Structural Discrimination against and Structural Support for Lesbian, Gay, and Bisexual People as a Predictor of Late HIV Diagnoses among Black Men who Have Sex with Men

Black men who have sex with men (MSM) have been consistently reported to have the highest estimated HIV incidence and prevalence among MSM. Despite broad theoretical understanding that discrimination is a major social and structural determinant that contributes to disparate HIV outcomes among Black MSM, relatively little extant research has empirically examined structural discrimination against sexual minorities as a predictor of HIV outcomes among this population. The present study therefore examines whether variation in policies that explicitly discriminate against lesbian, gay, and bisexual (LGB) people and variation in policies that explicitly protect LGB people differentially predict metropolitan statistical-area-level variation in late HIV diagnoses among Black MSM over time, from 2008 to 2014. HIV surveillance data on late HIV diagnoses among Black MSM in each of the 95 largest metropolitan statistical areas in the United States, from 2008 to 2014, were used along with data on time-varying state-level policies pertaining to the rights of LGB people. Results from multilevel models found a negative relationship between protective/supportive laws and late HIV diagnoses among Black MSM, and a positive relationship between discriminative laws and late HIV diagnoses among Black MSM. These findings illuminate the potential epidemiological importance of policies pertaining to LGB populations as structural determinants of HIV outcomes among Black MSM. They suggest a need for scrutiny and elimination of discriminatory policies, where such policies are currently in place, and for advocacy for policies that explicitly protect the rights of LGB people where they do not currently exist.

Willingness to utilize a mobile treatment unit in five counties at the epicenter of the US rural opioid epidemic

INTRODUCTION

US federal policies are evolving to expand the provision of mobile treatment units (MTUs) offering medications for opioid use disorder (MOUD). Mobile MOUD services are critical for rural areas with poor geographic access to fixed-site treatment providers. This study explored willingness to utilize an MTU among a sample of people who use opioids in rural Eastern Kentucky counties at the epicenter of the US opioid epidemic.

METHODS

The study analyzed Cross-sectional survey data from the Kentucky Communities and Researchers Engaging to Halt the Opioid Epidemic (CARE2HOPE) study covering five rural counties in the state. Logistic regression models investigated the association between willingness to utilize an MTU providing buprenorphine and naltrexone and potential correlates of willingness, identified using the Behavioral Model for Vulnerable Populations.

RESULTS

The analytic sample comprised 174 people who used opioids within the past six months. Willingness to utilize an MTU was high; 76.5 % of participants endorsed being willing. Those who had recently received MOUD treatment, compared to those who had not received any form of treatment or recovery support services, had six-fold higher odds of willingness to use an MTU. However, odds of being willing to utilize an MTU were 73 % lower among those who were under community supervision (e.g., parole, probation) and 81 % lower among participants who experienced an overdose within the past six months.

CONCLUSIONS

There was high acceptability of MTUs offering buprenorphine and naltrexone within this sample, highlighting the potential for MTUs to alleviate opioid-related harms in underserved rural areas. However, the finding that people who were recently under community supervision or had overdosed were significantly less willing to seek mobile MOUD treatment suggest barriers (e.g., stigma) to mobile MOUD at individual and systemic levels, which may prevent improving opioid-related outcomes in these rural communities given their high rates of criminal-legal involvement and overdose.

Correlates of Recent HIV Testing Among People Who Inject Drugs in Rural Areas: A Multi-site Cross-Sectional Study, 2018-2020

The Rural Opioid Initiative surveyed 2693 people who inject drugs (PWID) in eight rural U.S. areas in 2018-2020 about self-reported HIV testing in the past 6 months. Correlates of interest included receipt of any drug-related services, incarceration history, and structural barriers to care (e.g., lack of insurance, proximity to syringe service programs [SSP]). Overall, 20% of participants reported receiving an HIV test within the past 6 months. Multivariable generalized estimating equations showed that attending substance use disorder (SUD) treatment (OR 2.11, 95%CI [1.58, 2.82]), having health insurance (OR 1.42, 95%CI [1.01, 2.00]) and recent incarceration (OR 1.49, 95%CI [1.08, 2.04]) were positively associated with HIV testing, while experiencing a resource barrier to healthcare (inability to pay, lack of transportation, inconvenient hours, or lack of child care) had inverse (OR 0.73, 95%CI [0.56, 0.94]) association with HIV testing. We found that the prevalence of HIV testing among rural PWID is low, indicating an unmet need for testing. While SUD treatment or incarceration may increase chances for HIV testing for rural PWID, other avenues for expanding HIV testing, such as SSP, need to be explored.

"I'm not going to lay back and watch somebody die": a qualitative study of how people who use drugs' naloxone experiences are shaped by rural risk environment and overdose education/naloxone distribution intervention

BACKGROUND

Overdoses have surged in rural areas in the U.S. and globally for years, but harm reduction interventions have lagged. Overdose education and naloxone distribution (OEND) programs reduce overdose mortality, but little is known about people who use drugs' (PWUD) experience with these interventions in rural areas. Here, we analyze qualitative data with rural PWUD to learn about participants' experiences with an OEND intervention, and about how participants' perceptions of their rural risk environments influenced the interventions' effects.

METHODS

Twenty-nine one-on-one, semi-structured qualitative interviews were conducted with rural PWUD engaged in the CARE2HOPE OEND intervention in Appalachian Kentucky. Interviews were conducted via Zoom, audio-recorded, and transcribed verbatim. Thematic analysis was conducted, guided by the Rural Risk Environment Framework.

RESULTS

Participants' naloxone experiences were shaped by all domains of their rural risk environments. The OEND intervention transformed participants' roles locally, so they became an essential component of the local rural healthcare environment. The intervention provided access to naloxone and information, thereby increasing PWUDs' confidence in naloxone administration. Through the intervention, over half of participants gained knowledge on naloxone (access points, administration technique) and on the criminal-legal environment as it pertained to naloxone. Most participants opted to accept and carry naloxone, citing factors related to the social environment (responsibility to their community) and physical/healthcare environments (overdose prevalence, suboptimal emergency response systems). Over half of participants described recent experiences administering intervention-provided naloxone. These experiences were shaped by features of the local rural social environment (anticipated negative reaction from recipients, prior naloxone conversations).

CONCLUSIONS

By providing naloxone paired with non-stigmatizing health and policy information, the OEND intervention offered support that allowed participants to become a part of the healthcare environment. Findings highlight need for more OEND interventions; outreach to rural PWUD on local policy that impacts them; tailored strategies to help rural PWUD engage in productive dialogue with peers about naloxone and navigate interpersonal conflict associated with overdose reversal; and opportunities for rural PWUD to formally participate in emergency response systems as peer overdose responders. Trial registration The ClinicalTrials.gov ID for the CARE2HOPE intervention is NCT04134767. The registration date was October 19th, 2019.

"I'm not going to lay back and watch somebody die": A qualitative study of how people who use drugs' naloxone experiences are shaped by rural risk environment and naloxone distribution/overdose education intervention

Background

Overdoses have surged in rural areas in the U.S. and globally for years, but harm reduction interventions have lagged. Overdose education and naloxone distribution (OEND) programs are highly effective to prevent overdose mortality, but little is known about people who use drugs' (PWUD) experience with these interventions in rural areas. Here, we analyze qualitative data with rural PWUD to learn about their experiences with an OEND intervention, and about how their perceptions of their rural risk environments influenced the interventions' effects.

Methods

Twenty-nine one-on-one, semi-structured qualitative interviews were conducted with rural PWUD engaged in the CARE2HOPE OEND intervention in Appalachian Kentucky. Interviews were conducted via Zoom, audio-recorded, and transcribed verbatim. Thematic analysis was conducted, guided by the Rural Risk Environment Framework.

Results

The OEND intervention transformed participants' roles locally, so they became an essential component of the local rural healthcare environment. The intervention provided access to naloxone and information, thereby increasing PWUD's confidence in naloxone administration. Through the intervention, over half of participants gained knowledge on naloxone (access points, administration technique) and on the criminal-legal environment as it pertained to naloxone. Most participants opted to accept and carry naloxone, citing factors related to the social environment (sense of responsibility to their community) and physical/healthcare environments (high overdose prevalence, suboptimal emergency response systems). Over half of participants described recent experiences administering intervention-provided naloxone. These experiences were shaped by features of the local rural social environment (anticipated negative reaction from recipients, prior naloxone conversations).

Conclusions

By providing naloxone paired with non-stigmatizing health and policy information, the OEND intervention offered the material and informational support that allowed participants to become a part of the healthcare environment. Findings highlight need for more outreach to rural PWUD on local policy that impacts them; tailored strategies to help rural PWUD engage in productive dialogue with peers about naloxone and navigate interpersonal conflict associated with overdose reversal; and opportunities for rural PWUD to formally participate in emergency response systems as peer overdose responders.

Trial registration

The ClinicalTrials.gov ID for the CARE2HOPE intervention is NCT04134767. The registration date was October 19th, 2019.

Substance use disorder treatment and technology access among people who use drugs in rural areas of the United States: A cross-sectional survey

PURPOSE

To evaluate how technology access affected substance use disorder (SUD) treatment prior to COVID-19 for people who use drugs in rural areas.

METHODS

The Rural Opioid Initiative (January 2018-March 2020) was a cross-sectional study of people with prior 30-day injection drug or nonprescribed opioid use from rural areas of 10 states. Using multivariable mixed-effect regression models, we examined associations between participant technology access and SUD treatment.

FINDINGS

Of 3,026 participants, 71% used heroin and 76% used methamphetamine. Thirty-five percent had no cell phone and 10% had no prior 30-day internet use. Having both a cell phone and the internet was associated with increased days of medication for opioid use disorder (MOUD) use (aIRR 1.29 [95% CI 1.11-1.52]) and a higher likelihood of SUD counseling in the prior 30 days (aOR 1.28 [95% CI 1.05-1.57]). Lack of cell phone was associated with decreased days of MOUD (aIRR 0.77 [95% CI 0.66-0.91]) and a lower likelihood of prior 30-day SUD counseling (aOR 0.77 [95% CI 0.62-0.94]).

CONCLUSIONS

Expanding US rural SUD treatment engagement via telemedicine may require increased cell phone and mobile network access.

A qualitative analysis of rural syringe service program fidelity in Appalachian Kentucky: Staff and participant perspectives

PURPOSE

As drug-related epidemics have expanded from cities to rural areas, syringe service programs (SSPs) and other harm reduction programs have been slow to follow. The recent implementation of SSPs in rural areas demands attention to program fidelity based on core components of SSP success.

METHODS

Semistructured interviews conducted with clients and staff at 5 SSPs in 5 counties within 2 Central Appalachian health districts. Interviews covered fidelity of SSP implementation to 6 core components: (1) meet needs for harm reduction supplies; (2) education and counseling for sexual, injection, and overdose risks; (3) cooperation between SSPs and local law enforcement; (4) provide other health and social services; (5) ensure low threshold access to services; and (6) promote dignity, the impact of poor fidelity on vulnerability to drug-related harms, and the risk environment's influence on program fidelity. We applied thematic methods to analyze the data.

FINDINGS

Rural SSPs were mostly faithful to the 6 core components. Deviations from core components can be attributed to certain characteristics of the local rural risk environment outlined in the risk environment model, including geographic remoteness, lack of resources and underdeveloped infrastructure, and stigma against people who inject drugs (PWID) CONCLUSIONS: As drug-related epidemics continue to expand outside cities, scaling up SSPs to serve rural PWID is essential. Future research should explore whether the risk environment features identified also influence SSP fidelity in other rural areas and develop and test strategies to strengthen core components in these vulnerable areas.

Factors that influence enrollment in syringe services programs in rural areas: a qualitative study among program clients in Appalachian Kentucky

BACKGROUND

Enrolling sufficient number of people who inject drugs (PWID) into syringe services programs (SSP) is important to curtail outbreaks of drug-related harms. Still, little is known about barriers and facilitators to SSP enrollment in rural areas with no history of such programs. This study's purpose was to develop a grounded theory of the role of the risk environment and individual characteristics of PWID in shaping SSP enrollment in rural Kentucky.

METHODS

We conducted one-on-one semi-structured interviews with 41 clients of 5 SSPs that were established in rural counties in Appalachian Kentucky in 2017-2018. Interviews covered PWID needs, the process of becoming aware of SSPs, and barriers and facilitators to SSP enrollment. Applying constructivist grounded theory methods and guided by the Intersectional Risk Environment Framework (IREF), we applied open, axial and selective coding to develop the grounded theory.

RESULTS

Stigma, a feature of IREF's meso-level social domain, is the main factor hampering SSP enrollment. PWID hesitated to visit SSPs because of internalized stigma and because of anticipated stigma from police, friends, family and healthcare providers. Fear of stigma was often mitigated or amplified by a constellation of meso-level environmental factors related to healthcare (e.g., SSPs) and social (PWID networks) domains and by PWID's individual characteristics. SSPs mitigated stigma as a barrier to enrollment by providing low threshold services in a friendly atmosphere, and by offering their clients program IDs to protect them from paraphernalia charges. SSP clients spread positive information about the program within PWID networks and helped their hesitant peers to enroll by accompanying them to SSPs. Individual characteristics, including child custody, employment or high social status, made certain PWID more susceptible to drug-related stigma and hence more likely to delay SSP enrollment.

CONCLUSIONS

Features of the social and healthcare environments operating at the meso-level, as well as PWID's individual characteristics, appear to enhance or mitigate the effect of stigma as a barrier to SSP enrollment. SSPs opening in locations with high stigma against PWID need to ensure low threshold and friendly services, protect their clients from police and mobilize PWID networks to promote enrollment.

Buprenorphine dispensing in an epicenter of the U.S. opioid epidemic: A case study of the rural risk environment in Appalachian Kentucky

BACKGROUND

Buprenorphine is a cornerstone to curbing opioid epidemics, but emerging data suggest that rural pharmacists in the US sometimes refuse to dispense this medication. We conducted a case study to explore buprenorphine dispensing practices in 12 rural Appalachian Kentucky counties, and analyze whether and how they were shaped by features of the rural risk environment.

METHODS

In this case study, we conducted one-on-one semi-structured interviews with 14 pharmacists operating 15 pharmacies in these counties to explore buprenorphine dispensing practices and perceived influences on these practices. Thematic analyses of the resulting transcripts revealed three features of the rural risk environment that shaped dispensing. To explore these three risk environment features, we analyzed policy documents (e.g., Attorney General lawsuits) and administrative databases (e.g., incarceration data). Textual documents were analyzed using thematic analyses and administrative data were analyzed using descriptive statistics; memoes explored relationships among risk environment features and dispensing practices.

RESULTS

Twelve of the 15 pharmacies limited dispensing, by refusing to serve new patients; limiting dispensing to known patients or prescribers; or refusing to dispense buprenorphine altogether. Concerns about exceeding a "Drug Enforcement Administration (DEA) cap" on opioid dispensing stifled dispensing. A legacy of aggressive and fraudulent marketing of opioid analgesics (OAs) by pharmaceutical companies and physician OA overprescribing undermined pharmacist trust in buprenorphine and in its prescribers. The escalating local war on drugs may have undermined dispensing by reinforcing stigma against people who use drugs.

CONCLUSIONS

Initiatives to increase buprenorphine prescribing must be accompanied by policy changes to increase dispensing. Specifically, buprenorphine should be removed from opioid monitoring systems; efforts to de-escalate the war on drugs should be extended to encompass rural areas; initiatives to dismantle aggressive OA marketing should be strengthened; and efforts to re-build pharmacist trust in physicians are needed.

Trends in State Policy Support for Sexual Minorities and HIV-Related Outcomes Among Men Who Have Sex With Men in the United States, 2008-2014

BACKGROUND

To examine trends in state-level policy support for sexual minorities and HIV outcomes among men who have sex with men (MSM).

METHODS

This longitudinal analysis linked state-level policy support for sexual minorities [N = 94 metropolitan statistical areas (MSAs) in 38 states] to 7 years of data (2008-2014) from the Centers for Disease Control and Prevention on HIV outcomes among MSM. Using latent growth mixture modeling, we combined 11 state-level policies (eg, nondiscrimination laws including sexual orientation as a protected class) from 1999 to 2014, deriving the following 3 latent groups: consistently low policy support, consistently high policy support, and increasing trajectory of policy support. Outcomes were HIV diagnoses per 10,000 MSM, late diagnoses (number of deaths within 12 months of HIV diagnosis and AIDS diagnoses within 3 months of HIV diagnosis) per 10,000 MSM, AIDS diagnoses per 10,000 MSM with HIV, and AIDS-related mortality per 10,000 MSM with AIDS.

RESULTS

Compared with MSAs in states with low policy support and increasing policy support for sexual minorities, MSAs in states with the highest level of policy support had lower risks of HIV diagnoses [risk difference (RD) = -37.9, 95% confidence interval (CI): -54.7 to -21.0], late diagnoses (RD = -12.5, 95% CI: -20.4 to -4.7), and AIDS-related mortality (RD = -33.7, 95% CI: -61.2 to -6.2), controlling for time and 7 MSA-level covariates. In low policy support states, 27% of HIV diagnoses, 21% of late diagnoses, and 10% of AIDS deaths among MSM were attributable to the policy climate.

CONCLUSION

The state-level policy climate related to sexual minorities was associated with HIV health outcomes among MSM and could be a potential public health tool for HIV prevention and care.

Structural Determinants of Black MSM HIV Testing Coverage (2011-2016)

Over 30 years into the US HIV/AIDS epidemic, Black men who have sex with men (BMSM) continue to carry the highest burden of both HIV and AIDS cases. There is then, an urgent need to expand access to HIV prevention and treatment for all gay and bisexual men, underscoring the importance of the federal initiative 'Ending the Epidemic: A Plan for America'. This research examines structural factors associated with BMSM HIV testing coverage over time (2011-2016) in 85 US Metropolitan Statistical Areas (MSAs). We calculated MSA-specific annual measures of BMSM HIV testing coverage (2011-2016). Variables suggested by the Theory of Community Action (i.e., need, resource availability, institutional opposition and organized support) were analyzed as possible predictors of coverage using multilevel modeling. Relationships between BMSM HIV testing and the following covariates were positive: rates of BMSM living with HIV (b = 0.28), percent of Black residents employed (b = 0.19), Black heterosexual testing rate (b = 0.46), health expenditures per capita (b = 0.16), ACT UP organization presence in 1992 (b = 0.19), and syringe service presence (b = 0.12). Hard drug arrest rates at baseline (b = - 0.21) and change since baseline (b = - 0.10) were inversely associated with the outcome. Need, resources availability, organized support and institutional opposition are important determinants of place associated with BMSM HIV testing coverage. Efforts to reduce HIV incidence and lessen AIDS-related disparities among BMSM in the US require improved and innovative HIV prevention approaches directed toward BMSM including a fuller understanding of structural factors that may influence place variation in BMSM testing patterns and risk behavior in places of high need.

Actives, passives and power: heteronormative gender norms and their implications for intimate partner violence among men who have sex with men in Tajikistan

Global research reveals that gender-role norms have a profound effect on socio- and psycho-sexual expression (e.g. sexual positioning) among gay and bisexual men, which in turn may affect mental health and sexual risks. However, little is known about these factors among gay and bisexual men in Muslim-majority countries such as Tajikistan. Using a combination of in-depth individual interviews and focus-group assessments, this exploratory, qualitative study examined how gender roles might function as a social determinant for the practice of sexual positioning, which in turn may influence intimate partner violence (IPV), sexual risk and relational power. Results suggest that being the 'active' partner in sexual relationships closely aligns with the construct of hegemonic masculinity, affording actives more power in male-male relationships which may in some cases result in IPV directed against 'passives'. Despite this imbalance, passives also hold power in some cases, such as easier access to public resources such as the police and gay and bisexual focused services. Further research should examine gender norms and sexual positioning relative to IPV and sexual risks among Muslim men in Tajikistan.

Trends over time in HIV prevalence among people who inject drugs in 89 large US metropolitan statistical areas, 1992-2013

PURPOSE

After years of stable or declining HIV prevalence and declining incidence among people who inject drugs (PWID) in the United States, some rapidly emerging outbreaks have recently occurred in new areas (e.g., Scott County, Indiana). However, to our knowledge, trends over time in HIV prevalence among PWID in US metropolitan statistical areas (MSAs) across all major regions of the country have not been systematically estimated beyond 2002, and the extent to which HIV prevalence may be increasing in other areas is largely unknown. This article estimates HIV prevalence among PWID in 89 of the most populated US MSAs, both overall and by geographic region, using more recent surveillance and HIV testing data.

METHODS

We computed MSA-specific annual estimates of HIV prevalence (both diagnosed and undiagnosed infections) among PWID for these 89 MSAs, for 1992-2013, using several data series from the Centers for Disease Control and Prevention's (CDC) National HIV Surveillance System and National HIV Prevention Monitoring and Evaluation data; Holmberg's (1997) estimates of 1992 PWID population size and of HIV prevalence and incidence among PWID; and research estimates from published literature using 1992-2013 data. A mixed effects model, with time nested within MSAs, was used to regress the literature review estimates on all of the other data series. Multiple imputation was used to address missing data. Resulting estimates were validated using previous 1992-2002 estimates of HIV prevalence and data on antiretroviral (ARV) prescription volumes and examined for patterns based on geographic region, numbers of people tested for HIV, and baseline HIV prevalence.

RESULTS

Mean (across all MSAs) trends over time suggested decreases through 2002 (from approximately 11.4% in 1992 to 9.2% in 2002), followed by a period of stability, and steep increases after 2010 (to 10.6% in 2013). Validation analyses found a moderate positive correlation between our estimates and ARV prescription volumes (r = 0.45), and a very strong positive correlation (r = 0.94) between our estimates and previous estimates by Tempalski et al. (2009) for 1992-2002 (which used different methods). Analysis by region and baseline prevalence suggested that mean increases in later years were largely driven by MSAs in the Western United States and by MSAs in the Midwest that had low baseline prevalence. Our estimates suggest that prevalence decreased across all years in the Eastern United States. These trends were particularly clear when MSAs with very low numbers of people tested for HIV were removed from analyses to reduce unexplained variability in mean trajectories.

CONCLUSIONS

Our estimates suggest a fairly large degree of variation in 1992-2013 trajectories of PWID HIV prevalence among 89 US MSAs, particularly by geographic region. They suggest that public health responses in many MSAs (particularly those with larger HIV prevalence among PWID in the early 1990s) were sufficient to decrease or maintain HIV prevalence over time. However, future research should investigate potential factors driving the estimated increase in prevalence after 2002 MSAs in the West and Midwest. These findings have potentially important implications for program and/or policy decisions, but estimates for MSAs with low HIV testing denominators should be interpreted with caution and verified locally before planning action.

Predictors of historical change in drug treatment coverage among people who inject drugs in 90 large metropolitan areas in the USA, 1993-2007

Background

Adequate access to effective treatment and medication assisted therapies for opioid dependence has led to improved antiretroviral therapy adherence and decreases in morbidity among people who inject drugs (PWID), and can also address a broad range of social and public health problems. However, even with the success of syringe service programs and opioid substitution programs in European countries (and others) the US remains historically low in terms of coverage and access with regard to these programs. This manuscript investigates predictors of historical change in drug treatment coverage for PWID in 90 US metropolitan statistical areas (MSAs) during 1993–2007, a period in which, overall coverage did not change.

Methods

Drug treatment coverage was measured as the number of PWID in drug treatment, as calculated by treatment entry and census data, divided by numbers of PWID in each MSA. Variables suggested by the Theory of Community Action (i.e., need, resource availability, institutional opposition, organized support, and service symbiosis) were analyzed using mixed-effects multivariate models within dependent variables lagged in time to study predictors of later change in coverage.

Results

Mean coverage was low in 1993 (6.7%; SD 3.7), and did not increase by 2007 (6.4%; SD 4.5). Multivariate results indicate that increases in baseline unemployment rate (β = 0.312; pseudo-p < 0.0002) predict significantly higher treatment coverage; baseline poverty rate (β = − 0.486; pseudo-p < 0.0001), and baseline size of public health and social work workforce (β = 0.425; pseudo-p < 0.0001) were predictors of later mean coverage levels, and baseline HIV prevalence among PWID predicted variation in treatment coverage trajectories over time (baseline HIV * Time: β = 0.039; pseudo-p < 0.001). Finally, increases in black/white poverty disparity from baseline predicted significantly higher treatment coverage in MSAs (β = 1.269; pseudo-p < 0.0001).

Conclusions

While harm reduction programs have historically been contested and difficult to implement in many US communities, and despite efforts to increase treatment coverage for PWID, coverage has not increased. Contrary to our hypothesis, epidemiologic need, seems not to be associated with change in treatment coverage over time. Resource availability and institutional opposition are important predictors of change over time in coverage. These findings suggest that new ways have to be found to increase drug treatment coverage in spite of economic changes and belt-tightening policy changes that will make this difficult.

Relationship of Racial Residential Segregation to Newly Diagnosed Cases of HIV among Black Heterosexuals in US Metropolitan Areas, 2008-2015

Social science and public health literature has framed residential segregation as a potent structural determinant of the higher HIV burden among black heterosexuals, but empirical evidence has been limited. The purpose of this study is to test, for the first time, the association between racial segregation and newly diagnosed heterosexually acquired HIV cases among black adults and adolescents in 95 large US metropolitan statistical areas (MSAs) in 2008-2015. We operationalized racial segregation (the main exposure) using Massey and Denton's isolation index for black residents; the outcome was the rate of newly diagnosed HIV cases per 10,000 black adult heterosexuals. We tested the relationship of segregation to this outcome using multilevel multivariate models of longitudinal (2008-2015) MSA-level data, controlling for potential confounders and time. All covariates were lagged by 1 year and centered on baseline values. We preliminarily explored mediation of the focal relationship by inequalities in education, employment, and poverty rates. Segregation was positively associated with the outcome: a one standard deviation decrease in baseline isolation was associated with a 16.2% reduction in the rate of new HIV diagnoses; one standard deviation reduction in isolation over time was associated with 4.6% decrease in the outcome. Exploratory mediation analyses suggest that black/white socioeconomic inequality may mediate the relationship between segregation and HIV. Our study suggests that residential segregation may be a distal determinant of HIV among black heterosexuals. The findings further emphasize the need to address segregation as part of a comprehensive strategy to reduce racial inequities in HIV.

People, places, and stigma: A qualitative study exploring the overdose risk environment in rural Kentucky

BACKGROUND

Though overdose rates have been increasing in US rural areas for two decades, little is known about the rural risk environment for overdoses. This qualitative study explored the risk environment for overdoses among young adults in Eastern Kentucky, a rural epicenter of the US opioid epidemic.

METHODS

Participants were recruited via community-based outreach. Eligibility criteria included living in one of five rural Eastern Kentucky counties; being aged 18-35; and using opioids to get high in the past 30 days. Semi-structured interviews explored the rural risk environment, and strategies to prevent overdose and dying from an overdose. Interviews were transcribed verbatim and analyzed using constructivist grounded-theory methods.

RESULTS

In this sample (N = 19), participants reported using in a range of locations, including homes and outdoor settings; concerns about community stigma and law enforcement shaped the settings where participants used opioids and the strategies they deployed in these settings to prevent an overdose, and to survive an overdose. Almost half of participants reported using opioids in a "trap house" or other dealing locations, often to evade police after buying drugs, and reported that others present pressed them to use more than usual. If an overdose occurred in this setting, however, these same people might refuse to call EMS to protect themselves from arrest. Outdoor settings presented particular vulnerabilities to overdose and dying from an overdose. Most participants reported using opioids outdoors, where they skipped overdose prevention steps to reduce their risk of arrest; they worried that no one would find them if they overdosed, and that cell phone coverage would be too weak to summon EMS.

CONCLUSION

Findings suggest that initiatives to reduce overdoses in Eastern Kentucky would be strengthened by de-escalating the War on Drugs and engaging law enforcement in initiatives to protect the health of people who use opioids.

Using Web-Based Pin-Drop Maps to Capture Activity Spaces Among Young Adults Who Use Drugs in Rural Areas: Cross-Sectional Survey

Background

Epicenters of harmful drug use are expanding to US rural areas, with rural young adults bearing a disproportionate burden. A large body of work suggests that place characteristics (eg, spatial access to health services) shape vulnerability to drug-related harms among urban residents. Research on the role of place characteristics in shaping these harms among rural residents is nascent, as are methods of gathering place-based data.

Objective

We (1) analyzed whether young rural adults who used drugs answered self-administered Web-based mapping items about locations where they engaged in risk behaviors and (2) determined the precision of mapped locations.

Methods

Eligible individuals had to report recently using opioids to get high; be aged between 18 and 35 years; and live in the 5-county rural Appalachian Kentucky study area. We used targeted outreach and peer-referral methods to recruit participants. The survey asked participants to drop a pin in interactive maps to mark where they completed the survey, and where they had slept most; used drugs most; and had sex most in the past 6 months. Precision was assessed by (1) determining whether mapped locations were within 100 m of a structure and (2) calculating the Euclidean distance between the pin-drop home location and the street address where participants reported sleeping most often. Measures of central tendency and dispersion were calculated for all variables; distributions of missingness for mapping items and for the Euclidean distance variable were explored across participant characteristics.

Results

Of the 151 participants, 88.7% (134/151) completed all mapping items, and ≥92.1% (>139/151) dropped a pin at each of the 4 locations queried. Missingness did not vary across most participant characteristics, except that lower percentages of full-time workers and peer-recruited participants mapped some locations. Two-thirds of the pin-drop sex and drug use locations were less than 100 m from a structure, as were 92.1% (139/151) of pin-drop home locations. The median distance between the pin-drop and street-address home locations was 2.0 miles (25th percentile=0.8 miles; 75th percentile=5.5 miles); distances were shorter for high-school graduates, staff-recruited participants, and participants reporting no technical difficulties completing the survey.

Conclusions

Missingness for mapping items was low and unlikely to introduce bias, given that it varied across few participant characteristics. Precision results were mixed. In a rural study area of 1378 square miles, most pin-drop home addresses were near a structure; it is unsurprising that fewer drug and sex locations were near structures because most participants reported engaging in these activities outside at times. The error in pin-drop home locations, however, might be too large for some purposes. We offer several recommendations to strengthen future research, including gathering metadata on the extent to which participants zoom in on each map and recruiting participants via trusted staff.

States with higher minimum wages have lower STI rates among women: Results of an ecological study of 66 US metropolitan areas, 2003-2015

Prior research has found that places and people that are more economically disadvantaged have higher rates and risks, respectively, of sexually transmitted infections (STIs). Economic disadvantages at the level of places and people, however, are themselves influenced by economic policies. To enhance the policy relevance of STI research, we explore, for the first time, the relationship between state-level minimum wage policies and STI rates among women in a cohort of 66 large metropolitan statistical areas (MSAs) in the US spanning 2003-2015. Our annual state-level minimum wage measure was adjusted for inflation and cost of living. STI outcomes (rates of primary and secondary syphilis, gonorrhea and chlamydia per 100,000 women) were obtained from the CDC. We used multivariable hierarchical linear models to test the hypothesis that higher minimum wages would be associated with lower STI rates. We preliminarily explored possible socioeconomic mediators of the minimum wage/STI relationship (e.g., MSA-level rates of poverty, employment, and incarceration). We found that a $1 increase in the price-adjusted minimum wage over time was associated with a 19.7% decrease in syphilis rates among women and with an 8.5% drop in gonorrhea rates among women. The association between minimum wage and chlamydia rates did not meet our cutpoint for substantive significance. Preliminary mediation analyses suggest that MSA-level employment among women may mediate the relationship between minimum wage and gonorrhea. Consistent with an emerging body of research on minimum wage and health, our findings suggest that increasing the minimum wage may have a protective effect on STI rates among women. If other studies support this finding, public health strategies to reduce STIs among women should include advocating for a higher minimum wage.

Police killings of Black people and rates of sexually transmitted infections: a cross-sectional analysis of 75 large US metropolitan areas, 2016

OBJECTIVES

Emerging literature shows that racialised police brutality, a form of structural racism, significantly affects health and well-being of racial/ethnic minorities in the USA. While public health research suggests that structural racism is a distal determinant of sexually transmitted infections (STIs) among Black people, no studies have empirically linked police violence to STIs. To address this gap, our study measures associations between police killings and rates of STIs among Black residents of US metropolitan statistical areas (MSAs).

METHODS

This cross-sectional ecological analysis assessed associations between the number of Black people killed by police in 2015 and rates of primary and secondary syphilis, gonorrhoea and chlamydia per 100 000 Black residents of all ages in 2016 in 75 large MSAs. Multivariable models controlled for MSA-level demographic and socioeconomic characteristics, police expenditures, violent crime, arrest and incarceration rates, insurance rates and healthcare funding.

RESULTS

In 2015, the median number of Black people killed by police per MSA was 1.0. In multivariable models, police killings were positively and significantly associated with syphilis and gonorrhoea rates among Black residents. Each additional police killing in 2015 was associated with syphilis rates that were 7.5% higher and gonorrhoea rates that were 4.0% higher in 2016.

CONCLUSIONS

Police killings of Black people may increase MSA-level risk of STI infections among Black residents. If future longitudinal analyses support these findings, efforts to reduce STIs among Black people should include reducing police brutality and addressing mechanisms linking this violence to STIs.

Pharmacists' attitudes and practices about selling syringes to people who inject drugs in Tajikistan: Results of a syringe purchase audit and a survey

BACKGROUND

In Tajikistan, governmental policies leave the decision whether or not to sell syringes to people who inject drugs (PWID) to pharmacists' discretion. This exploratory study tests a theory-driven model explaining Tajikistani pharmacists' actual syringe sale practices to inform future HIV advocacy activities.

METHODS

Data were collected via attempts to purchase syringes without prescription and a subsequent survey among a sample of 232 pharmacists in two cities (Dushanbe and Kulob) in Tajikistan in 2015. The survey collected data on attitudes and beliefs related to selling syringes to PWID, stigma against PWID and background contextual factors such as social conservatism, HIV and drug use knowledge. Structural equation modelling was used to assess the relationships between syringe sale practice and pharmacists' attitudinal and background factors.

RESULTS

The majority (87.9%, n = 204) of sampled pharmacists agreed to sell syringes to the study research assistants without a prescription. According to the final model, agreeing to sell syringes was moderately associated with the reported intent to provide syringes without prescription (β = 0.36, p < 0.001), lower stigma against PWID (β=-0.43, p = 0.01), and stronger social conservatism (β = 0.35, p = 0.02). Intent to provide syringes correlated with positive attitudes towards provision of syringes (β = 0.35, p = 0.008), which in turn were negatively associated with stigma (β=-0.54, p < 0.001) and positively with age (β = 0.20, p = 0.03). Stigma against PWID was directly associated with social conservatism (β = 0.47, p < 0.001) and inversely with university-level education (β=-0.28, p < 0.001).

CONCLUSION

We demonstrated the accessibility of over-the-counter syringes in urban pharmacies of Tajikistan and emphasized the role of stigma in shaping pharmacists' syringe sale practices. Advocacy interventions should target pharmacists to reduce stigmatization of PWID and ensure access to clean syringes.

Rural risk environments for hepatitis c among young adults in appalachian kentucky

BACKGROUND

Rural Kentucky is an epicenter of hepatitis C(HCV), especially among young adults who inject drugs. While the Risk Environment Framework (REF) has been used widely to study and address socio-ecological determinants of infectious disease among people who inject drugs (PWID), it has been almost exclusively applied to urban environments. Applying REF to rural environments can enhance our understanding of the drivers of HCV epidemics in these hard-hit areas, and inform the creation and implementation of harm reduction interventions in this local context.

METHODS

Participants were recruited between March and August 2017 via community-based outreach methods (e.g., cookouts, flyers) and peer referral. Individuals who met eligibility criteria (aged 18-35, recently used prescription opioids and/or heroin to get high, lived in one of the 5 target counties) participated indepth, semi-structured interviews. The interview guide was informed by the REF, and covered HCV-related risk behaviors and environmental features that shaped vulnerability to engaging in these behaviors. Interviews were transcribed and analyzed using constructivist grounded-theory methods.

RESULTS

Participants (N=19) described multiple intersecting risk environment features that shaped vulnerability to HCV transmission. Economic decline generated intergenerational poverty, dwindling employment prospects, and diminished social enrichment opportunities that collectively contributed to substance misuse and risky injection practices. Geographic isolation, lack of collective knowledge about HCV transmission risks, scarce harm reduction services, familial poverty, and fear of law enforcement interacted to increase the odds of people injecting in "trap houses" (akin to shooting galleries) or secluded areas, spaces in which they rushed to inject and shared injection equipment. Pervasive stigma was a structural barrier to adopting, expanding, and using harm reduction services.

CONCLUSION

This exploratory study identified features of rural risk environments that may contribute to significant HCV burdens in Appalachian Kentucky. Findings signal the importance of expanding proven harm reduction strategies and anti-stigma interventions tailored to rural contexts.

HIV and syphilis epidemic among MSM and non-MSM aged 50 and above in Shanghai, China: A yearly cross-sectional study, 2008-2014

The magnitude of the HIV and syphilis epidemic among Chinese men ages 50 and older is unclear. In this study, we aimed to characterise and compare the prevalence of HIV and syphilis infections; linkage to care among those infected with HIV; and the geographic distribution of the two epidemics among elderly men who have sex with men (MSM) and non-MSM in Shanghai, China. This cross-sectional study involved 12,910 men ages 50 and above who participated in the HIV voluntary and counselling testing programme each year from 2008 to 2014. HIV prevalence among MSM in our sample ranged between 4.9% and 15.4%, while syphilis frequency among non-MSM decreased from 26.0% to 18.7%. Further, in 2014, MSM participants had a higher HIV prevalence than non-MSM (4.9% vs 1.8%), whereas syphilis was higher in older non-MSM compared to MSM (18.7% vs 12.4%). Among those infected with HIV, 121/211 (53.75%) of participants were linked to HIV treatment, where the linkage rate was comparable to that in Kunming [Zhao, S., Zhao, G., Zhang, W., liao, B., Chu C., Wang J., & Li, L. (2015). Compare the difference of efficiency between voluntary counseling testing and provider-initiated testing counseling for identifying HIV/AIDS in Kunming. Chinese Journal of AIDS & STD, 21(7), 623-625]. The high burden of HIV and syphilis among men ages 50 and older in Shanghai, China highlights the need to target older Chinese men, both MSM and non-MSM, with prevention efforts.

Stigmatization of people who inject drugs (PWID) by pharmacists in Tajikistan: sociocultural context and implications for a pharmacy-based prevention approach

Background

Pharmacies are an important source of sterile syringes for people who inject drugs (PWID) in Tajikistan who are under high risk of HIV and hepatitis C virus. Accessibility of sterile syringes at pharmacies without prescription may depend on pharmacists’ attitudes towards PWID. This qualitative inquiry examines meanings and processes of stigmatization of PWID among pharmacists and pharmacy students in Tajikistan.

Methods

We conducted semi-structured interviews with 19 pharmacists and 9 students (N = 28) in the cities of Dushanbe and Kulob, Tajikistan. The interview topics included personal attitudes towards drug use and PWID, encounters with PWID, awareness and beliefs related to drug dependence and HIV, and attitudes and practices related to providing syringes to PWID. Interview transcripts were analysed using thematic analysis methods.

Results

The main themes included the significance of religion in defining attitudes towards drug use, labelling of PWID, negative stereotypes (PWID are prone to crime, violence, and irrational aggression; inflict harm to families and society; are able to control drug use), emotions triggered by PWID (fear, sympathy) and discrimination against PWID (rejection, isolation, ostracism, limiting resources to PWID). The religious ban on drug use and pharmacists’ moral and legal responsibility for the consequences of drug use were frequently mentioned as reasons for rejecting syringe sales. Still, many participants acknowledged the need for distributing syringes to PWID to prevent HIV.

Conclusions

Stigma against PWID in Tajikistan plays an important role in shaping pharmacists’ attitudes towards provision of services to this population. Local sociocultural context, in particular religious beliefs and social conservatism, may facilitate stigmatizing beliefs.

Qualitative examination of enacted stigma towards gay and bisexual men and related health outcomes in Tajikistan, Central Asia

Gay and bisexual men (GBM) in Tajikistan are an extremely stigmatised group at high risk for sexually transmitted infections and HIV. However, there is a paucity of research on how and in what way stigma affects their lives. We conducted a qualitative study to examine the impact of stigma on GBM's lives in Tajikistan, focusing on stigma enactors, settings, factors affecting vulnerability of GBM and health consequences. Eight individual in-depth interviews and 3 focus-group discussions with 13 participants (N   =   21) from GBM community were conducted in two cities of Tajikistan. Results reveal that police frequently engage in blackmail and perpetrate sexual and physical violence against GBM. Service providers often discriminate against GBM limiting their access to health and legal services. Exposure to stigma results in chronic stress affecting mental health of GBM. Fear of disclosure, low social cohesion, absence of prominent opinion leaders and activists reduce resilience of GBM community to stigma. State-sanctioned violations of human rights of marginalised populations and lack of effective legal protection mechanisms have enabled widespread harassment of GBM. These findings warrant further research on stigma leading to the development of culturally adapted and tailored multilevel structural interventions, including broad legal and policy reforms.

Estimating self-reported sex practices, drug use, depression, and intimate partner violence among MSM in China: a comparison of three recruitment methods

Men who have sex with men (MSM) are the group at highest risk for HIV in China. Researchers have used various recruitment methods to reach this population hidden from the hetero-normative culture. To inform future recruitment strategies, we compared estimates of socio-demographic characteristics, HIV risk behaviors, depression, and intimate partner violence (IPV) across three samples of MSM and money boys in Shanghai, China. Data were collected from three community-based samples of MSM and money boys (n = 1352) recruited via respondent-driven sampling (RDS) (n = 404), community popular opinion leaders (CPOL) (n = 385), and Internet and venue-based sampling (VBS) (n = 546). Different recruitment methods generated samples with statistically significant differences among a number of socio-demographic characteristics, sexual behaviors, drug use, depression scores, and exposure to IPV. Specifically, RDS participants had lower education (p = .002), income levels (p < .001), and were more likely to report condomless sex with a woman (p < .001). CPOL participants were younger (p < .001), more likely to report lifetime condomless anal sex (p = .009), more than 10 male partners in the past 30 days (p < .001), and were less likely to experience violence by a male intimate partner (p = .001). VBS participants had lowest depression score (p = .005) and were more likely to report lifetime drug use (p = .003). Our findings reinforce that each recruitment method may reach a sub-group of MSM with a specific risk profile, so multiple methods may be needed to obtain a representative sample of MSM. Interventions may use specific recruitment methods to target certain segments of the MSM population.

Drug preparation, injection, and sharing practices in Tajikistan: a qualitative study in Kulob and Khorog

Background

Sharing injection equipment remains an important rout of transmission of HIV and HCV infections in the region of Eastern Europe and Central Asia. Tajikistan is one of the most affected countries with high rates of injection drug use and related epidemics.The aim of this qualitative study was to describe drug use practices and related behaviors in two Tajik cities – Kulob and Khorog.

Methods

Twelve focus group discussions (6 per city) with 100 people who inject drugs recruited through needle and syringe program (NSP) outreach in May 2014. Topics covered included specific drugs injected, drug prices and purity, access to sterile equipment, safe injection practices and types of syringes and needles used. Qualitative thematic analysis was performed using NVivo 10 software.

Results

All participants were male and ranged in age from 20 to 78 years. Thematic analysis showed that cheap Afghan heroin, often adulterated by dealers with other admixtures, was the only drug injected. Drug injectors often added Dimedrol (Diphenhydramine) to increase the potency of “low quality” heroin. NSPs were a major source of sterile equipment. Very few participants report direct sharing of needles and syringes. Conversely, many participants reported preparing drugs jointly and sharing injection paraphernalia. Using drugs in an outdoor setting and experiencing withdrawal were major contributors to sharing equipment, using non-sterile water, not boiling and not filtering the drug solution.

Conclusion

Qualitative research can provide insights into risk behaviors that may be missed in quantitative studies. These finding have important implications for planning risk reduction interventions in Tajikistan. Prevention should specifically focus on indirect sharing practices.

Factors that influence the characteristics of needles and syringes used by people who inject drugs in Tajikistan

BACKGROUND

"Low dead space" syringes with permanently attached needles retain less fluid, blood, and HIV after use than standard "high dead space" syringes. This reduces the probability of HIV transmission if they are shared by people who inject drugs (PWID). The World Health Organization recently recommended that needle and syringe programs (NSP) offer clients low dead space syringes. The success of this recommendation will depend on PWID switching to low dead space needles and syringes. This paper examines the needles and syringes that PWID in Tajikistan use and factors that influence their choices.

METHODS

In May 2014, we conducted six focus groups in Kulob and six in Khorog, Tajikistan, with a total of 100 participants. NSP staff members recruited participants. Focus group topics included the needles and syringes used and factors that influence choice of needles and syringes. Focus groups were conducted in Russian and Tajik, audio recorded, transcribed, and translated into English. The translated files were imported into NVivo 10 for coding and analysis.

RESULTS

All participants in both cities were male and reported injecting heroin. Everyone also reported using syringes with detachable needles almost exclusively. The most popular syringe sizes were 2 and 5 ml. Needles ranged in gauge from 25 to 21 g. Needle gauge was influenced by the size of the vein, the viscosity of drug solution to be injected, and problems with blood clotting. Needles ranged in length from 12 to 38 mm, with 25 and 32 mm being the most popular. Needle length was influenced by the depth of the vein being used. Many PWID inject volumes of fluid greater than 1 ml into deep veins that require needles at least 25 mm long and 25 g in diameter.

CONCLUSION

Most low dead space syringes are 1-ml insulin syringes with 12 mm 28 g permanently attached needles. Findings from this project suggest that these will not be acceptable to PWID who need larger syringes and longer and thicker needles that are detachable. Low dead space detachable needles appear to be an acceptable option that could overcome barriers to the widespread use of low dead space equipment for reducing HIV and HCV transmission.