Associations between neighborhood characteristics and sexual risk behaviors among HIV-infected and HIV-uninfected women in the southern United States

Exploring Psychosocial and Structural Syndemic Effects as Predictors of HIV Risk Behaviors Among Black Women (HPTN 064)

Background: Syndemic models have been used in previous studies exploring HIV-related outcomes; however, these models do not fully consider intersecting psychosocial (e.g., substance use, depressive symptoms) and structural factors (unstable housing, concentrated housing vacancy) that influence the lived experiences of women. Therefore, there is a need to explore the syndemic effects of psychosocial and structural factors on HIV risk behaviors to better explain the multilevel factors shaping HIV disparities among black women. Methods: This analysis uses baseline data (May 2009-August 2010) from non-Hispanic black women enrolled in the HIV Prevention Trials Network 064 Women's Seroincidence Study (HPTN 064) and the American Community Survey 5-year estimates from 2007 to 2011. Three parameterizations of syndemic factors were applied in this analysis a cumulative syndemic index, three syndemic groups reflecting the level of influence (psychosocial syndemic group, participant-level structural syndemic group, and a neighborhood-level structural syndemic group), and syndemic factor groups. Clustered mixed effects log-binomial analyses measured the relationship of each syndemic parameterization on HIV risk behaviors in 1,347 black women enrolled in HPTN 064. Results: A higher syndemic score was significantly associated with increased prevalence of unknown HIV status of the last male sex partner (adjusted prevalence ratio (aPR) = 1.07, 95% confidence interval or CI 1.04-1.10), involvement in exchange sex (aPR = 1.17, 95% CI: 1.14-1.20), and multiple sex partners (aPR = 1.07, 95% CI: 1.06-1.09) in the last 6 months. A dose-response relationship was observed between the number of syndemic groups and HIV risk behaviors, therefore, being in multiple syndemic groups was significantly associated with increased prevalence of reporting HIV risk behaviors compared with being in one syndemic group. In addition, being in all three syndemic groups was associated with increased prevalence of unknown HIV status of the last male sex partner (aPR = 1.67, 95% CI: 1.43-1.95) and multiple sex partners (aPR = 1.53, 95% CI: 1.36-1.72). Conclusions: Findings highlight syndemic factors influence the lived experiences of black women.

Joint effects of individual socioeconomic status and residential neighborhood context on vaginal microbiome composition

Introduction

The vaginal microbiome is a dynamic ecosystem that is important for women's health. Its composition has been associated with risk for menopausal symptoms, sexually transmitted infections, gynecologic cancer, and preterm birth. Conventional risk factors for a vaginal microbiome linked with these adverse health outcomes include sexual behaviors, hygiene practices, individual social factors, and stress levels. However, there has been limited research on socio-contextual determinants, and whether neighborhood context modifies the association with individual socioeconomic factors.

Methods

Socioeconomically diverse pregnant African American women in Atlanta, Georgia (n = 439) provided residential addresses and first trimester vaginal swab samples, which underwent sequencing, taxonomic classification, and assignment into mutually exclusive CST (community state types) via hierarchical clustering. Linear probability models were used to estimate prevalence differences (PD) for the associations of neighborhood factors with vaginal microbiome CST and to evaluate for additive interaction with maternal level of education, health insurance type, and recruitment hospital.

Results

Factors such as higher (vs. lower) maternal education, private (vs. public) insurance, and private (vs. public) hospital were associated with higher prevalence of Lactobacillus-dominant vaginal microbiome CSTs typically associated with better health outcomes. When considering the joint effects of these individual socioeconomic status and residential neighborhood factors on vaginal microbiome CST, most combinations showed a greater than additive effect among the doubly exposed; however, in the case of local income homogeneity and local racial homogeneity, there was evidence of a crossover effect between those with less-advantaged individual socioeconomic status and those with more-advantaged individual socioeconomic status. Compared to women at the public hospital who lived in economically diverse neighborhoods, women at the private hospital who lived in economically diverse neighborhoods had a 21.9% higher prevalence of Lactobacillus-dominant CSTs, while women at the private hospital who lived in less economically diverse neighborhoods (the doubly exposed) had only an 11.7% higher prevalence of Lactobacillus-dominant CSTs, showing a crossover effect (interaction term p-value = 0.004).

Discussion

In this study, aspects of residential neighborhood context were experienced differently by women on the basis of their individual resources, and the joint effects of these exposures on vaginal microbiome CST showed a departure from simple additivity for some factors.

A Systematic Review of Neighborhood-Level Influences on HIV Vulnerability

A better understanding of the social-structural factors that influence HIV vulnerability is crucial to achieve the goal of ending the HIV epidemic by 2030. Given the role of neighborhoods in HIV outcomes, synthesis of findings from such research is key to inform efforts toward HIV eradication. We conducted a systematic review to examine the relationship between neighborhood-level factors (e.g., poverty) and HIV vulnerability (via sexual behaviors and substance use). We searched six electronic databases for studies published from January 1, 2007 through November 30, 2017 (PROSPERO CRD42018084384). We also mapped the studies' geographic distribution to determine whether they aligned with high HIV prevalence areas and/or the "Ending the HIV Epidemic: A Plan for the United States". Fifty-five articles met inclusion criteria. Neighborhood disadvantage, whether measured objectively or subjectively, is one of the most robust correlates of HIV vulnerability. Tests of associations more consistently documented a relationship between neighborhood-level factors and drug use than sexual risk behaviors. There was limited geographic distribution of the studies, with a paucity of research in several counties and states where HIV incidence/prevalence is a concern. Neighborhood influences on HIV vulnerability are the consequence of centuries-old laws, policies and practices that maintain racialized inequities (e.g., racial residential segregation, inequitable urban housing policies). We will not eradicate HIV without multi-level, neighborhood-based approaches to undo these injustices. Our findings inform future research, interventions and policies.

Longitudinal predictors of male sexual partner risk among Black and Latina women in their late thirties: ethnic/racial identity commitment as a protective factor

This study aimed to investigate predictors of male sexual partner risk among Latinas and Black women in their late thirties. We used multiple regression analysis to examine factors associated with male sexual partner risk among 296 women who participated in two waves of the Harlem Longitudinal Development Study (New York, 2011-2013 and 2014-2016). Women who experienced childhood sexual abuse had higher risk partners than those who did not [b = 0.16, 95% confidence interval (CI) = 0.06, 0.28]. Earlier marijuana use was a risk factor for partner risk in the late thirties (b = 0.12, 95% CI = 0.04, 0.27). Higher levels of ethnic/racial identity commitment mitigated this risk (b = - 0.15, 95% CI = - 0.26, - 0.04). Ethnic/racial identity commitment can be protective against male sexual partner risk among Latina and Black women who use marijuana. Further research should explore the protective role of different dimensions of ethnic/racial identity against sexually transmitted infections, including HIV.

Longitudinal Associations Between Neighborhood Factors and HIV Care Outcomes in the WIHS

Identifying structural determinants affecting HIV outcomes is important for informing interventions across heterogeneous geographies. Longitudinal hierarchical generalized mixed-effects models were used to quantify the associations between changes in certain structural-level factors on HIV care engagement, medication adherence, and viral suppression. Among women living with HIV in the WIHS, ten-unit increases in census-tract level proportions of unemployment, poverty, and lack of car ownership were inversely associated with viral suppression and medication adherence, while educational attainment and owner-occupied housing were positively associated with both outcomes. Notably, increased residential stability (aOR 5.68, 95% CI 2.93, 9.04) was positively associated with HIV care engagement, as were unemployment (aOR: 1.59, 95% CI 1.57, 1.60), lack of car ownership (aOR 1.14, 95% CI 1.13, 1.15), and female-headed households (aOR 1.23, 95% CI 1.22, 1.23). This underscores the importance of understanding neighborhood context, including factors that may not always be considered influential, in achieving optimal HIV-related outcomes.

Discrepancies in Local, State, and National Alcohol Outlet Listings: Implications for Research and Interventions

BACKGROUND

The availability of local, state, and national data on alcohol outlet density have important implications for policies and interventions aiming to reduce alcohol-related problems. High-quality data on locations of alcohol outlets is important to accurately inform community interventions and public health initiatives, but such data is often not maintained, readily available, or of sufficient quality. Objectives: This study aims to examine the discrepancies between alcohol outlet databases and how neighborhood characteristics (i.e. income, majority racial population, urbanicity) are associated with the discrepancies between databases. Methods: Data was collected from national (n = 1), local (n = 2), and state databases (n = 3). Negative binomial regression models were used to assess discrepancies in alcohol outlet count at the ZIP code level based on the data source. Results: The average density of alcohol outlets (per 1000 residents) ranged from 0.71 to 2.17 in Maryland, 1.65 to 5.17 in Wisconsin, and 1.09 to 1.22 in Oregon based on different sources of data. Findings suggest high income areas (>200% poverty level) have fewer discrepancies (IR = 0.775, p < 0.01), low income areas (below poverty level) have greater discrepancies (IR = 4.990, p < 0.01), and urban areas tend to have fewer discrepancies (IR = 0.378, p < 0.01) between datasets. Conclusion: Interventions and policies depend on valid and reliable data; researchers, policymakers, and local agencies need to collaborate to develop methods to maintain accurate and accessible data.

The Relationship Between Economic Deprivation, Housing Instability and Transactional Sex Among Women in North Carolina (HPTN 064)

Transactional sex is associated with socioeconomic disadvantage and HIV risk but few studies in the United States (US) have examined both individual and area-level predictors of transactional sex or distinguished transactional sex from sex work. We combined data from HIV Prevention Trials Network 064 study and the US Census to estimate prevalence ratios (PR) for the relationship between census-level and individual measures of economic deprivation and housing instability on transactional sex in 417 women in North Carolina. Increased transactional sex was associated with food insecurity (PR 1.86; 95%; CI 1.57, 2.19), housing instability (PR 1.33; 95% CI 1.11, 1.59), substance abuse (PR 1.90; 95% CI 1.64, 2.19) and partner incarceration (PR 1.32; 95% CI 1.09, 1.61). Census-level indicators were not associated with transactional sex, adjusted for individual-level covariates. Interventions should support housing stability and financial opportunities among southern African American women to reduce HIV risk, particularly among women with incarcerated partners.

Health Disparities and the Digital Divide: The Relationship between Communication Inequalities and Quality of Life among Women in a Nationwide Prospective Cohort Study in the United States

Background: Communication inequalities can affect health-seeking behaviors yet the relationship between Internet use and overall health is inconclusive. Communication-related inequalities vary by race/ethnicity and SES but existing research primarily includes middle-class Whites. We therefore examined the relationship between communication-related inequalities-measured by daily Internet use-and health-related quality of life (QOL) using a nationwide prospective cohort study in the United States that consists of primarily low income, minority women. Methods: We examined Internet use and QOL among participants in the Women's Interagency HIV Study. Data collection occurred from October 2014-September 2015 in Chicago, New York, Washington DC, San Francisco, Atlanta, Chapel Hill, Birmingham/Jackson and Miami. We used multi-variable analyses to examine the relationship between daily Internet use and QOL. Results: The sample of 1,915 women was 73% African American and 15% Hispanic; 53% reported an annual income of ≤$12,000. Women with daily Internet use reported a higher QOL at six months, as did women with at least a high school diploma, income >$12,000, and non-White race; older women and those with reported drug use, depressive symptoms and loneliness had lower QOL. Conclusions: Overcoming communication inequalities may be one pathway through which to improve overall QOL and address public health priorities. Reducing communication-related inequalities-e.g, by providing reliable Internet access-and thus improving access to health promoting information, may lead to improved health outcomes.

Broken (windows) theory: A meta-analysis of the evidence for the pathways from neighborhood disorder to resident health outcomes and behaviors

The criminological "broken windows" theory (BWT) has inspired public health researchers to test the impact of neighborhood disorder on an array of resident health behaviors and outcomes. This paper identifies and meta-analyzes the evidence for three mechanisms (pathways) by which neighborhood disorder is argued to impact health, accounting for methodological inconsistencies across studies. A search identified 198 studies (152 with sufficient data for meta-analysis) testing any of the three pathways or downstream, general health outcomes. The meta-analysis found that perceived disorder was consistently associated with mental health outcomes, as well as substance abuse, and measures of overall health. This supported the psychosocial model of disadvantage, in which stressful contexts impact mental health and related sequelae. There was no consistent evidence for disorder's impact on physical health or risky behavior. Further examination revealed that support for BWT-related hypotheses has been overstated owing to data censoring and the failure to consistently include critical covariates, like socioeconomic status and collective efficacy. Even where there is evidence that BWT impacts outcomes, it is driven by studies that measured disorder as the perceptions of the focal individual, potentially conflating pessimism about the neighborhood with mental health.

The Effects of School-Based Discrimination on Adolescents of Color Sexual Health Outcomes: A Social Determinants Approach

Social inequalities are at the heart of disparities in sexual health outcomes among African American and Latino/a adolescents living in the United States. Schools are typically the largest and primary context in youth development. School characteristics such as peer and teacher discrimination and school performance were examined to determine whether such characteristics predict sexual behavior in adolescents of color. This study utilized a representative sample of high school age students to assess sexual risk behavior. Findings indicate that there was a clear disparity in sexually transmitted infection diagnoses. School characteristics such as teacher discrimination and Grade Point Average were significant predictors to sexual risky behaviors among adolescents of color. The study adds to the literature in examining contextual factors that are associated with adolescent sexual risk behavior, and findings provide implications for future prevention work.