2006 were not statistically significant, yet from 1st quarter 2007 through 4th quarter 2019, the rate of diversion cases increased by 0.0067 cases per 100 000 per quarter (p < 0.001). Buprenorphine diversion rates per 100 000 prescriptions dispensed indicated a gradual increase over time; from 3rd quarter 2010 through 4th quarter 2019, diversion rates showed a statistically significant increase of 0.28 cases (p = 0.037) per quarter on average. The Northeast was the only region that did not observe an increase in the average quarterly change in buprenorphine diversion rates after 2006.

CONCLUSIONS

Findings from this study illustrate longitudinal national trends of increasing buprenorphine diversion. Continued systematic surveillance of this phenomenon is needed.

Ride hailing app use and drunk/drugged driving among young adult nightclub patrons

OBJECTIVE

Nightclub patrons who consume alcohol and drugs in these venues would appear to be an important population to target with on-demand ride hailing app (RHA) services to reduce drunk/drugged driving (DUI). The present study is an exploratory examination of RHA use to avoid DUI behavior, as well as the perceived barriers and benefits of such RHA use, among young adult nightclub patrons in Miami who use drugs.

METHODS

Completers of a 2011-2015 randomized controlled trial of brief interventions to reduce health risk behaviors among young adult nightclub patrons were recruited to participate in a single self-administered computer-assisted interview about health risks, driving behaviors, and RHA perceptions and use. Recruitment (N = 123) began in June 2016 and ended in July 2017. Bivariable logistic regression and ANOVA models examined group differences between: (a) those who had used an RHA to avoid DUI vs. not; and (b) those who used RHAs as their primary mode of transportation to nightclubs vs. not.

RESULTS

About half were female (52.8%); median age was 29; 59.4% Hispanic, 31.7% Black, 8.1% white, 0.8% other race/ethnicity. Recent alcohol and marijuana use were almost universally endorsed, and more than half reported recent use/misuse of cocaine (72.4%), MDMA (63.4%), and prescription benzodiazepines (62.6%) and opioids (56.9%). More than 80% reported driving under the influence of alcohol and/or drugs in the past 12 months, and 17.1% experienced a DUI arrest in the prior two years. Almost two-thirds (65.9%) of participants had used an on-demand RHA to avoid DUI, but self-driving or riding in another's car were the most common (76.4%) primary modes of transportation to clubs. RHAs were the primary mode of travel to clubs for 21 (17.1%) respondents. Participants whose friends strongly disapproved of DUI were more than twice as likely to have used RHAs for this reason compared to those who had not done so. Those reporting RHA use to avoid DUI were less likely than others to have driven under the influence in the past 12 months and were somewhat more likely to endorse DUI-related risks. Those who used alternate modes of transportation were more likely than those who used RHAs as their primary mode of transportation to clubs to endorse the expense of RHAs and the lack of RHA drivers near their favorite clubs as barriers to RHA use to travel to nightclubs.

CONCLUSIONS

This novel study among a high-risk population points to the potential for on-demand RHAs to reduce DUI behaviors and arrests among young adult nightclub patrons who consume alcohol and/or drugs in the context of the club experience. Our findings point to key educational, peer support, and structural targets for intervention to increase the use of RHAs among this population, specifically, club-based incentives for increasing RHA availability and affordability. Research is needed to fully elucidate the findings of this exploratory study, including potential differences in intervention approaches depending on the location-specific public transportation options.

Descriptions of Gabapentin Misuse and Associated Behaviors among a Sample of Opioid (Mis)users in South Florida

Gabapentin has received increased attention due to a growing number of reports of misuse and diversion. However, significant details about gabapentin misuse are scant. Data are drawn from a mixed-methods study examining gabapentin misuse in South Florida. The sample includes 49 respondents who were age 18 or over and reported past year use of illicit opioids and/or the misuse of prescription opioid medications, as well as, recent (past 90 days) gabapentin misuse. Respondents were female (40.8%), Hispanic (30.6%), Black (16.3%), white (49.0%), and other race/ethnicity (4.1%). Mean age was 37.6. Many respondents (43%) misused gabapentin without ever receiving a prescription and 14% misused prior to being prescribed. Mean frequency of recent misuse was 25.4 days and included a mean of 51.65 pills/doses. Prevalent routes of administration included swallowing (85.7%) and snorting (10.2%). Gabapentin misuse occurred concomitantly with any opioid (44.9%), benzodiazepines (38.8%), alcohol (24.5%), and powder cocaine (24.5), among others. Respondents' descriptions indicate that gabapentin produces feelings reminiscent of alcohol intoxication or opioid-induced euphoria, but for some it produces no noticeable effect or only alleviates pain. Greater understanding of gabapentin misuse, especially associated behaviors and concomitant use is needed to inform prevention and intervention efforts, and to guide policy approaches.

The Social Environmental Context of Resilience Among Substance-Using African American/Black Men Who Have Sex With Men

Resilience theory has been suggested as a framework for research on HIV prevention among men who have sex with men. Among this population, literature indicates that African American/Black men who have sex with men experience additional health disparities including elevated HIV incidence rates, victimization, and poor physical health. Conceptualizing resilience as a part of one's social environment, this qualitative study investigates resilience processes and HIV transmission risk among a sample of 21 substance-using African American/Black men who have sex with men. Data from in-depth interviews describe the social environmental context in which resilience is exhibited and document the influence of homophobia, expressions of agency, and access to social, economic, and cultural capital on resilience processes. Central to this are expressions of hidden resilience, in which African American/Black men who have sex with men mitigate risk and experience their lives as subjectively successful, whether or not outsiders see it as such.

Preliminary Evidence of Pregabalin Misuse among Prescription and/or Illicit Opioid (Mis)users

Pregabalin is approved for the management of neuropathic pain, partial-onset seizures, and fibromyalgia. Although it is considered to have low potential for abuse, reports of misuse of pregabalin are emerging. The present study contributes to this literature by presenting preliminary evidence of pregabalin misuse. Mixed method interviews were conducted with prescription and/or illicit opioid (mis)users who reported a history of pregabalin misuse (N = 5). During semi-structured interviews, respondents provided descriptions of this practice, including motivation, route of administration, source, and drugs used/misused in combination with pregabalin. Motivations for pregabalin misuse included the self-treatment of physical pain (N = 1) and to achieve a desired psychoactive effect and/or combat opioid withdrawal symptoms (N = 4). Respondents described the misuse of pregabalin to potentiate the effects of heroin and cocaine, to feel "tipsy," and to experiment. We believe this report represents the first detailed contextual data about the misuse of pregabalin in the U.S. These misuse practices may represent an early indication of a growing problem. The recent permissibility of lower price generic versions has the potential to increase availability, decrease prices, and exacerbate pregabalin misuse.

Factors Associated with Gabapentin Misuse among People Who Inject Drugs in Appalachian Kentucky

Gabapentin is misused to potentiate the euphoric effects of opioids, self-treat physical pain, and moderate opioid withdrawal symptoms. Because examinations of gabapentin misuse among people who inject drugs (PWID) are scant, the aim of this study is to identify factors associated with gabapentin misuse among this population. Methods: Data are drawn from a study examining the uptake of syringe service programs (SSPs) in Appalachian Kentucky. The sample includes 324 PWID who were age 18 and over and reported past month drug injection. Logistic regression models were constructed to examine recent (past 90 days) gabapentin misuse. Results: Participants are female (50.0%); Hispanic (2.2%), Black (1.5%), white (90.7%), and other race/ethnicity (4.6%). Mean age is 37. Participants reporting gabapentin misuse had higher odds of reporting (mis)use of marijuana, cocaine, methamphetamine, prescription opioids, benzodiazepines, prescription stimulants, fentanyl, and buprenorphine (p < .042); severe substance use disorder (p < .000); and recent physical pain (p < .003). In multivariable models, findings related to misuse of prescription opioids and buprenorphine; severe substance use disorder; and recent physical pain or discomfort, remained significant (p < .042). Conclusions: This is one of the first studies to examine gabapentin misuse among PWID. It is possible that individuals reporting recent gabapentin misuse are attempting to self-treat physical pain when healthcare is limited. Gabapentin may also be misused to achieve desired central nervous system effects and to potentiate opioid highs. Syringe service programs can educate PWID about the potential dangers of polydrug use involving gabapentin and to connect PWID with needed healthcare services.

An ethnographic decision model of the initiation of gabapentin misuse among prescription and/or illicit opioid (mis)user

AIMS

Gabapentin is used in the treatment of seizures and neuralgia, and it is prescribed off-label to treat substance use disorders and withdrawal symptoms. Recent research documents misuse of gabapentin, especially among prescription opioid misusers. The present study contributes to this literature by examining the initiation of gabapentin misuse.

METHODS

Qualitative interviews were conducted with prescription and/or illicit opioid (mis)users who reported a history of gabapentin misuse (N = 62) and who did not (N = 29). During semi-structured interviews, respondents provided descriptions of the first time they misused gabapentin. An ethnographic decision model was constructed to illustrate the factors that influence the initiation decision.

RESULTS

Multiple individual, social, and environmental factors influence the decision to initiate gabapentin misuse. Respondents described the initiation decision related to: a) wanting to feel a psychoactive high during times of limited access to one's preferred drug because of institutional barriers (e.g., substance abuse treatment; jail; transitional living facility; N = 18); b) the desire to use multiple drugs, including for experimentation or to potentiate another substance (N = 18); and c) the need to self-treat withdrawal symptoms during periods of opioid nonuse or when opioids were unavailable (N = 16). Respondents also initiated gabapentin misuse to self-treat physical pain (N = 10).

CONCLUSIONS

Multiple approaches are needed to mitigate gabapentin misuse, including limiting availability in institutional settings and informal channels as well as addressing the needs of drug users who experience physical pain and withdrawal symptoms. Continued research is needed to examine therapeutic uses of gabapentin and behaviors related to misuse.

Gabapentin prescribed during substance abuse treatment: The perspective of treatment providers

BACKGROUND

Gabapentin, a prescription medication approved for the treatment of seizures and neuralgia, is often prescribed off-label for substance use treatment, mental health problems, and pain. Emerging reports also suggest it is misused for the purpose of getting high. The present study examines substance abuse treatment provider key informants' experiences with gabapentin prescribed to clients in treatment. The focus of this exploratory study is to ascertain how gabapentin is used in these settings and the benefits and risks for clients.

METHODS

Key informants from South Florida participated in confidential, in-depth interviews (N = 12). Data analyses included descriptive and in vivo coding schemes and employed a descriptive qualitative approach.

RESULTS

All key informants recognized the benefits of prescribing gabapentin to clients in treatment for problems related to withdrawal symptoms, mental distress and pain. At the same time, half of participants described gabapentin misuse among clients and four key informants described such misuse as a first marker of relapse. Key informants also stated that more research must be done about how to use gabapentin effectively in treatment settings.

CONCLUSIONS

These findings illustrate the lack of clarity about the efficacy of administration of gabapentin in treatment settings. Additional research about how to best use gabapentin, for whom it may be beneficial, and the effect of prescribed gabapentin on addiction recovery is needed.

Sexual risk behaviours associated with unlicensed driving among young adults in Miami's electronic dance music nightclub scene

Literature indicates that unlicensed driving (UD) offenders report substance use risk behaviours, yet data related to sexual risk behaviours is unknown. This study examined sexual and other risk behaviours among young adults in Miami, Florida, comparing UD and non-UD offenders (n=498). Compared with others, UD offenders were more likely to report group sex history, being high for sex half the time or more, purchasing sex and sexually transmissible infection history. Results suggest that locating sexual risk reduction interventions inside of the justice system would benefit UD offenders.

Preliminary evidence of HIV seroconversion among HIV-negative men who have sex with men taking non-prescribed antiretroviral medication for HIV prevention in Miami, Florida, USA

Background Limited information suggests that men who have sex with men (MSM) are informally obtaining antiretroviral medication (ARVs) and using them for HIV pre-exposure prophylaxis (PrEP).

METHODS

Data are drawn from an on-going study examining the use of non-prescribed ARVs for PrEP. To date, 24 qualitative interviews have been conducted with HIV-negative, substance-using MSM living in Miami, Florida, USA. Data are presented from two participants who reported HIV seroconversion while using non-prescribed ARVs for PrEP.

RESULTS

Preliminary data indicate that some young MSM: (i) lack awareness of and accurate information about the efficacious use of PrEP; (ii) obtain non-prescribed ARVs from HIV-positive sex partners and use these medications for PrEP in a way that does not provide adequate protection against HIV infection or cohere with established guidelines; and (iii) engage in multiple HIV transmission risk behaviours, including condomless anal sex and injection drug use.

CONCLUSIONS

The informal, non-prescribed and non-medically supervised use of ARVs for HIV prevention has the potential to undermine the protective benefits of PrEP and leave men unprotected against HIV transmission and at risk for ARV resistance.

The informal use of antiretroviral medications for HIV prevention by men who have sex with men in South Florida: initiation, use practices, medications and motivations

Limited data suggest that some gay and other men who have sex with men are using antiretroviral medications informally, without a prescription, for HIV prevention. This qualitative study examined this phenomenon among gay and other men who have sex with men in South Florida. Participants initiated informal antiretroviral medication use as a means of protecting each other and because of the confidence in knowledge of antiretroviral medications shared by their friends and sex partners. The most commonly used medications included Truvada and Stribild. Motivations for use included condom avoidance, risk reduction, and fear of recent HIV exposure. Participants described positive and negative sentiments related to informal use, including concerns about informal antiretroviral medications offering sufficient protection against HIV, and limited knowledge about pre-exposure prophylaxis (PrEP). Because the antiretroviral medications used for PrEP have the potential to prevent HIV infection, future research must consider the informal antiretroviral medication use and related concerns, including adherence, diversion and viral resistance.

Foster care, syndemic health disparities and associations with HIV/STI diagnoses among young adult substance users

OBJECTIVES

Foster care history is associated with many health and social problems, including sexual risk behaviours, HIV and other sexually transmitted infections (STIs). This cross-sectional study compares sexual risk behaviours among a sample of young adult substance users in Miami (N=602) with and without foster care histories.

METHODS

Participants completed a comprehensive assessment which included sections on foster care, sexual risk behaviours and related health and social problems. Logistic regression was used to examine the relationship between foster care history, associated syndemic vulnerabilities and increased likelihood of having a prior HIV/STI diagnosis.

RESULTS

Bivariate analyses indicated that foster care alumni were more likely to report a prior HIV/STI diagnosis, higher condomless sex frequencies, being high on alcohol or drugs during sex, sexual victimisation and a history of homelessness compared with other participants in the sample (p<0.05). Multivariate analyses revealed that foster care history, sexual victimisation and group sex participation are associated with a prior HIV/STI diagnosis (p<0.05). Group sex participation doubled the odds of a prior HIV/STI diagnosis for foster care alumni, compared with other participants (p<0.5).

CONCLUSIONS

This exploratory study identifies characteristics that distinguish foster care alumni from non-alumni and signals the need to better serve the sexual and related health needs of individuals with foster care histories. Clinicians and healthcare providers should provide foster care alumni with detailed HIV/STI risk reduction information and resources and services to address related syndemic vulnerabilities (eg, victimisation and homelessness).

Frequency of Group Sex Participation and Risk for HIV/STI Among Young Adult Nightclub Scene Participants

OBJECTIVES

This study examines frequency of group sex participation and associated characteristics and behaviors among a sample of heterosexual young adult participants in Miami's nightclub scene (n = 498).

METHODS

Baseline survey assessments were analyzed using zero-inflated binomial regression.

RESULTS

Forty-one percent of the sample reported group sex participation history. Greater frequency of group sex is associated with buying sex, sex with an injection drug user, being high during sex, condomless vaginal sex, victimization history, and sexually transmitted infection incidence (p < .02).

CONCLUSIONS

Sexually transmitted infection prevention and intervention efforts should address risks associated with group sex participation.

Residential Proximity to Electronic Dance Music Nightclubs and Associations with Substance Use, Sexual Behaviors, and Related Problems

This study examines the association between proximity of place of residence to preferred nightclub and substance use, sexual risk behaviors, and related problems, among a sample of 498 young adult substance users in Miami who report regular nightclub participation. Hierarchal linear models and logistic regressions were constructed to examine the impact of residential proximity to preferred nightclub on risk behaviors. Compared with participants residing in closer proximity to their preferred nightclub, participants residing further away reported higher intensities of alcohol and cocaine use (p < .01), greater condomless vaginal sex frequencies (p < .001), and more substance dependence symptoms (p < .05). Conversely, participants residing in closer proximity to their preferred nightclub had higher likelihood of arrest history (p < .05) than participants residing further away. Results suggest that participants residing further from their preferred nightclubs may be more invested in the nightclub outing and, therefore, engage in more risk behaviors.

Motivations for Selling Ecstasy among Young Adults in the Electronic Dance Music Club Culture in Brazil

This article describes data on the motivations for selling ecstasy among young adults in the electronic dance music (EDM) club culture in Brazil. Individual interviews were conducted with 20 individuals recruited for their involvement in the EDM club scene. Eligible participants were aged 18-39 and reported ecstasy and/or LSD use one or more times in the past 90 days. Exclusion criteria included current treatment for drug/alcohol problems and cognitive impairment or clinically evident psychiatric disorder. Mean age was 22.92 (SD 2.77), 60% were male, 45% reported 12 or more years of education, 50% did not have a primary partner, 50% were living alone, and all had friends who also used ecstasy. Three main themes emerged: (1) "easy" transition from ecstasy user to seller; (2) desire to achieve popularity and fame; and (3) need to sell ecstasy to maintain the high cost of EDM club scene participation. This is one of the first studies of ecstasy sellers in Brazil. The results demonstrate the ease with which the participants transition from ecstasy user to seller. Given the potential health and social dangers associated with ecstasy use, public health campaigns to prevent ecstasy use and policy initiatives to limit the ecstasy supply are warranted.

Serious mental illness among young adult women who use drugs in the club scene: co-occurring biopsychosocial factors

Young women who regularly attend nightclubs are at risk for numerous health and social consequences, including mental distress, sexual and physical victimization and substance dependence. This paper uses a biopsychosocial framework to examine co-occurring mental health problems, victimization, substance dependence, sexual risk and physical pain among a sample of young women who use drugs (N = 222) in Miami's club scene. The majority of women were under 24 years old, Hispanic, and identified as heterosexual. Almost all the women reported past 90-day use of alcohol, ecstasy/MDMA, marijuana, cocaine and prescription opioids and benzodiazepines; 32% of women reported being in a monogamous relationship while 41.9% reported having three or more sexual partners in the past 90 days; 65.3% met DSM-IV criteria for substance dependence; 60.4% met DSM-IV criteria for serious mental illness (SMI) and 59.9% were victimized as minors. Women who had SMI had higher odds of substance dependence, concurrent physical pain, three or more sexual partners in the past 90 days, childhood victimization and severe abuse-related trauma. The high levels of interconnected mental health, victimization, trauma, physical pain, substance dependence and sexual risk factors observed are underreported in the literature, as young women club scene participants appear to be more similar to other marginalized drug-involved populations than previously considered. While further research is needed, it appears these young women are in great need of outreach for primary health, mental health, HIV prevention, increased social support and substance abuse treatment services.

A randomized trial of brief assessment interventions for young adults who use drugs in the club scene

BACKGROUND

Efficacious interventions to reduce drug use and its consequences for club drug using populations are not apparent in the literature. We tested interviewer- (CAPI) and self-administered (ACASI) comprehensive health and social risk assessments as distinct interventions compared to waitlist control.

METHODS

750 men and women ages 18-39 with multidrug use and heterosexual behavior were randomized in equal proportions to the three conditions. Instrumentation included well-tested measures of drug use, risky sex, mental distress and substance dependence.

RESULTS

The sample was 56% male; mean age=25. Reported risk behaviors and health consequences did not differ by assessment modality. Adjusted HLM analyses showed a significant main effect of assigned condition on all outcomes. CAPI participants had greater reductions in drug use, risky sex, mental distress and substance dependence symptoms, and greater increases in abstinence, compared to ACASI intervention or control participants at 12months, except that the CAPI and ACASI conditions had similar efficacy for reductions in drug use. Effect sizes for CAPI versus ACASI participants were d=0.2-0.3, and between CAPI and controls d=0.2-0.4. Effect sizes for improved outcomes between ACASI compared to controls were small to non-significant.

CONCLUSIONS

The study established the therapeutic benefit of interviewer interaction in reducing risky behavior among this young drug using population. The study demonstrated the efficacy and acceptability of a low threshold intervention in reducing drug use, sexual risk and related co-morbidities among a not-in-treatment young adult population that exhibits severe and complex levels of drug use, but that is also highly resistant to intervention.

Law enforcement-derived data on gabapentin diversion and misuse, 2002-2015: diversion rates and qualitative research findings

PURPOSE

Recent limited epidemiologic and case reports suggest that gabapentin is being misused, especially among prescription opioid misusers. However, no apparent studies have reported data from law enforcement on the diversion and misuse of gabapentin.

METHODS

Case report data are drawn from a quarterly survey of prescription drug diversion completed by a national sample of law enforcement and regulatory agencies who engage in drug diversion investigations. Rates of gabapentin diversion per 100 000 population were calculated for each quarter from 2002 through 2015. Qualitative data are drawn from a brief questionnaire completed by a subsample of survey respondents and were organized and presented by theme.

RESULTS

In total, 407 new cases of diverted gabapentin were reported during the time period, with diversion rates steadily increasing from zero cases in the first 2 quarters of 2002 to a high of 0.027 cases per 100 000 population in the fourth quarter of 2015. Qualitative data suggest that gabapentin is being misused in conjunction with prescription opioids and that gabapentin and heroin are being combined and consumed together. Law enforcement reporters found these drug use trends to be contributing to gabapentin diversion.

CONCLUSIONS

The recent increase in gabapentin diversion appears to be related to the opioid epidemic, based on law enforcement descriptions of gabapentin being misused in combination with opioids. Yet epidemiological data related to this finding is limited and research conducted among gabapentin misusers is needed to understand this problem in more depth. Greater monitoring of gabapentin abuse and diversion appear warranted.

Benzodiazepine Dependence among Young Adult Participants in the Club Scene Who Use Drugs

Young adults ages 18-29 report the highest rates of benzodiazepine (BZD) misuse in the United States. The majority of club drug users are also in this age group, and BZD misuse is prevalent among participants in club scenes. This article examines BZD dependence and its correlates among young adult participants in the electronic dance music (EDM) culture in Miami, Florida, who use drugs. Structured interviews were with men and women (N = 356) ages 18 to 29 who reported regular attendance at EDM venues and recent use of both club drugs and BZDs. Prevalences of BZD-related problems were 12.6% for BZD dependence, 21.1% BZD abuse, and 24.2% BZD abuse and/or dependence. In a multivariate logistic regression model, younger age (OR 0.85; 95% CI 0.76, 0.96), severe mental distress (OR 8.30; 95% CI 3.07, 22.49), daily marijuana use (OR 2.10; 95% CI 1.03, 4.27), and heavy opioid use (OR 2.33; 95% CI 1.12, 4.83) were associated with BZD dependence. BZD dependence was higher in this sample than in other populations described in the literature. The links between BZD dependence, overdose history, and heavy opioid misuse are especially worrisome among this young sample. Recommendations for intervention and research are discussed.

Abuse and Diversion of Immediate Release Opioid Analgesics as Compared to Extended Release Formulations in the United States

BACKGROUND

Therapeutic use and abuse of prescription opioids in the United States increased substantially between 1990 and 2010. The Centers for Disease Control estimated deaths related to pharmaceutical opioids reached nearly 19,000 in 2014. Of prescription opioids sold, 10% are extended release (ER) and 90% immediate release (IR). However, most regulations and interventions have focused on decreasing ER abuse. Our objective was to compare rates of abuse and diversion of ER and IR opioid analgesics over time using multiple surveillance programs.

METHODS

Rates of abuse and diversion of ER and IR opioid formulations were compared using data from four surveillance programs in the Researched Abuse, Diversion and Addiction Related Surveillance (RADARS®) System. Data were evaluated from 2009 through 2015, and Poisson regression used to compare IR and ER opioid cases over time.

RESULTS

From 2009 to 2015, IR opioids were prescribed at a rate 12 to 16 times higher than ER. In the Poison Center Program, population-adjusted rates of Intentional Abuse for IR were 4.6 fold higher than ER opioids (p<0.001). In the Drug Diversion Program, population-adjusted rates of diversion were 6.1 fold higher for IR than ER opioids (p<0.001). In the Opioid Treatment Program, population-adjusted rates of endorsements for abuse were 1.6 fold higher for IR opioids than ER (p = 0.002). In the Survey of Key Informants' Patients Program, population-adjusted rates of endorsements for abuse were 1.5 fold higher for IR opioids than ER (p<0.001).

CONCLUSIONS

Between 2009 and 2015, IR opioids were prescribed at a much higher rate than ER opioids. Results from four surveillance programs show population-adjusted rates of prescription opioid abuse were markedly higher for IR than ER medications. For the greatest public health benefit, future interventions to decrease prescription opioid abuse should focus on both IR and ER formulations.

Sustained reduction of diversion and abuse after introduction of an abuse deterrent formulation of extended release oxycodone

BACKGROUND

The development of abuse deterrent formulations is one strategy for reducing prescription opioid misuse and abuse. A putative abuse deterrent formulation of oxycodone extended release (OxyContin^®) was introduced in 2010. Early reports demonstrated reduced abuse and diversion, however, an analysis of social media found 32 feasible methods to circumvent the abuse deterrent mechanism. We measured trends of diversion, abuse and street price of OxyContin to assess the durability of the initial reduction in abuse.

METHODS

Data from the Poison Center Program, Drug Diversion Program, Opioid Treatment Program, Survey of Key Informant Patients Program and StreetRx program of the Researched Abuse, Diversion, and Addiction-Related Surveillance (RADARS^®) System were used. The average quarterly rates of abuse and diversion for OxyContin were compared from before reformulation to the rate in second quarter 2015. Rates were adjusted for population using US Census data and drug availability.

RESULTS

OxyContin abuse and diversion declined significantly each quarter after reformulation and persisted for 5 years. The rate of abuse of other opioid analgesics increased initially and then decreased, but to lesser extent than OxyContin. Abuse through both oral and non-oral routes of self-administration declined following the reformulation. The geometric mean difference in the street price of reformulated OxyContin was 36% lower than the reformulated product in the year after reformulation.

DISCUSSION

Despite methods to circumvent the abuse deterrent mechanism, abuse and diversion of OxyContin decreased promptly following the introduction of a crush- and solubility- resistant formulation and continued to decrease over the subsequent 5 years.

HIV testing and engagement in care among highly vulnerable female sex workers: implications for treatment as prevention models

BACKGROUND

Although emerging Treatment as Prevention models can be effective in reducing HIV incidence among high-risk populations, many HIV infected individuals remain undiagnosed or fail to engage in HIV care.

METHODS

This study examined the factors associated with HIV testing and care among a population of substance using female sex workers.

RESULTS

Recent HIV testing was associated with higher education level, having a regular health care provider or clinic, recent crack use, and higher sexual risk behaviors; HIV treatment utilization was associated with higher levels of social support, having a regular health care provider or clinic, housing stability and insurance coverage. Qualitative data revealed HIV-related stigma, denial, social isolation, and substance use as barriers to HIV testing and treatment; social support and accessibility of services were key enablers.

CONCLUSIONS

Improving HIV testing and linkage to treatment among female sex workers will require structural initiatives to reduce stigma and increase service seeking support.

Alternate Routes of Administration among Prescription Opioid Misusers and Associations with Sexual HIV Transmission Risk Behaviors

Literature suggests that young adult prescription opioid misusers who are using alternate routes of administration (e.g., snorting, injecting) may be engaging in sexual and non-sexual HIV risk behaviors. This study examines demographics, substance use, sexual risk behavior, and health and social problems associated with alternate routes of administration of prescription opioids among a sample of young adult prescription opioid misusers. Data are drawn from baseline assessments from a behavioral intervention trial. Eligible participants were ages 18-39, and reported recent (past 90 days) heterosexual sex, and recent and regular substance use and attendance at large, recognized local nightclubs. The analyses include 446 racially/ethnically diverse participants. In bivariate regression models, compared to those who did not, participants reporting alternate routes of administration (n = 209) were more likely to be White (p < 0.025) and report group sex participation history (p = 0.002), sex with an injection drug user (p = 0.003), sexual victimization history (p = 0.003), and severe mental distress (p < 0.000). White race, group sex participation history, and severe mental distress remained significant in the multivariate model. Alternate routes of administration of prescription opioids are associated with sexual HIV transmission risk behaviors. Early prevention and intervention efforts that address sexual and non-sexual HIV risk behaviors are warranted.

Misunderstanding of Pre-Exposure Prophylaxis Use Among Men Who Have Sex with Men: Public Health and Policy Implications

Purpose: Street markets in antiretroviral medications for HIV have been documented, but sources of demand are not well understood. We report unexpected findings from qualitative research suggesting that some demand is for informal pre-exposure prophylaxis (PrEP).

Methods: Focus groups with young men who have sex with men (N = 31) yielded information on their understanding and use of PrEP.

Results: Of those who had heard of it, few understood PrEP to be a physician-prescribed regimen; most believed it to be a pill taken before and/or after sex and acquired on the street or through HIV-positive friends.

Conclusion: Implications for PrEP rollout and public health policy are discussed.

A Qualitative Study of African American/Black MSM's Experiences of Participating in a Substance Use and Sexual Risk Reduction Intervention

The majority of new HIV infections in the United States are among men who have sex with men (MSM), and African American/Black MSM are especially affected. Employing a grounded theory approach, this study presents qualitative data from 21 African American/Black MSM who participated in a substance use and sexual risk reduction intervention trial (Project ROOM [men Reaching Out to Other Men]) in South Florida. African American/Black MSM from Project ROOM reduced their substance use and sexual risk behaviors at a faster rate than other men in the study. The present study examines how the experiences of participation in Project ROOM influenced the behavior change among African American/Black MSM. In-depth interviews indicate that study assessments enhanced African American/Black men's mindfulness and self-realization of behaviors leading to behavior modification and changes in social relationships. Furthermore, these findings suggest that interventions tailored to the social environment of HIV transmission and substance use behaviors are key to reducing risk behaviors among this population.

Characteristics associated with group sex participation among men and women in the club drug scene

This study examined the demographics, substance use and sexual risk behaviours associated with group sex (GS) participation among a sample of club drug users (n=498) in Miami. Men (n=128; 46.3%) and women (n=75; 33.7%) reported histories of GS. Group sex participation among men and women was associated with heroin and injection drug use, trading or selling sex, and sex while high, compared with no GS participation. Moreover, among men, GS was associated with buying sex and sex with an injection drug user; among women, GS was associated with substance dependence, a history of sexually transmissible infections and crack cocaine use, compared with no GS participation.

The Social Environmental Elements of Resilience among Vulnerable African American/Black Men Who Have Sex with Men

Resilience theory has been suggested as a strong framework for research on HIV prevention among men who have sex with men (MSM). Among this population, literature indicates that African American/Black MSM are particularly vulnerable to health and social disparities associated with HIV transmission risk. Conceptualizing resilience as a part of one's social environment, this qualitative study investigates the specific elements of resilience, and the associated contexts and relationships, among a sample of 21 substance-using African American/Black MSM. Data indicate that: 1) elements contributing to resilience are multiple and co-occurring, including inner strengths, social relationships, diversity of experience, religion/spirituality, altruism, and creativity; 2) as an element of resilience, social support was experienced differently among men who did and did not have supportive relationships with other gay and bisexual men, which has implications for social service provision and intervention approaches; and 3) diversity of experiences and relationships is an important influencing factor on expressions of resilience. Social services or interventions that facilitate the development of these elements of resilience will likely be especially beneficial for vulnerable African American/Black MSM.

Risk and Protective Factors Associated with Personal Mastery Among Sexual Minority African American Female Sex Workers

Research among sexual minorities has traditionally examined problems such as substance use, HIV risk, mental health problems, and victimization. Among sexual minority street-based female sex workers, these vulnerabilities can be magnified. Grounded in theories of resilience, this study examines risk and protective factors associated with a high level of personal mastery among a vulnerable population of women. Data are drawn from baseline interviews from street-based African American female sex workers enrolled in a randomized intervention trial in Miami, Florida. We compare sexual minority (N=197) and heterosexual (N=365) women on measures of risk and protective factors; among sexual minority women we present logistic regression analyses which reveal that severe mental distress and HIV transmission risk are associated with low levels of personal mastery, while protective factors of transportation access and social support are associated with high levels of personal mastery. These findings suggest that these protective factors may potentially facilitate the development of personal mastery and represent beneficial avenues for intervention efforts.

Health and social problems associated with prescription opioid misuse among a diverse sample of substance-using MSM

This study examines associations between prescription opioid misuse and demographics, substance use, sexual behavior, and related health and social problems. Baseline data were collected between 2008 and 2010 from 515 high risk men who have sex with men, ages 18-55, in the Miami-Ft. Lauderdale metropolitan area who reported heavy substance use and HIV risk in the past 90 days. Prescription opioid misuse was associated with other substance use, drug injection, substance dependence, and history of arrest. Implications, limitations, and directions for future study are discussed.

HIV risk among substance-using men who have sex with men and women (MSMW): findings from South Florida

Compared with men who have sex with men only (MSMO), men who have sex with men and women (MSMW) consistently report higher rates of two HIV risk behaviors: transactional sex (TS) and concurrent substance use and sex (CSS). Within MSMW, little is known about how synergistic epidemics ("syndemics") affect TS and CSS. Using a sample of substance-using MSM (n = 515) in South Florida, we compared TS and CSS among MSMO and MSMW; examined whether, within MSMW (n = 86), TS and CSS predict unprotected anal intercourse with partners of serodiscordant/unknown HIV status (SU-UAI); and tested whether syndemics predict TS and CSS. MSMW reported higher rates of engaging in both TS and CSS (AOR = 1.7; 95 % CI 1.0-3.0). Within MSMW, engagement in both TS and CSS predicted SU-UAI (AOR = 3.3; 95 % CI 1.2-9.6); and syndemics predicted TS and CSS involvement (p < 0.01). Substance-using MSMW may benefit from interventions targeting TS, CSS, and background syndemics.

Under treatment of pain: a prescription for opioid misuse among the elderly?

OBJECTIVE

To examine the demographic, physical, and mental health characteristics; current drug use patterns; motivations for use; and diversion sources among elderly prescription opioid misusers.

DESIGN

Mixed methods design.

SETTING

Research field offices, or senior or community center offices in South Florida.

SUBJECTS

Individuals aged 60 and over reporting past 90-day prescription medication misuse; only prescription opioid misusers (N = 88) were included in the final analysis.

METHODS

The Global Appraisal of Individual Needs was the main survey instrument. A subsample of elderly reporting substantial prescription drug misuse were chosen for the in-depth interview (N = 30).

RESULTS

The mean age was 63.3. Fifty percent reported ever being admitted to a drug treatment program; several endorsed recent illicit drug use: powder cocaine and/or crack (35.2%), marijuana (30.7%), heroin (14.8%). The majority reported past year severe physical pain and discomfort (86.4%), and misuse of their primary opioid for pain (80.7%); over half (52.3%) obtained their primary opioid from their regular doctor. Qualitative data highlight the misuse of prescription opioids due to untreated or undertreated pain. Participants with primary opioid misuse for pain had over 12 times higher odds of obtaining the medication from their regular doctor (odds ratio [OR] = 12.22, P = 0.002) and had lower odds of using a dealer (OR = 0.20, P = 0.005).

CONCLUSIONS

Findings suggest that this group of elderly participants often misuse their own prescriptions for pain management. This study highlights the need to educate prescribing professionals on appropriate pain management for older adults while still being sensitive to issues of substance abuse and dependence.

Vulnerable infected populations and street markets for ARVs: Potential implications for PrEP rollout in the USA

Widespread diversion of antiretroviral (ARV) medications to illicit markets has recently been documented among indigent patients in South Florida. The recent approval of ARVs for pre-exposure prophylaxis (PrEP) has the potential to broaden these illicit markets, as high-risk individuals seek ARVs without a prescription or medical supervision. Nonadherence among diverters and unsupervised use of ARVs for treatment or PrEP increase risks of treatment failure, drug resistance, and disease transmission. We report the scope of ARV diversion among substance-using men who have sex with men in South Florida. Structured interviews (N = 515) queried demographics, HIV status, mental distress, substance dependence, and sexual risks. HIV-positive participants answered questions about medical care, treatment, and ARV adherence and diversion. Median age was 39. Of 46.4% who were HIV-positive, 79.1% were prescribed ARVs. Of these, 27% reported selling/trading ARVs. Reasons for diversion were sharing/trading with friends, sale/trade for money/drugs, and sale/trade of unused medications. ARV diverters, compared to nondiverters, were more likely to be substance dependent (74.5% vs. 58.7%, p = 0.046) and have traded sex for money/drugs (60.8% vs. 32.6%, p < 0.001), and less likely to be adherent to ARVs (54.9% vs. 73.9%, p = 0.012). ARV diversion should be a particular concern in communities of high-risk men who have sex with men as uninfected men in such communities are likely to benefit most from PrEP but unlikely to have access to PrEP and necessary ancillary services through the health-care system. The implications of diversion for increased risks of treatment failure, disease transmission, and PrEP failure should be carefully considered in developing policy and behavioral supports to scaling up treatment as prevention and PrEP.

Resilience and syndemic risk factors among African-American female sex workers

Research on street-based female sex workers documents a multitude of problems faced by these women, such as substance use, HIV risk, mental health problems, victimization, and homelessness. The presence of problems such as these is understood as a syndemic, or co-occurrence of two or more risk factors that act synergistically to create an excess burden of disease. However, the syndemic framework has not previously incorporated the examination of resilience to understand what protective factors enable female sex workers to cope with syndemic risk. Using 562 baseline interviews from street-based African-American female sex workers enrolled in a randomized intervention trial, this study is the first to investigate expressions of resilience among this vulnerable population. Specifically, these analyses examine high levels of resilience, as measured by personal mastery, in order to understand the contributions of syndemic risk factors and protective factors on the expression of resilience. In bivariate logistic regression models, women with high resilience reported significantly higher odds of high school education, greater access to transportation, and more social support, in addition to lower odds of foster care history, homelessness, substance dependence, severe mental distress, victimization, and HIV risk. In the multivariate model, higher odds of high school education and increased social support, in addition to lower odds of mental distress and HIV risk remained associated with high resilience. The findings suggest specific targets for intervention to assist female sex workers in coping with syndemic risk factors and achieving better health outcomes. These include the prioritizing of education and training opportunities and the enhancement of social support.

Substance use and sexual risk mediated by social support among Black men

Health and social disparities are widespread among men who have sex with men (MSM). Although literature indicates that Black MSM (BMSM) are no more likely than other MSM to report sexual risk behaviors, such as unprotected anal intercourse, studies have reported that buying and trading sex appear to be important risk factors for BMSM. Substance use generally is not significantly greater among BMSM than other MSM, studies have found that BMSM report more powder and crack cocaine use than other MSM. The lack of adequate coping skills and social support for BMSM has also been documented. This paper examines differences in substance use, sexual risk behaviors and social support among Black and non-black MSM, in a sample of 515 men participating in a randomized intervention trial. BMSM reported higher rates of substance dependence (72.2 vs. 59.5%, P = .015) and buying sex (49.1 vs. 17.4%, P < .000) than non-Black MSM. BMSM also reported lower levels of social support than other MSM on all measures included in the study; e.g., getting help and emotional support from others (38.0 vs. 52.8%, P < .006). Mediation analyses showed that BMSM's higher rates of substance dependence and buying sex are partially mediated by lower levels of social support. Our data appear to show that lack of social support is an important influence on risk behaviors among BMSM. Qualitative data also supported these findings. Sexual risk and substance use prevention interventions should address BMSM's capacity to build adequate and supportive relationships.

Interview as intervention: the case of young adult multidrug users in the club scene

This paper reports on changes in substance use and substance dependence symptoms-without intervention-among young adult multidrug users in the club scene, ages 18-29, (N = 444) who participated in a natural history study. Computer-assisted personal interviews at baseline and 6-, 12-, and 18-month follow-ups included well-tested measures of substance use and dependence. Changes in substance dependence symptoms and drug use frequencies were calculated using Cohen's d statistic. Mean age was 22; 40% were female; 58% were Hispanic, 17% White, and 21% Black. At 18-month follow-up assessment, participants reported significantly fewer days of cocaine (d = -.85 at 18 months), ecstasy (d = -.93), benzodiazepine (d = -.82), and prescription opioid (d = -.81) use, as well as reduced substance dependence symptoms (d = -.42). These results, together with data from focus groups with completers, suggest that comprehensive health and social risk assessments may have quite strong intervention effects among young adult multidrug users.

Risk and protective factors associated with gay neighborhood residence

Using a sample of 482 ethnically diverse current substance using men who have sex with men who reported recent unprotected anal intercourse, this study compared health risk behaviors-substance use and sexual HIV risk-and one health protective factor-prosocial activities-between men who live in a gay neighborhood and those who do not. Data are drawn from comprehensive health and social risk assessments administered in South Florida. In a multivariate logistic regression model, methamphetamine use, high rates of receptive unprotected anal intercourse, and lower levels of prosocial engagement were found to be risk factors associated with gay neighborhood residence. Compared with living elsewhere, gay neighborhood residence appeared to be protective against cocaine use and substance dependence. Implications of the findings for prevention interventions are discussed, as is the need for further research regarding decisions about neighborhood residence and how neighborhood risk and protective factors emerge and are sustained.