Correlates of Sexual Coercion among People Who Inject Drugs (PWID) in Los Angeles and San Francisco, CA

Effect of Histamine H2 Receptor Antagonists on All-Cause Mortality in Critically Ill Patients With Essential Hypertension: A Retrospective Cohort Study

Previous studies found that histamine H2 receptor antagonists (H2RAs) had blood pressure lowering and cardioprotective effects, but the impact of H2RAs on the survival outcomes of critically ill patients with essential hypertension is still unclear. The aim of this study was to investigate the association of H2RAs exposure with all-cause mortality in patients with essential hypertension based on Medical Information Mart for Intensive Care III database. A total of 17,739 patients were included, involving 8482 H2RAs users and 9257 non-H2RAs users. Propensity score matching (PSM) was performed to improve balance between 2 groups that were exposed to H2RAs or not. Kaplan-Meier survival curves were used to compare the cumulative survival rates and multivariable Cox regression models were performed to evaluate the association between H2RAs exposure and all-cause mortality. After 1:1 PSM, 4416 pairs of patients were enrolled. The results revealed potentially significant association between H2RAs exposure and decreased 30-day, 90-day, and 1-year mortalities in multivariate analyses (HR = 0.783, 95% CI: 0.696-0.882 for 30-day; HR = 0.860, 95% CI: 0.778-0.950 for 90-day; and HR = 0.883, 95% CI: 0.811-0.961 for 1-year mortality, respectively). Covariate effect analyses showed that the use of H2RAs was more beneficial in essential hypertension patients with age ≥ 60, BMI ≥ 25 kg/m2, coronary arteriosclerosis, stroke, and acute kidney failure, respectively. In conclusion, H2RAs exposure was related to lower mortalities in critically ill patients with essential hypertension, which provided novel potential strategy for the use of H2RAs in essential hypertension patients.

Project T-SHARP: study protocol for a multi-site randomized controlled trial of tele-harm reduction for people with HIV who inject drugs

BACKGROUND

The resurgence of HIV outbreaks and rising prevalence among people who inject drugs (PWID) remain exigent obstacles to Ending the HIV Epidemic in the USA. Adapting a low threshold, comprehensive treatment model for PWID with HIV can leverage syringe services programs (SSPs) to increase availability and accessibility of antiretrovirals (ART), medications for opioid use disorder (MOUD), and hepatitis C cure. We developed Tele-Harm Reduction, a telehealth-enhanced, harm reduction intervention delivered within an SSP venue.

METHODS

The T-SHARP trial is an open-label, multi-site, randomized controlled superiority trial with two parallel treatment arms. Participants (n=240) recruited from SSPs in Miami, Ft. Lauderdale, and Tampa, Florida, who are PWID with uncontrolled HIV (i.e., HIV RNA>200) will be randomized to Tele-Harm Reduction or off-site linkage to HIV care. The primary objective is to compare the efficacy of Tele-Harm Reduction for initiation of ART at SSPs vs. off-site linkage to an HIV clinic with respect to viral suppression across follow-up (suppression at 3, 6, and 12 months post randomization). Participants with HIV RNA<200 copies/ml will be considered virally suppressed. The primary trial outcome is time-averaged HIV viral suppression (HIV RNA <200 copies/ml) over 3-, 6-, and 12-month follow-up. Secondary outcomes include initiation of MOUD measured by urine drug screen and HCV cure, defined as achieving 12-week sustained virologic response (negative HCV RNA at 12 weeks post treatment completion). A cost-effectiveness analysis will be performed.

DISCUSSION

The T-SHARP Trial will be the first to our knowledge to test the efficacy of an innovative telehealth intervention with PWID with uncontrolled HIV delivered via an SSP to support HIV viral suppression. Tele-Harm Reduction is further facilitated by a peer to support adherence and bridge the digital divide. This innovative, flipped healthcare model sets aside the traditional healthcare system, reduces multi-level barriers to care, and meets PWID where they are. The T-SHARP trial is a pragmatic clinical trial that seeks to transform the way that PWID access HIV care and improve HIV clinical outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05208697. Trial registry name: Tele-Harm Reduction. Registration date: January 26, 2022.

Prevalence and Correlates of Sexual Violence Experienced by Young Adult Black Men Who Have Sex with Men

Men who have sex with men (MSM) experience high prevalence of sexual violence (SV), and SV has well-documented effects on health. Research gaps are especially evident for young Black MSM (YBMSM), who experience significant HIV disparities and syndemics, including multiple forms of violence victimization. We examined lifetime prevalence of SV (having been forced or frightened into sexual activity) in a cross-sectional sample of YBMSM (N = 1732), and tested associations of demographic, psychosocial, and structural factors using multivariable regression. YBMSM were recruited between 2013 and 2015 using modified venue-based time-location sampling (e.g., at bars and clubs) in Dallas and Houston, Texas. Approximately 17% of YBMSM experienced any SV in their lifetimes. SV was associated with high school non-completion (OR 1.78; 95% CI 1.15-2.77), lower psychological resilience (OR 0.84; 95% CI 0.71-0.98), lifetime history of homelessness (OR 5.52; 95% CI 3.80-8.02), recent financial hardship (OR 2.16; 95% CI 1.48-3.14), and recent transactional sex (OR 3.87; 95% CI 2.43-6.15). We also examined differences by age of SV onset (childhood versus adulthood). YBMSM with adolescent/emerging adult-onset SV may have been more ambivalent in reporting lifetime SV experience, compared to men with childhood-onset SV, and correlates differed by age of onset. Childhood-onset SV was associated with high school non-completion, lower levels of psychological resilience, history of homelessness, recent financial hardship, and recent transactional sex. Adolescent/emerging adult-onset SV was associated with greater depressive symptoms, history of homelessness, and recent financial hardship. There is a need for multi-level approaches to SV prevention and treatment, including services and supports that are culturally-relevant and responsive to the needs of YBMSM.

Correlates of Transactional Sex and Violent Victimization among Men Who Inject Drugs in Los Angeles and San Francisco, California

Men who inject drugs (MWID) and engage in transactional sex (i.e., receive money or drugs in exchange for sex) are vulnerable to HIV and violence. However, MWID who engage in transactional sex have been less studied than women. We examine factors associated with transactional sex among MWID in Los Angeles and San Francisco and whether transactional sex is associated with violent victimization. MWID were recruited using targeted sampling methods in 2011-2013 and completed surveys that covered demographics, drug use, HIV risk, violence, transactional sex, and other items. Multivariable logistic regression was used to (1) determine factors independently associated with transactional sex and (2) determine if transactional sex was independently associated with violence victimization in the last 6 months among MWID. An interaction term between income source and sexual identity was included in the transactional sex model. Of the 572 male PWID in the sample, 47 (8%) reported transactional sex in the past 6 months. Self-reported HIV infection was 7% for MWID who did not report transactional sex, 17% for MWID who reported transactional sex, and 24% for MWID who reported transactional sex and reported gay or bisexual identity. In multivariable analysis, transactional sex was positively associated with gay or bisexual identity (GB without illegal income adjusted odds ratio [AOR] = 5.16; 95% confidence interval [CI] = 1.86-14.27; GB with illegal income AOR = 13.55, CI = 4.57-40.13), coerced sex in the last 12 months (AOR = 11.66, CI = 1.94-70.12), and violent victimization in the last 12 months (AOR = 2.31, CI = 1.13-4.75). Transactional sex was negatively associated with heroin injection (last 30 days) (AOR = 0.37; 95% CI = 0.18-0.78). Transactional sex was independently associated with violent victimization in the last 12 months (AOR = 2.04; 95% CI = 1.00-4.14) while controlling for confounders. MWID who engaged in transactional sex are at elevated risk for HIV and multiple forms of violent victimization. Interventions focused on this at-risk subpopulation are urgently needed and should include access to substance use disorder treatment, victimization services, and harm reduction services across the HIV care continuum.

Willingness to initiate pre-exposure prophylaxis (PrEP) and its use among opioid-dependent individuals in drug treatment

BACKGROUND

People who use drugs (PWUD) continue to experience a disproportionate HIV burden due to drug- and sex-related risk behaviors. Pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV infection, but very little is known about PrEP use among PWUD and their willingness to initiate PrEP.

METHODS

We conducted a cross-sectional survey among 234 HIV-negative, opioid-dependent individuals recruited from an urban methadone clinic. Participants were assessed using an audio-computer assisted self-interview technique. Bivariate and multiple logistic regressions were used to explore independent correlates of actual PrEP use and willingness to initiate PrEP.

RESULTS

One-fourth (25.6 %) of participants had previously used PrEP. Over two-thirds (67.1 %) of participants had previously heard of PrEP, and 65.0 % were willing to take it. In multivariable logistic regression analyses, the number of times participants engaged in HIV testing (aOR = 1.66, p < 0.01) and whether they visited a healthcare provider (aOR=20.81, p = 0.02) were associated with a higher likelihood of PrEP use, while perceived HIV risk (aOR=2.71, p < 0.01) and previous use of PrEP (aOR=3.57, p < 0.01) were significantly associated with willingness to initiate PrEP.

CONCLUSION

PrEP use was low among PWUD, but their willingness to initiate PrEP was moderate, which indicated a significant discrepancy between actual PrEP use and willingness to use it. Our findings highlight the importance of healthcare providers engaging opioid-dependent individuals in discussions about PrEP and the need for innovative strategies to increase their awareness of PrEP and modify their perceptions of HIV risk.

HIV Pre-Exposure Prophylaxis Prevention Awareness, Willingness, and Perceived Barriers among People Who Inject Drugs in Los Angeles and San Francisco, CA, 2016-2018

BACKGROUND

Pre-exposure prophylaxis (PrEP) for HIV prevention is indicated for people who inject drugs (PWID), yet most studies do not focus on PWID. This study examines factors associated with PrEP awareness and willingness, and identifies perceived barriers to PrEP among PWID. Methods: PWID were interviewed in Los Angeles and San Francisco, CA from 2016 to 2018. We analyzed data from self-reported HIV-negative participants who had injected drugs within the past 6 months (n = 469). Questions on PrEP included awareness, willingness, barriers, and uptake. Multiple logistic regression models of factors associated with awareness of, and willingness to, take PrEP were developed. Descriptive statistics on perceived PrEP barriers are reported. Results: Among HIV-negative PWID, 40% were aware of PrEP, 59% reported willingness to take PrEP, and 2% were currently taking PrEP. In multivariable analysis, PrEP awareness was associated with study site and sexual minority status, higher educational attainment, and HIV testing in the last 6 months. Willingness to take PrEP was associated with self-reported risk (paying sex partner in the last 6 months, sharing drug paraphernalia, and being injected by another PWID) and perceived HIV risk. The most common perceived barriers to PrEP were copays, concerns about increased HIV or sexually transmitted risk with PrEP, and concerns about reduction of medication efficacy without daily use. Conclusion: PrEP awareness among PWID remains inadequate. Willingness to take PrEP was moderate and was most desired by PWID who engaged in high-risk behaviors. Interventions to increase PrEP awareness and willingness, and to facilitate PrEP uptake among PWID are needed.

A Syndemic Model of Exchange Sex Among HIV-Positive Men Who Have Sex With Men

Exchange sex is a behavior associated with HIV transmission risk among men who have sex with men (MSM). Few studies have examined exchange sex among HIV-positive MSM. We utilize a syndemic framework to account for co-occurring psychosocial problems that suggest the presence of intertwining epidemics (i.e., syndemics), which have not been examined within the context of exchange sex among HIV-positive MSM. In 2015, MSM were recruited via online sexual networking Web site and app advertisements for Sex Positive!^[+], a video-based online intervention that aimed to improve health outcomes for men living with HIV. Participants completed surveys every three months for a year. Surveys covered demographics, drug use, exchange sex, intimate partner violence (IPV), and past 2-week depressive symptoms. We conducted three logistic regression models to assess syndemic factors associated with exchange sex in the past 3 months. Of the 722 HIV-positive MSM included in the sample, 59 (8%) reported exchange sex in the past 3 months at 12-month follow-up. HIV-positive MSM who had more syndemic factors had greater odds of exchange sex. Exchange sex was associated with being African-American/Black, age 18-29 years, past and present experiences with IPV, stimulant use, polysubstance use, and depressive symptoms. Exchange sex was associated with multiple psychosocial factors, indicating exchange sex may be part of a syndemic involving substance use, depression, HIV, and IPV. Interventions should address the social and behavioral circumstances that perpetuate environments that can foster multiple negative health outcomes.

Interest in linkage to PrEP among people who inject drugs accessing syringe services; Miami, Florida

Background

People who inject drugs (PWID) are at an increased risk for HIV infection due to injection and sexual risk behaviors. This study aims to examine PrEP knowledge, awareness, and willingness to be linked to PrEP services at a syringe services program (SSP), and examine the relationship between substance use and interest in PrEP linkage.

Methods

Data were collected using a cross-sectional survey of IDEA SSP clients in Miami, FL (N = 157). Based on reported substance injected, participants were classified into opioid-only injection or polysubstance injection. Socio-demographics and HIV risk were examined using Pearson’s Chi-Squared analysis. Bivariate and multivariable logistic regression models were used to test for significant correlates of interest in PrEP linkage.

Results

Only 28.3% of PWID surveyed had previously heard of PrEP. However, 57.2% were interested in receiving more information about PrEP. In the adjusted model, people with opioid-only use were significantly less likely to report interest in being linked to PrEP.

Conclusion

Knowledge, awareness, and interest in being linked to PrEP were low among PWID surveyed. No participants of the study were successfully linked to PrEP services through direct referrals. Further research is needed to examine low threshold service delivery of PrEP to PWID at SSPs.

Supervised injection facility use and exposure to violence among a cohort of people who inject drugs: A gender-based analysis

BACKGROUND

Supervised injection facilities (SIFs) have been established in many settings, in part to reduce risks associated with injecting in public, including exposure to violence. However, the relationship between SIF use and experiencing violence has not yet been thoroughly evaluated. We sought to longitudinally examine the gender-specific relationship between SIF use and exposure to violence among people who inject drugs (PWID) in a Canadian setting.

METHODS

Data were drawn from two prospective cohort studies of PWID in Vancouver, Canada, between December 2005 and December 2016. Semi-annually, participants completed questionnaires that elicited data concerning sociodemographic characteristics, behavioural patterns, violent encounters and health service utilization. We used multivariable generalized estimating equations (GEE) to estimate the independent association between exclusively injecting drugs at a SIF and experiencing physical or sexual violence among men and women PWID, respectively.

RESULTS

Of 1930 PWID followed for a median of four years, 679 (35.2%) were women and the median age was 41 years at baseline. In total, 353 (52.0%) women and 694 (55.5%) men reported experiencing at least one incident of violence during follow-up. In multivariable analyses, exclusive SIF use was associated with decreased odds of experiencing violence among men after adjusting for potential confounders (Adjusted Odds Ratio [AOR] = 0.64; 95% confidence interval [CI]: 0.46-0.89). Exclusive SIF use was not significantly associated with experiencing violence among women in adjusted analyses (AOR = 0.97; 95% CI: 0.57-1.66).

CONCLUSION

In light of the recent expansion of SIFs in Canada, our finding of a protective association between exclusive SIF use and exposure to violence among men is encouraging. The fact that we did not observe a significant association between SIF use and experiencing violence among women highlights the need for social-structural interventions that are more responsive to the specific needs of women PWID in relation to violence prevention.

HIV Pre-exposure Prophylaxis for People Who Inject Drugs: The Context of Co-occurring Injection- and Sexual-Related HIV Risk in the U.S. Northeast

Background: People who inject drugs (PWID) are at increased risk for HIV infection through sharing contaminated needles and injection equipment, and engaging in condomless sex. Objectives: To qualitatively examine the overlapping nature of these behaviors among PWID in the US Northeast. Methods: We recruited HIV-uninfected PWID and key informants through community-based organizations. Qualitative interviews explored sexual partnerships as they related to sharing contaminated needles and injection equipment, engaging in condomless sex, and associated indications for PrEP among PWID. Results: Among 33 PWID, 66% engaged in condomless vaginal or anal sex in the past 3 months, and 27% had three or more sexual partners in this same time period. Over half engaged in any past month distributive or receptive syringe sharing (64%). We identified three contexts through which overlapping sexual and injection-related HIV risks emerged, including (1) multiple concurrent sexual partnerships; (2) using and injecting drugs with sexual partners (including increase injecting of crystal methamphetamine); and (3) exchanging sex for money or drugs (including among male PWID). Condom use was inconsistent across these contexts. Limited interactions with healthcare providers often resulted in sexual risks being overlooked in light of competing health concerns. Conclusions: Sexual risk for HIV acquisition is complex and multi-faceted among PWID yet may be overlooked by prevention and healthcare providers. Comprehensive HIV prevention efforts must acknowledge the distinct contexts in which overlapping injection and sexual risk behaviors occur. Increased sexual health screening and risk reduction services including PrEP for PWID may help curtail transmission in this population.