Developing Measures of Pathways that May Link Macro Social/Structural Changes with HIV Epidemiology

Will the Russian war in Ukraine unleash larger epidemics of HIV, TB and associated conditions and diseases in Ukraine?

The Russian war in Ukraine poses many risks for the spread of HIV, TB and associated conditions, including possible increases in the numbers of people who inject drugs or engage in sex work in the years ahead. Ukrainian civil society and volunteer efforts have been able to maintain and at times expand services for HIV Key Populations. The extent of mutual-aid and volunteer efforts as well as the continued strength and vitality of harm reduction organizations such as the Alliance for Public Health and the rest of civil society will be crucial resources for postwar efforts to assist Key Populations and prevent the spread of HIV, TB and other diseases. The postwar period will pose great economic and political difficulties for Ukrainians, including large populations of people physically and/or psychically damaged and in pain who might become people who inject drugs. Local and international support for public health and for harm reduction will be needed to prevent potentially large-scale increases in infectious disease and related mortality.

Sociopolitical Diagnostic Tools to Understand National and Local Response Capabilities and Vulnerabilities to Epidemics and Guide Research into How to Improve the Global Response to Pathogens

The AIDS and COVID-19 pandemics demonstrated that nations at similar economic development levels varied widely in their capacity to protect the health of their residents. For AIDS, Britain and Australia brought gay representatives into official counsels and adopted harm reduction far more rapidly than the United States or Spain, and East African countries responded more effectively than South Africa or the Democratic Republic of the Congo. National responses to COVID-19 varied widely, with New Zealand, China, and Vietnam more effective than Italy, Brazil, or the United States. Further, as phylogenetic research has demonstrated, these pandemics spread from one country to another, with those that responded poorly acting as sources for mutations and potentially sources of transmission to countries with more effective responses. Many observers expressed surprise at the poor responses of the United States to COVID-19, but in retrospect the cutbacks in public health funding at state and national levels made it clear that this was a predictable weakness even in addition to the political vacillations that crippled the US and Brazilian responses. In a time of global sociopolitical and climate instability, it is important to measure and conduct research into spatial and time variations in 1. public health and medical funding, 2. social influence networks, social cohesion and trust, and stigmatization, 3. income inequality, 4. social conflict, and 5. other factors that affect responsiveness to pandemics.

Emerging Zoonotic Infections, Social Processes and Their Measurement and Enhanced Surveillance to Improve Zoonotic Epidemic Responses: A "Big Events" Perspective

Zoonotic epidemics and pandemics have become frequent. From HIV/AIDS through COVID-19, they demonstrate that pandemics are social processes as well as health occurrences. The roots of these pandemics lie in changes in the socioeconomic interface between humanity and non-human host species that facilitate interspecies transmission. The degree to which zoonoses spread has been increased by the greater speed and extent of modern transportation and trade. Pre-existing sociopolitical and economic structures and conflicts in societies also affect pathogen propagation. As an epidemic develops, it can itself become a social and political factor, and change and interact with pre-existing sociobehavioral norms and institutional structures. This paper uses a "Big Events" approach to frame these processes. Based on this framework, we discuss how social readiness surveys implemented both before and during an outbreak might help public health predict how overall systems might react to an epidemic and/or to disease control measures, and thus might inform interventions to mitigate potential adverse outcomes or possibly preventing outbreaks from developing into epidemics. We conclude by considering what "pathways measures", in addition to those we and others have already developed, might usefully be developed and validated to assist outbreak and epidemic disease responses.

The stigma system: How sociopolitical domination, scapegoating, and stigma shape public health

Stigma is a fundamental driver of adverse health outcomes. Although stigma is often studied at the individual level to focus on how stigma influences the mental and physical health of the stigmatized, considerable research has shown that stigma is multilevel and structural. This paper proposes a theoretical approach that synthesizes the literature on stigma with the literature on scapegoating and divide-and-rule as strategies that the wealthy and powerful use to maintain their power and wealth; the literatures on racial, gender, and other subordination; the literature on ideology and organization in sociopolitical systems; and the literature on resistance and rebellion against stigma, oppression and other forms of subordination. we develop a model of the "stigma system" as a dialectic of interacting and conflicting structures and processes. Understanding this system can help public health reorient stigma interventions to address the sources of stigma as well as the individual problems that stigma creates. On a broader level, this model can help those opposing stigma and its effects to develop alliances and strategies with which to oppose stigma and the processes that create it.

Big Events theory and measures may help explain emerging long-term effects of current crises

Big Events are periods during which abnormal large-scale events like war, economic collapse, revolts, or pandemics disrupt daily life and expectations about the future. They can lead to rapid change in health-related norms, beliefs, social networks and behavioural practices. The world is undergoing such Big Events through the interaction of COVID-19, a large economic downturn, massive social unrest in many countries, and ever-worsening effects of global climate change. Previous research, mainly on HIV/AIDS, suggests that the health effects of Big Events can be profound, but are contingent: Sometimes Big Events led to enormous outbreaks of HIV and associated diseases and conditions such as injection drug use, sex trading, and tuberculosis, but in other circumstances, Big Events did not do so. This paper discusses and presents hypotheses about pathways through which the current Big Events might lead to better or worse short and long term outcomes for various health conditions and diseases; considers how pre-existing societal conditions and changing 'pathway' variables can influence the impact of Big Events; discusses how to measure these pathways; and suggests ways in which research and surveillance might be conducted to improve human capacity to prevent or mitigate the effects of Big Events on human health.

Socially-supportive norms and mutual aid of people who use opioids: An analysis of Reddit during the initial COVID-19 pandemic

BACKGROUND

Big events (i.e., unique historical disruptions) like the COVID-19 epidemic and its associated period of social distancing can transform social structures, social interactions, and social norms. Social distancing rules and the fear of infection have greatly reduced face-to-face interactions, increased loneliness, reduced ties to helping institutions, and may also have disrupted the opioid use behaviors of people who use drugs. This research used Reddit to examine the impact of COVID-19 on the social networks and social processes of people who use opioids.

METHODS

Data were collected from the social media forum, Reddit.com. At the beginning of the COVID-19 pandemic in the U.S. (March 5, 2020, to May 13, 2020), 2,000 Reddit posts were collected from the two most popular opioid subreddits (r/OpiatesRecovery, r/Opiates). Posts were reviewed for relevance to COVID-19 and opioid use resulting in a final sample of 300. Thematic analysis was guided by the Big Events framework.

RESULTS

The COVID-19 pandemic was found to create changes in the social networks and daily lives among persons who use opioids. Adaptions to these changes shifted social networks leading to robust social support and mutual aid on Reddit, including sharing and seeking advice on facing withdrawal, dealing with isolation, managing cravings, and accessing recovery resources.

CONCLUSIONS

Reddit provided an important source of social support and mutual aid for persons who use opioids. Findings indicate online social support networks are beneficial to persons who use opioids, particularly during big events where isolation from other social support resources may occur.

Drug Injection-Related Norms and High-Risk Behaviors of People Who Inject Drugs in Athens, Greece

Drug use involves social interactions. Therefore, norms in the proximal environment of people who inject drugs (PWID) can favor behaviors that may result in HIV transmission. This work aimed at studying drug injection-related norms and their potential association with risky behaviors among PWID in Athens, Greece, in the context of economic recession and political activism that followed the fiscal crisis and soon after a recent HIV outbreak had leveled off. The Transmission Reduction Intervention Project (TRIP) was a social network-based approach (June 2013 to July 2015) that involved two groups of PWID seeds-with recent HIV infection and with long-term HIV infection and one control group of HIV-negative PWID. Network contacts of seeds were also enrolled. TRIP participants answered a questionnaire that included items on injection-related norms and behaviors. TRIP recruited 320 PWID (HIV positive, 44.4%). TRIP participants, especially those without HIV, often recalled or perceived as normative among their partners and in their networks some behaviors that can lead to HIV transmission. TRIP participants who recalled that they were encouraged by their regular drug partners to use an unclean syringe were almost twice as likely to report that they share syringes [odds ratio (OR) = 2.03; 95% confidence interval (CI) = 1.86-2.21], or give syringes to someone else (OR = 1.70; 95% CI = 1.42-2.04) as those who did not recall such an encouragement. Associations were modified by HIV status. HIV negatives, who were reportedly encouraged to share nonsyringe injecting equipment, were almost 4.5 times as likely to share that material as HIV-negative participants who were not encouraged (OR = 4.59, 95% CI = 4.12-5.11). Further research is needed on the multiple determinants (social, economic, and political) of norms in the social environments of PWID. Since peer norms are associated with risky behaviors, interventions should be developed to encourage norms and peer pressure against the sharing of injection equipment.

New Measures for Research on Men Who Have Sex with Men and for At-Risk Heterosexuals: Tools to Study Links Between Structural Interventions or Large-Scale Social Change and HIV Risk Behaviors, Service Use, and Infection

Large-scale structural interventions and "Big Events" like revolutions, wars and major disasters can affect HIV transmission by changing the sizes of at-risk populations, making high-risk behaviors more or less likely, or changing contexts in which risk occurs. This paper describes new measures to investigate hypothesized pathways that could connect macro-social changes to subsequent HIV transmission. We developed a "menu" of novel scales and indexes on topics including norms about sex and drug injecting under different conditions, experiencing denial of dignity, agreement with cultural themes about what actions are needed for survival or resistance, solidarity and other issues. We interviewed 298 at-risk heterosexuals and 256 men who have sex with men in New York City about these measures and possible validators for them. Most measures showed evidence of criterion validity (absolute magnitude of Pearson's r ≥ 0.20) and reliability (Cronbach's alpha ≥ 0.70). These measures can be (cautiously) used to understand how macro-changes affect HIV and other risk. Many can also be used to understand risk contexts and dynamics in more normal situations. Additional efforts to improve and to replicate the validation of these measures should be conducted.

Age Cohort Differences in Sexual Behaviors Among Black Men Who Have Sex With Men and Women

Little attention has focused on generational or age-related differences in human immunodeficiency virus/sexually transmitted infection (HIV/STI) risk behaviors among Black men who have sex with men and women (BMSMW). We examined sexual risk behaviors between BMSMW ages 40 and under compared to over age 40. Analysis was conducted using Centers for Disease Control and Prevention (CDC)-sponsored intervention data among BMSMW in Los Angeles, Chicago, and Philadelphia (n = 546). Pearson's chi-square tests were conducted to evaluate associations between age groups and behavioral outcomes. Logistic regression was used to evaluate the odds of behavioral outcomes by age group, adjusting for sexual orientation and study location, within strata of HIV status. HIV-positive BMSMW over age 40 had 62% reduced odds of having a nonmain female partner of HIV-negative or unknown status compared to those ages 40 and under (adjusted odds ratio [AOR] 0.38, 95% confidence interval [CI] = 0.15, 0.95). Among HIV-negative BMSMW, the older cohort was associated with greater odds of having condomless insertive anal intercourse (IAI) with most recent main male partner (AOR 2.44, 95% CI = 1.12, 5.32) and having a concurrent partnership while with their recent main female partner (AOR = 2.6, 95% CI = 1.10, 4.67). For both groups, odds of engaging in certain risk behaviors increased with increasing age. Prevention efforts should consider generational differences and age in HIV risks among BMSMW.

Interpersonal Attacks on the Dignity of Members of HIV Key Populations: A Descriptive and Exploratory Study

Attacks on peoples' dignity help to produce and maintain stigmatization and interpersonal hostility. As part of an effort to develop innovative measures of possible pathways between structural interventions or socially-disruptive Big Events and HIV outbreaks, we developed items to measure dignity denial. These measures were administered to 300 people who inject drugs (PWID), 260 high-risk heterosexuals who do not inject drugs, and 191 men who have sex with men who do not inject drugs (MSM). All of the PWID and many of the high risk heterosexuals and MSM were referred to our study in 2012-2015 by a large New York city study that used respondent-driven sampling; the others were recruited by chain-referral. Members of all three key populations experienced attacks on their dignity fairly often and also reported frequently seeing others' dignity being attacked. Relatives are major sources of dignity attacks. MSM were significantly more likely to report having their dignity attacked by police officers than were the other groups. 40 % or more of each key population reported that dignity attacks are followed "sometimes" or more often both by using more drugs and also by using more alcohol. Dignity attacks and their health effects require more research and creative interventions, some of which might take untraditional forms like social movements.

Income inequality, drug-related arrests, and the health of people who inject drugs: Reflections on seventeen years of research

This paper reviews and then discusses selected findings from a seventeen year study about the population prevalence of people who inject drugs (PWID) and of HIV prevalence and mortality among PWID in 96 large US metropolitan areas. Unlike most research, this study was conducted with the metropolitan area as the level of analysis. It found that metropolitan area measures of income inequality and of structural racism predicted all of these outcomes, and that rates of arrest for heroin and/or cocaine predicted HIV prevalence and mortality but did not predict changes in PWID population prevalence. Income inequality and measures of structural racism were associated with hard drug arrests or other properties of policing. These findings, whose limitations and implications for further research are discussed, suggest that efforts to respond to HIV and to drug injection should include supra-individual efforts to reduce both income inequality and racism. At a time when major social movements in many countries are trying to reduce inequality, racism and oppression (including reforming drug laws), these macro-social issues in public health should be both addressable and a priority in both research and action.