The intersection of violence, substance use, depression, and STDs: testing of a syndemic pattern among patients attending an urban STD clinic

Adverse childhood experiences as precursors to cannabis use in adulthood: A systematic review

BACKGROUND

Individuals with a history of Adverse Childhood Experiences (ACEs) are at risk of subsequent cannabis use. However, at present no existing systematic review explores ACEs as they relate to cannabis use.

OBJECTIVE

The aim of this systematic review paper is to examine how adverse childhood experiences (ACEs) impact rates, patterns, and the nature of cannabis use in adulthood.

METHODS

Guided by the PRISMA statement, this systematic review focuses on longitudinal studies that report cannabis use in adulthood. Databases searched include PubMed and Embase.

RESULTS

Ultimately, 28 manuscripts were selected for inclusion, ranging in scope from smaller community-focused studies to nationally representative longitudinal surveys; 22 of 28 studies occurred in the United States, with sample size ranging from 303 to 15,960 participants. Instruments used to assess ACEs and cannabis use varied considerably across studies, leading to loss of consistency. Nevertheless, presence of ACEs-childhood sexual abuse in particular-was consistently associated with cannabis use later in life. Frequency and severity of ACEs was found to exert an additive cumulative effect on severity of cannabis use.

CONCLUSIONS

This systematic review lays the foundation of the current state of the science regarding ACEs and cannabis use, which can provide further insight into a better understanding of this relationship and provide potential intervention opportunities.

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.

Acceptability of integrating mental health and substance use care within sexual health services among young sexual and gender minority men in Vancouver, Canada

BACKGROUND

Despite well-established evidence showing that young sexual and gender minority (SGM) men experience disproportionate mental health and substance use inequities, few sexual health services provide mental health and substance use care. This qualitative study examined the experiences and perspectives about integrated care models within sexual health services among young SGM men experiencing mental health and substance use challenges.

METHODS

Semi-structured interviews were conducted with 50 SGM men aged 18-30 years who reported using substances with sex in Vancouver, Canada. Interviews were analyzed using thematic analysis.

RESULTS

Three themes were identified: 1) participants asserted that their sexual health, mental health and substance use-related health needs were interrelated and that not addressing all three concurrently could result in even more negative health outcomes. These concurrent health needs were described as stemming from the oppressive social conditions in which SGM men live. 2) Although sexual health clinics were considered a safe place to discuss sexual health needs, participants reported not being invited by health providers to engage in discussions about their mental health and substance use health-related needs. Participants also perceived how stigmas associated with mental health and substance use limited their ability to express and receive support. 3) Participants identified key characteristics they preferred and wanted within integrated care, including training for health providers on mental health and SGM men's health and connections (e.g., referral processes) between services. Participants also recommended integrating social support programs to help them address SGM-related social challenges.

CONCLUSION

Our findings highlight that SGM men's sexual health, mental health and substance use-related health needs and preferences are interrelated and should be addressed together. Tailored training and resources as well as structural adaptations to improve communication channels and collaborative connections between health providers are required to facilitate the development of integrated care for young SGM men.

The REACH (Resiliency, Engagement, and Accessibility for Comorbid HIV/PTSD/SUD populations) Protocol: Using a Universal Screener to Improve Mental Health and Enhance HIV Care Outcomes

Among people living with HIV (PLWH), 50% report substance use disorders (SUDs), and 30-61% report posttraumatic stress disorder (PTSD). Comorbid PTSD/SUD/HIV has been linked to faster HIV progression and twice the rate of death, lower medical adherence and retention, and increased viral load compared to PLWH without co-occurring PTSD or SUD. A critical first step in establishing comprehensive mental health services for PLWH is the implementation of an evidence-based screening protocol for PTSD and SUDs to facilitate referrals to specialty mental health providers. Guided by the Consolidated Framework for Implementation Research, this mixed-methods study aimed to examine the feasibility of delivering the REACH (Resiliency, Engagement, and Accessibility for Comorbid HIV/PTSD/SUD populations) Screening protocol. Three case managers were instructed to provide the REACH screening electronically to all patients that they saw for enrollment or re-enrollment appointments over 3 months (n=102). Of the 70 patients who completed the screener, 27% had clinically significant PTSD symptoms and 48.6% had SUD concerns. Qualitative feedback revealed themes related to beliefs about SU and PTSD, attitudes toward screening, comfort in the discussion of SU and PTSD, and referral and treatment considerations. Discussion includes lessons learned for implementation of this assessment of PTSD/SUD in PLWH as a novel approach to increase mental health engagement and promote health equity, with the potential long-term impact of improving HIV care outcomes via ameliorating mental health/SUD, and implications for prevention of HIV transmission. Implementation science can be leveraged to understand the gap in the utilization of existing evidence-based screening tools in HIV care settings.

Adolescent Girls and Young Women's Experiences of Living with HIV in the Context of Patriarchal Culture in Sub-Saharan Africa: A Scoping Review

Adolescent girls and young women (AGYW) in sub-Saharan Africa are disproportionately affected by the human immunodeficiency virus (HIV) due to socio-cultural gender, power, and economic disparities. This scoping review examined the literature to explore what is known about AGYW's everyday personal, relational, and social experiences of HIV to help shape future protective HIV policy and practice. Six databases were searched: Medline, CINAHL, Scopus, ASSIA, Google Scholar, and ProQuest, resulting in a total of 12,581 articles. Of these, 40 articles were included in the review. Key themes generated from the thematic analysis were relational and psychosocial challenges, inhibiting sexual expression, poverty, stigma, and discrimination; managing health in everyday life; agency and resilience; and personal space and social support. In conclusion, the review found a lack of understanding of AGYW's everyday experiences of living with HIV from their own perspectives. There was also little consideration of the role of patriarchal culture and how this constrains AGYW's ability to negotiate their relationships. Further research is needed to reveal AGYW's perspectives on living with HIV in sub-Saharan Africa.

Mediating Roles of Intimate Partner Violence, Stress, and Social Support on Depressive Symptoms Among Thai Women

Prior research has shown that intimate partner violence (IPV), stress, and social support are associated with depressive symptoms. However, a possible mediating role of these variables linking depressive symptoms has not been fully investigated in Thailand. This study was conducted to assess the mediating roles of IPV, stress, and social support in the relationships between childhood abuse (CA), number of sexual partners (NSP), and depressive symptoms among 400 Thai women attending gynecology clinics. Results indicated that IPV was significantly positively correlated with stress and depressive symptoms but negatively correlated with social support. CA and NSP were significantly positively correlated with IPV, stress, and depressive symptoms, but negatively correlated with social support. Structural equation models (SEMs) showed that not only did IPV severity exhibit significantly indirect effect on depressive symptoms (β = .178; p < .05), but it also had a significant, positive total effect on depressive symptoms (β = .252; p < .05). In particular, IPV severity had the fully mediating effect on depressive symptoms through social support (β = -.204; p < .05) and stress (β = .158; p < .05). CA severity and NSP exhibited the significant indirect effect on depressive symptoms through IPV severity, stress, and social support. All the models analyzed showed that stress had an important mediator role (β = .583; p < .05) on depressive symptoms. The model fitted very well to the empirical data and explained 53% of variance. Findings affirmed the important role of these mediators as well as the need to design interventions for reducing stress or increasing support for women experiencing IPV. Utilizing an empowerment approach among female outpatients to decrease stress and depressive symptoms is recommended.

Gaps in the congenital syphilis prevention cascade: qualitative findings from Kern County, California

Background

Congenital syphilis is preventable through timely access to prenatal care, syphilis screening and treatment of pregnant women diagnosed as infected. In 2018, California had the second highest number of congenital syphilis cases in the United States (U.S.), a nearly twofold increase in cases since 2014. This study assessed gaps in preventing congenital syphilis in the high morbidity region of Kern County, California.

Methods

Between May 2018 and January 2019, we conducted five focus group discussions with pregnant/postpartum women and ten semi-structured interviews with prenatal care providers in Kern County. Focus group and interview data were recorded, transcribed, and analyzed to identify emergent themes pertaining to facilitators and barriers at each step (prenatal care, syphilis screening and treatment) in the congenital syphilis prevention cascade.

Results

Gaps in congenital syphilis prevention discussed in focus group discussions with pregnant/postpartum women were related to limited prenatal care access, social-, economic-, and cultural-barriers, and substance use and co-occurring intimate partner/domestic violence. The gaps identified from interviews with prenatal care providers included social economic vulnerabilities of pregnant women and stigma and shame around the vulnerabilities, distrust in medical system, prenatal substance use, limited prenatal substance use disorder treatment facilities, and inadequate provider training on context-specific congenital syphilis management strategies. Gaps in partner notification, screening and treatment for syphilis were brought up by pregnant/postpartum women and prenatal care providers.

Conclusions

Congenital syphilis continues to increase in Kern County and throughout the U.S. In high syphilis morbidity areas, comprehensive and tailored public health approaches addressing setting-specific gaps in prenatal screening and treatment are needed.

Are There Global Syndemics?

In this article, we address the nature of syndemics and whether, as some have asserted, these epidemiological phenomena are global configurations. Our argument that syndemics are not global rests on recognition that they are composed of social/environment contexts, disease clusters, demographics, and biologies that vary across locations. These points are illustrated with the cases of syndemics involving COVID-19, diabetes mellitus, and HIV/AIDS. We draw on theoretical discourse from epidemiology, biology, and anthropology to present what we believe is a more accurate framework for thinking about syndemics with shared elements.

Cumulative Burden of Mental Health Factors and Engagement in HIV Care in Argentina

BACKGROUND

Cumulative burden of multiple mental health conditions may worsen physical health outcomes in vulnerable populations. Accordingly, identifying cumulative burdens of mental health conditions that may affect HIV treatment and care can guide public health strategies to reduce their impact on HIV-related health outcomes. This study examined the relationship between the cumulative burden of mental health conditions and factors associated with engagement in HIV care in Argentina.

METHOD

Data for this study was obtained at baseline from Conexiones y Opciones Positivas en la Argentina 2 (COPA2). Participants (N = 360) were cisgender patients living with HIV who were lost to care, recruited from seven clinics serving people living with HIV in four Argentine urban centers. Cumulative burden of mental health conditions (i.e., depressive symptoms, problematic substance use, unhealthy alcohol use, and psychotic symptoms) was assessed.

RESULTS

Every one-point increase in the number of mental health conditions present was associated with a decrement in patient-provider communication (b = - 0.22, p < .001), self-efficacy (b = - 0.13, p = .012), and motivation for adherence (b = - 0.11, p = .039).

CONCLUSION

This study found cumulative burden of depression, problematic substance use, unhealthy alcohol use, and psychotic symptoms to be negatively associated with factors related to engagement in HIV care. Results highlight the importance of identification and treatment of challenges to mental health, in order to ameliorate their influence on engagement in HIV care.

Intimate partner violence and factors associated with sexually transmitted infections among Thai women attending gynecology clinics

Intimate partner violence (IPV) and sexually transmitted infections (STIs) are significant public health problems worldwide. However, most research on this association and risk of STIs has been conducted in Western countries and may not be generalizable to women living in different contexts, such as Thailand. We aimed to examine prevalence of IPV and identify factors associated with STIs among Thai women. Participants were patients aged 15-49 years attending two gynecology clinics at a university hospital in Bangkok, Thailand. Data were collected through an anonymous structured questionnaire, including sociodemographic characteristics, IPV, childhood abuse (CA), sexual risk behaviors, alcohol use, depressive symptoms, and self-reported STI diagnosis. Multivariate logistic regression analyses were used to examine factors associated with STI diagnosis. Among 400 participants, 84 (21%) had ever experienced at least one type of IPV in the past year. IPV, CA, age at first sex, multiple sexual partners, and alcohol use were significantly associated with STI-positive. Women who reported IPV (OR = 2.65, 95% CI = 1.11-6.28), experienced CA (OR = 5.59, 95% CI = 1.08-28.99), and had multiple sexual partners (OR = 1.39, 95% CI = 1.08-1.79) were significantly more likely to have an STI. Incorporation of IPV screening into general STIs screening is needed for this population to prevent and decrease IPV and STI consequences. Further research is also needed to understand the pathways linking IPV and STI risk to optimize the design of effective prevention interventions.

A need for trauma informed care in sexually transmitted disease clinics

OBJECTIVE

This review examines trauma from violence as a risk factor for sexually transmitted diseases (STDs) among women attending STD clinics. The review also aims to suggest trauma informed care (TIC) integrated into STD clinics might more effectively address traumatic effects of violence linked to sexual risk behaviors among this population.

DESIGN AND SAMPLE

A systematic literature review was conducted to identify empirical studies examining the relationship between multiple forms of violence and sexual risk behaviors among women attending STD clinics.

RESULTS

All studies found high rates of violence including childhood sexual abuse, intimate partner violence, and/or community violence associated with high rates of sexual risk behaviors among women attending these settings. Researchers recommend screening for multiple forms of violence, interdisciplinary STD clinic services, and more trauma informed sexual risk reduction interventions to address multiple forms of violence found prevalent among this population.

CONCLUSION

Women attending STD clinics very often experience multiple forms of violence during their lifetime. TIC to address traumatic effects of violence might reduce sexual risk behaviors and sexually transmitted disease rates for improved health outcomes among this population.

From silos to buckets: a qualitative study of how sexual health clinics address their clients' mental health needs

OBJECTIVES

To describe the current constraints, facilitators, and future prospects for addressing mental health and substance use (MHSU) concerns within sexual health clinics in two cities in British Columbia, Canada.

METHODS

We conducted in-depth interviews with 22 providers (14 nurses, 3 physicians, 3 administrators, 2 other health professionals) from six sexual health clinics.

RESULTS

Providers consistently affirmed that MHSU-related concerns co-occur with sexual health concerns among clients presenting to sexual health clinics. Three factors constrained the providers' abilities to effectively address MHSU service needs: (1) clinic mandates or funding models (specific to sexually transmitted infections (STI)/HIV or reproductive health); (2) "siloing" (i.e., physical and administrative separation) of services; and (3) limited familiarity with MHSU service referral pathways. Mental health stigma was an additional provider-perceived barrier for sexual health clinic clients. The low barrier, "safe" nature of sexual health clinics, however, facilitated the ability of clients to open up about MHSU concerns, while the acquired experiences of sexual health nurses in counselling enabled clinicians to address clients' MHSU needs. In response to this context, participants described actionable solutions, specifically co-location of sexual health and MHSU services.

CONCLUSION

Sexual health clinicians in British Columbia generally affirm the results of previous quantitative and client-focused research showing high rates of MHSU-related needs among sexual health clinic clients. Providers prioritized specific short-term (referral-focused) and long-term (healthcare re-organization, co-location of sexual and MHSU services) solutions for improving access to MHSU services for those using sexual health services.

A Mental Health-Physical Health-Violence (MPV) Syndemic Factor in Women with Mental Disorders

This study extended research on syndemics for women with mental disorders by including self-reported mental and physical health conditions. Syndemics explain complex relationships among co-occurring conditions, and the social circumstances that influence their overlap. Data were from the baseline assessment of a randomized trial of Healthy Home, a nursing home-visit intervention for women with children. 172 adult women who were in mental health or substance use treatment completed measures (in Spanish or English) of anxiety, depression, violence during adulthood, physical health, and cigarette use. Structural Equation Modeling was used to evaluate a single-factor syndemic, and to test the relationships of theoretical predictors of the syndemic: income, number of children, women's abuse during childhood, mental health stigma, social support, and stress. Results supported a single factor syndemic model that explained variation in mental health, physical health, and violence during adulthood. Stress, β = .45, p < .001, and stigma, β = .22, p = .007, were related to the syndemic factor. There was evidence that self-reported mental and physical health share covariation, which suggested that integrated services for women with mental disorders may have synergistic effects on health. Findings suggest the need to develop and test interventions that address stress and stigma as a means of reducing health disparities for women with mental disorders.

Validating the Syndemic Threat Surrounding Sexual Minority Men's Health in a Population-Based Study With National Registry Linkage and a Heterosexual Comparison

BACKGROUND

Research on the syndemic health threats facing sexual minority men suggests that the elevated risk of HIV among this population co-occurs with other psychosocial health disparities. This study aimed to conduct a population-based examination of clinically assessed syndemic predictors of HIV infection among gay and bisexual, compared with heterosexual, men.

SETTING AND METHODS

The sample comprised adult men in the Stockholm Public Health Cohort. A total of 29,328 (91.9%) self-identified as heterosexual, 535 (1.7%) as gay, and 396 (1.2%) as bisexual. We linked survey responses to national health registry data.

RESULTS

Gay men had vastly elevated risk of HIV infection (>150 times) compared with heterosexuals. Gay men also had an elevated risk of depression, suicidality, and violent assaults compared with heterosexuals. Bisexual men had 16 times higher risk of being HIV-positive than heterosexual men. The number of psychosocial syndemic conditions was significantly associated with HIV infection among gay men (adjusted odds ratio [AOR] = 1.67; 95% confidence interval [95% CI]: 1.18 to 2.36), but not among bisexual and heterosexual men (AOR = 0.51; 95% CI: 0.07 to 3.59; AOR = 1.92; 95% CI: 0.96 to 3.84). Among gay men, the association between co-occurring syndemic conditions and odds of HIV infection was synergistic (ie, more than additive).

CONCLUSIONS

This study confirms emerging evidence of the syndemic health threats affecting sexual minority men, finds stronger evidence for syndemics among gay compared with bisexual men, and suggests the need for HIV-prevention interventions that comprehensively address the co-occurring, and synergistically perpetuating, disparities affecting this population.

Depression, injecting drug use, and risky sexual behavior syndemic among women who inject drugs in Kenya: a cross-sectional survey

BACKGROUND

Injecting drug use (IDU) is a key driver of the HIV epidemic particularly when individuals experience psychosocial conditions and risky sexual behavior in a syndemic manner. This study sets out to assess evidence of a syndemic pattern of psychosocial conditions (IDU, depression, intimate partner violence (IPV)) on one the hand and risky sexual behavior on the other while accounting for the socio-economic disadvantage among women who inject drugs (WWID) in low-income urban settings in Kenya.

METHODS

Using a cross-sectional study design, this study recruited 306 WWIDs from two sites in Nairobi between January 2017 and July 2017. Multiple methodologies including descriptive analyses of co-occurrences of psychosocial conditions at the individual level, standard logistic regression analyses to examine relationships and interactions within and between psychosocial conditions and risky sexual behavior, and classification trees algorithm for predictive modeling via machine learning were employed.

RESULTS

The prevalence of the psychosocial conditions was as follows: IDU, 88%; depression, 77.1%; and IPV, 84%. The prevalence of risky sexual behavior was 69.3%. IDU and depression were related to each other (P < 0.05) and each of them with risky sexual behavior (P < 0.05). The highest 2-way and 3-way co-occurrence of conditions were reported in IDU and depression (72%) and in IDU, depression, and risky sexual behavior (62%), respectively, indicating clustering of the conditions at the individual level. Further, each additional psychosocial condition (IDU and depression) was associated with sixfold odds (P = 0.000) of having risky sexual behavior suggesting a dose-response relationship. Logistic regression analyses incorporating multiplicative interactive effects returned three significant variables (P < 0.05): IDU*depression interaction effect, "Age when delivered the first child," and "Income." Classification tree modeling represented a 5-level interaction analysis with IDU and depression predicted to have the highest influence on risky sexual behavior.

CONCLUSION

Findings provide possible evidence of a syndemic pattern involving IDU, depression, and risky sexual behavior suggesting the need for an integrated approach to the implementation of harm reduction interventions among WWID in low-income urban settings in Kenya. This work highlights the need for further studies to authenticate the findings and to characterize pathways in the syndemic development in WWID.

Is There a Continuum of Risk for Sexually Transmitted Infections Among African American Women?

This study compared sexual risk behaviors and sexually transmitted infection prevalence among African American women who have sex with women, women who have sex with men with a single male partner, women who have sex with men with 4 or more male partners, and women who have sex with women and men at a sexually transmitted disease clinic. The results suggest that, despite differences in prevalence, there was not a clear continuum of sexually transmitted infection risk among African American women in the study; all women were at risk.

Behavioral, Psychological, Gender, and Health Service Correlates to Herpes Simplex Virus Type 2 Infection among Young Adult Mexican-American Women Living in a Disadvantaged Community

Herpes simplex virus type 2 (HSV-2) is among the most prevalent sexually transmitted infections in the United States. Despite this, there has been limited research on the correlates to HSV-2 among disadvantaged and marginalized women, particularly among Latinas. Data for the present analysis include 125 young adult Mexican-American women enrolled in a longitudinal study in a disadvantaged urban community in San Antonio, Texas. The current rate of tested HSV-2 infection is 56.8%. Our findings suggest strong comorbidity of genital herpes with injecting heroin use, Hepatitis C, sexual violence, incarceration, and mental illness. Contributing to this population's nexus of risk are the low rates of health service utilization among those infected with HSV-2. Integration between behavioral health and primary care, including access to preventative services, are essential for improving the health of Latinas living in disadvantaged neighborhoods.

Co-Occurring Psychosocial Problems and Multiple Sexual Partners among Men Who Have Sex with Men in Shanghai, China: A Syndemic Approach

We aimed to apply syndemic theory to verify the association and reinforcing effects between psychosocial problems and multiple sexual partners (MSP) of men who have sex with men (MSM) in Shanghai, China. A cross-sectional study was conducted among 547 MSM in Shanghai, China using a face-to-face survey. Sociodemographic and psychosocial data were collected, as well as information on MSP and condomless anal sex. In the 6 months prior to the survey, 54.3% of the MSM sample had had MSP. Univariate analysis showed that self-esteem, depression, loneliness, sexual compulsivity, and involuntary subordination (IS) were associated with MSP. Sexual compulsivity (multivariate odds ratio [ORm] = 2.94, 95% CI = 1.76-4.91) and IS (ORm = 1.79, 95% CI = 1.14-2.81) remained significant in multivariate analysis. MSM with five or more psychosocial problems had greater odds of (adjusted odds ratios = 3.06, 95% CI = 1.49-6.25) having MSP in the previous 6 months than the non-syndemic group. Our findings provide preliminary confirmation of the additive relationship of syndemic psychosocial health conditions and MSP among MSM in Shanghai, China. An integrated intervention with special focus on sexual compulsivity and IS is needed.

Sexual Health Behavior and Mental Health Among Older African American Women: The Sistahs, Sexuality, and Mental Health Well-Being Project

BACKGROUND

In Los Angeles County, the rates of sexually transmitted infections and diseases among African Americans represent a significant public health disparity. Older African American women are at particular risk as they are more likely to engage in high-risk sexual behaviors and report social isolation and loneliness than their younger counterparts. However, the literature on the relationship between sexual health and mental health in this group is limited. The purpose of this study was to use a community-based participatory research (CBPR) approach to better understand sexual health behaviors and mental health among African American women over 50 years of age who reside in South Los Angeles.

MATERIALS AND METHODS

This project was divided into two phases. Phase I (January-March 2017) of the project consisted of four dialog/focus groups (N = 45) (ages: 50-80; M_age = 67). The purpose of Phase II (April 2017) was to present study results from Phase I to the community via a community-based conference, as well as gather feedback and generate discussion about the next steps for community prevention/intervention.

RESULTS

Women reported that they did not feel comfortable discussing sexual practices with their physician, partners, and friends. Most women identified depression, loneliness, and self-esteem issues as reasons for engaging in high-risk sexual behaviors. During Phase II, potential intervention avenues emerged to address issues such as lack of physician-patient communication, lack of community support, and dialogs about sex.

CONCLUSIONS

The use of CBPR greatly enhanced our knowledge of the core issues surrounding sexual health and mental health among older African American women.

Pilot Studies Examining Feasibility of Substance Use Disorder Screening and Treatment Linkage at Urban Sexually Transmitted Disease Clinics

BACKGROUND

Sexually transmitted disease (STD) clinics provide critical public health services for screening and treatment of sexually transmitted infections throughout the United States. These settings serve high-risk populations, often on a walk-in basis, and may be promising venues for integrating substance use disorder (SUD) services.

METHODS

We report findings from 2 pilot studies conducted at Baltimore City Health Department's STD clinics. The screening study characterized rates of SUDs among STD clinic patients. Patients waiting for services completed a diagnostic interview mapping to Diagnostic and Statistical Manual of Mental Disorders, 5th Edition SUD criteria (n = 100). The Treatment Linkage Feasibility study examined the feasibility of linking STD clinic patients with opioid and/or cocaine use disorders to SUD treatment in the community (n = 21), using SUD-focused Patient Navigation services for 1 month after the STD clinic visit. Assessments were conducted at baseline and 1-month follow-up.

RESULTS

In the screening study, the majority of STD clinic patients met diagnostic criteria for alcohol and/or drug SUD (57%). Substance-specific SUD rates among patients were 35% for alcohol, 31% for cannabis, 11% for opioids, and 8% for stimulants (cocaine/amphetamines). In the Treatment Linkage Feasibility study, 57% (12/21) of participants attended at least 1 SUD service, and 38% (8/21) were actively enrolled in SUD treatment by 1-month follow-up. The sample reported significant reductions in past 30-day cocaine use from baseline to follow-up (P = 0.01).

CONCLUSIONS

SUD rates are high among STD clinic patients. STD clinics are viable settings for initiating SUD treatment linkage services. Larger-scale research on integrating SUD services in these settings is needed.

Associations of Drug Use, Violence, and Depressive Symptoms with Sexual Risk Behaviors Among Women with Alcohol Misuse

BACKGROUND

Alcohol misuse is associated with increased human immunodeficiency virus sexual risk behaviors by women. Drug use, intimate partner violence (IPV), and depressive symptoms frequently co-occur, are well-recognized alcohol misuse comorbidities, and may interact to increase risk behaviors. Using a syndemic framework we examined associations between drug use, IPV, and depressive symptoms and sexual risk behaviors by 400 women with alcohol misuse attending an urban sexually transmitted infections clinic.

METHODS

Participants completed computer-assisted interviews querying drug use, IPV, and depressive symptoms and sexual risk behavior outcomes-unprotected sex under the influence of alcohol, sex for drugs/money, and number of lifetime sexual partners. We used multivariable analysis to estimate prevalence ratios (PR) for independent and joint associations between drug use, IPV, and depressive symptoms and our outcomes. To investigate synergy between risk factors we calculated the relative excess prevalence owing to interaction for all variable combinations.

RESULTS

In multivariable analysis, drug use, IPV, and depressive symptoms alone and in combination were associated with higher prevalence/count of risk behaviors compared with women with alcohol misuse alone. The greatest prevalence/count occurred when all three were present (unprotected sex under the influence of alcohol [PR, 2.6; 95% confidence interval, 1.3-4.9]), sex for money or drugs [PR, 2.6; 95% confidence interval, 1.7-4.2], and number of lifetime partners [PR, 3.2; 95% confidence interval, 1.9-5.2]). Drug use, IPV, and depressive symptoms did not interact synergistically to increase sexual risk behavior prevalence.

CONCLUSIONS

A higher prevalence of sexual risk behaviors by women with alcohol misuse combined with drug use, IPV, and depressive symptoms supports the need for alcohol interventions addressing these additional comorbidities.

Correlates of Condom use Among Community College Women: The Role of Victimization, Substance Use, and Mental Health Symptoms

Research is needed to understand intersecting health risks among community college students. Applying a syndemic framework, the present research explored childhood sexual victimization, adolescent sexual victimization, intimate partner violence (IPV), marijuana use, alcohol consumption, and symptoms of depression and post-traumatic stress disorder as additive as well as interactive correlates of women's condom use. Questionnaires were administered to a sample of 212 women between the ages of 18 to 24 attending a community college. A series of logistic regression analyses documented that an increased number of psychosocial risk factors was associated with not using a condom during sexual intercourse. Experiencing both adolescent sexual victimization and lifetime intimate partner violence (IPV), compared to experiencing one form of victimization, increased the odds of not using a condom. Endorsing both lifetime IPV and past year marijuana use, compared to endorsing only one of these factors, also increased the odds of not using a condom. These findings highlight the importance of targeting intersections between adolescent sexual victimization, IPV, marijuana use, and sexual risk behavior when developing educational programs for community college women.

Psychosocial Stressors and Sexual Health Among Southern African American Women Who Have Sex with Women

PURPOSE

We examined the association of psychosocial stressors (depressive symptoms, incarceration, and intimate partner violence [IPV]) with sexual behaviors, sexually transmitted infection (STI) history, and STI diagnoses among African American women who have sex with women (AAWSW).

METHODS

This was a secondary analysis from a study of AAWSW ≥16 years. Multivariable Poisson regression estimated risk ratios (RRs) for the association between depressive symptoms, incarceration, and IPV and sexual behaviors, STI history, and STI diagnosis at enrollment, adjusting for age and sexual orientation identity.

RESULTS

Of 165 AAWSW, the mean depressive symptom score was 1.0 (SD ±0.8); 22.4% reported incarceration and 62.4% reported IPV. Depressive symptoms were associated with alcohol/drug use at last sexual encounter (RR = 1.52, 95% confidence interval [CI]: 1.18-1.95) and STI diagnosis (RR = 1.19; 95% CI: 1.05-1.34). Incarceration was associated with STI history (RR = 1.28; 95% CI: 1.07-1.53). IPV was associated with alcohol/drug use during sex with women (RR = 1.42; 95% CI: 1.05-1.92) and STI history (RR = 1.42, 95% CI: 1.13-1.78), particularly trichomoniasis (RR 2.50; 95% CI: 1.52-4.12). Among AAWSW reporting sex with men (n = 144), depressive symptoms were associated with sex in exchange for money/drugs (RR = 1.98; 95% CI: 1.17-3.34) and alcohol/drug use during sex with men (RR = 1.24; 95% CI: 1.05-1.46). Incarceration was associated with sex in exchange for money/drugs with men (RR = 5.21; 95% CI: 1.86-14.57); IPV was associated with sex in exchange for money/drugs (RR = 5.04; 95% CI: 1.18-21.50) and alcohol/drug use during sex with men (RR = 1.66; 95% CI: 1.14-2.41).

CONCLUSION

Providers and public health programs should address both psychosocial stressors and STI risk among AAWSW.

The Associations of Area-Level Violent Crime Rates and Self-Reported Violent Crime Exposure with Adolescent Behavioral Health

The effects of witnessing and experiencing crime have seldom been disaggregated. Little research has assessed the effect of multiple exposures to crime. We assess independent contributions of self-reported crime and area-level crime to adolescent behavioral health outcomes. Cross sectional data on 5519 adolescents from the Comprehensive Community Mental Health Services for Children and their Families Program was linked to FBI crime rate data to assess associations of mutually exclusive categories of self-reported crime exposure and area-level crime rates with mental health and substance abuse. Self-reported crime exposure was significantly associated with poorer behavioral health. Violent victimization had the largest association with all outcomes except internalizing scores. All self-reported crime variables were significantly associated with three of the outcomes. Area-level crime rates were associated with one mental health outcome. Providers should assess direct and indirect crime exposure rather than only focusing on violent victimization.

Substance Use Disorders, Violence, Mental Health, and HIV: Differentiating a Syndemic Factor by Gender and Sexuality

This paper measures syndemic substance use disorder, violence, and mental health and compares the syndemic among HIV-infected heterosexual men, heterosexual women, and men who have sex with men (MSM). Data were from a sample of high needs substance-using, HIV-infected people in South Florida between 2010 and 2012 (n = 481). We used confirmatory factor analysis to measure a syndemic latent variable and applied measurement invariance models to identify group differences in the data structure of syndemic co-morbidities among heterosexual men, heterosexual women, and MSM. We found that variables used to measure the syndemic fit each sub-group, supporting that substance use disorder, violence, and mental health coincide in HIV-infected individuals. Heterosexual men and MSM demonstrated similar syndemic latent variable factor loadings, but significantly different item intercepts, indicating that heterosexual men had larger mean values on substance use disorder, anxiety, and depression than MSM. Heterosexual men and heterosexual women demonstrated significantly different syndemic variable factor loadings, indicating that anxiety and depression contribute more (and substance use contributes less) to the syndemic in heterosexual men compared to heterosexual women. MSM and heterosexual women demonstrated similar syndemic latent variable factor loadings and intercepts, but had significantly different factor residual variances indicating more variance in violent victimization and depression for MSM and more variance in stress for heterosexual women than what is captured by the observed syndemic indicators. Furthermore, heterosexual women had a larger syndemic factor mean than MSM, indicating that the syndemic burden is greater among heterosexual women than MSM. Our findings support that measurement invariance can elucidate differences in the syndemic to tailor interventions to sub-group needs.

Depressive Symptoms, Acute Alcohol Intoxication, and Risk Rationale Effects on Men's Condom Use Resistance

This study examined the role of depressive symptoms, acute intoxication, and risk rationale in men's use of condom use resistance (CUR) tactics in an experimental study. Participants included 313 heterosexual male, nonproblem drinkers, ages 21 to 30. Participants were randomized to one of four beverage conditions: no alcohol, placebo, low (.04%) alcohol dose, or high (.08%) alcohol dose. They read an eroticized scenario depicting a consensual sexual encounter with a female partner who requested a condom to prevent either pregnancy or sexually transmitted infections (STIs) (risk rationale) and then indicated their intentions to use 10 different CUR tactics. Hypotheses related to the pharmacological, dosage, and expectancy effects of alcohol were tested in a generalized linear model. In intoxicated (.04% and .08%) men who were given a pregnancy risk rationale, depressive symptoms were associated with stronger intentions to use CUR tactics than in sober (control and placebo) men. Men who received a high alcohol dose (.08%) and who were given a pregnancy risk rationale reported higher intentions to use CUR tactics than those who received a lower alcohol dose (.04%). Findings suggest that the pharmacological effects of alcohol on men's likelihood to resist condoms vary by the saliency of the risk rationale and mood-related variables.

Perceived need for depression treatment among persons entering inpatient opioid detoxification

BACKGROUND AND OBJECTIVES

Depression is common among persons with opioid use disorder. We examined the perceived need for depression treatment (PNDT) among opioid-dependent patients and the relationship of PNDT to depression screening result.

METHODS

Between May and December 2015, we surveyed consecutive persons (n = 440) seeking inpatient opioid detoxification. We used the Patient Health Questionnaire-2 (PHQ-2) to screen for depression. To assess perceived need for depression services, participants were asked, "Do you believe you should be treated for depression?" Response options were recorded into four categories: "Not Depressed (ND)," "Perceive Need for Depression Treatment (PNDT)," "Depressed/Don't Want Treatment," and "Currently Treated."

RESULTS

Participants' mean age was 32.3 (±8.7) years; 70.7% were male. Nearly two out of three persons screened positive for depression yet only 8.2% were being treated for depression prior to admission. Screening positive for depression was associated with a 2.95 (95%CI 1.82-4.81, p < .005) fold increase in the expected odds of PNDT. But nearly half of those depressed (48%) did not perceive the need for treatment. Approximately 40% of the participants (n = 177) perceived that they were not depressed; of these persons, 52% screened positive for depression.

DISCUSSION AND CONCLUSIONS

Detoxification program staff should screen patients for depression, and if a clinical diagnosis is confirmed, discuss treatment options, exploring the level of interest in mental health treatment for depression.

SCIENTIFIC SIGNIFICANCE

Screening for and addressing depression, including patients' interest in treatment, should be central to post-detoxification aftercare planning. (Am J Addict 2017;26:395-399).

[Prevalence of intimate partner violence and associated factors after disclosing the diagnosis of a sexually transmissible disease]

The objective of this study was to investigate factors associated with intimate partner violence after disclosing the diagnosis of sexually transmissible diseases (STDs) in Fortaleza, Ceará State, Brazil. This cross-sectional study enrolled 221 individuals treated at STD clinics. Multivariate logistic regression was performed. A total of 28.1% of individuals committed some type of intimate partner violence after disclosure of the diagnosis. Committing intimate partner violence was associated with alcohol use (OR = 2.79; 95%CI: 1.25-6.22; p = 0.012), the partner having relations with someone else during the current relationship (OR = 4.71; 95%CI: 2.24-9.91; p = 0.000), a history of violence prior to the STD (OR = 2.87; 95%CI: 1.22-6.73; p = 0.015), and having suffered violence after diagnosis of the STD (OR = 6.53; 95%CI: 3.06-13.93; p = 0.000). Intimate partner violence following disclosure of the STD signals that health professionals should identify patients' difficulties in revealing an STD diagnosis to their partners.

Depression, alcohol use, and intimate partner violence among outpatients in rural Uganda: vulnerabilities for HIV, STIs and high risk sexual behavior

Background

Intimate partner violence (IPV), alcohol use, and depression are key vulnerabilities for HIV in Uganda, and taken together may have a synergistic effect on risk. Our objective was to investigate the associations between depression, IPV, and alcohol use and HIV-risk indicators among a sample of outpatients in rural Uganda, and the effect of co-occurrence of these factors on HIV-risk indicators.

Methods

In a structured interview we collected data on high-risk sexual behavior, depression symptoms, emotional and physical IPV, and alcohol use, as well as a blood sample for HIV and syphilis tests and a urine sample for chlamydia and gonorrhea tests from 325 male and female outpatients receiving provider-initiated HIV testing and counseling (PITC) at a public hospital outpatient clinic in rural Uganda. We used logistic regression and generalized linear modeling to test independent associations between depression, IPV, and alcohol use and HIV-risk indicators, as well as the effect of co-occurrence on HIV-risk indicators.

Results

Twelve percent of men and 15% of women had two or more of the following conditions: depression, IPV, and alcohol use; another 29% of men and 33% of women had 1 condition. Each condition was independently associated with HIV risk behavior for men and women, and for women, depression was associated with testing positive for HIV or a sexually transmitted infection (STI). Men with one condition (AOR 2.32, 95% CI 1.95–2.77) and two or more conditions (AOR 12.77, 95% CI 7.97–20.47) reported more high risk sex acts compared to those with no potential co-occurring conditions. For men, experiencing two or more conditions increased risky sex more than one alone (χ² 24.68, p < 0.001). Women experiencing one condition (AOR 3.33, 95% CI 137–8.08) and two co-occurring conditions (AOR 5.87, 95% CI 1.99–17.35) were more likely to test positive for HIV or an STI and women with two co-occurring conditions were also at increased risk for risky sex (AOR 2.18, 95% CI 1.64–2.91). We also found preliminary evidence suggesting synergistic effects between depression and emotional IPV and between alcohol use and depression.

Conclusions

This study demonstrates the co-occurrence of depression, IPV, and alcohol use in men and women in an outpatient setting in rural Uganda. The co-occurrence of these factors was associated with greater HIV risk, highlighting the need for a more holistic approach to HIV prevention and care research and programming.

Substance use and STI acquisition: Secondary analysis from the AWARE study

OBJECTIVES

Sexually transmitted infections (STIs) are significant public health and financial burdens in the United States. This manuscript examines the relationship between substance use and prevalent and incident STIs in HIV-negative adult patients at STI clinics.

METHODS

A secondary analysis of Project AWARE was performed based on 5012 patients from 9 STI clinics. STIs were assessed by laboratory assay and substance use by self-report. Patterns of substance use were assessed using latent class analysis. The relationship of latent class to STI rates was investigated using Poisson regression by population groups at high risk for STIs defined by participant's and partner's gender.

RESULTS

Drug use patterns differed by risk group and substance use was related to STI rates with the relationships varying by risk behavior group. Substance use treatment participation was associated with increased STI rates.

CONCLUSIONS

Substance use focused interventions may be useful in STI clinics to reduce morbidity associated with substance use. Conversely, gender-specific sexual health interventions may be useful in substance use treatment.

HIV Risk Behavior Among Methamphetamine Users Entering Substance Abuse Treatment in Cape Town, South Africa

South Africa is experiencing a growing methamphetamine problem, and there is concern that methamphetamine use may accelerate HIV transmission. There has been little research on the HIV prevention needs of methamphetamine users receiving substance abuse treatment in South Africa. This study assessed the prevalence and correlates of HIV risk behaviors among 269 methamphetamine users entering substance abuse treatment in two clinics in Cape Town. The prevalence of sexual risk behaviors was high among sexually active participants: 34 % multiple partners, 26 % unprotected intercourse with a casual partner, and 24 % sex trading for money/methamphetamine. The strongest predictor of all sexual risk behaviors was concurrent other drug use. Over half had not been HIV tested in the past year, and 25 % had never been tested, although attitudes toward HIV testing were overwhelmingly positive. This population of primarily heterosexual, non-injecting methamphetamine users is a high-risk group in need of targeted HIV prevention interventions. Substance abuse treatment is an ideal setting in which to reach methamphetamine users for HIV services.

The Prevalence of and Factors Associated with Alcohol-Related Problems in a Community Sample of African American Women

Purpose. This study examines the prevalence of alcohol-related problems, the factors underlying these problems, and whether or not there is evidence of syndemic effects in a community population of southern, urban African American women. Methods. Questionnaire-based interviews were conducted with 817 women, all African American, from 80 targeted census block groups in Atlanta, Georgia. Results. Most of the alcohol users (67.8%) experienced at least one problem as a result of their alcohol (ab)use, with most women experiencing two or more such problems. Eight factors were found to be associated with experiencing more alcohol problems: being aged 30 or older, having had no recent health insurance, lower levels of educational attainment, self-identifying as lesbian or bisexual, experiencing greater amounts of childhood maltreatment, greater impulsivity, perceiving one's local community or neighborhood to be unsafe, and having a larger number of criminally involved friends. Conclusions. Drinking-related problems were prevalent in this population. Numerous factors underlie the extent to which African American women experienced problems resulting from their alcohol use. There is strong evidence of syndemic-type effects influencing drinking problems in this population, and future efforts to reduce the negative impact of alcohol (ab)use ought to consider the adoption of programs using a syndemics' theory approach.

The Value of Using a Syndemics Theory Conceptual Model to Understand the Factors Associated with Obesity in a Southern, Urban Community Sample of Disadvantaged African-American Adults

For this study, a syndemics theory approach was used to examine the factors associated with adulthood obesity in a community-based sample of African-American adults. Interviews were conducted with 1,274 African-American adults residing in Atlanta, Georgia in 80 strategically chosen census tracts, selected on the basis of factors such as low household income, low levels of educational attainment among heads of household, and low levels of labor force participation. Comparisons were made between normal-weight persons (body mass index [BMI] = 18.5-24.9; n = 800) and obese persons (BMI = 30.0 or greater; n = 474). Structural equation analysis was used to examine the interrelationships among variables. One quarter (25.6%) of the study participants were classified as obese. Five factors were related directly to obesity. These were gender, age, relationship status,frequency of eating 3 meals per day, and frequency of alcohol consumption. The frequency of alcohol consumption was an endogenous measure and 7 factors were identified as underlying this measure. The 7 factors were gender, age, sexual orientation, self-esteem, impulsivity, criminality of friends, and neighborhood violence. The structural model developed for this study proved to be useful for conceptualizing the factors underlying obesity and there was considerable evidence of syndemic effects among key predictors. The myriad factors underlying obesity in this population interacted with one another in such a manner as to support the use of syndemics theory-based models in future research. In particular, obesity researchers might wish to consider the interplay of demographic factors such as age and gender, psychosocial characteristics such as self-esteem and impulsivity, alcohol use/abuse, and community factors such as neighborhood violence and criminality influences.

How the Interaction of Childhood Sexual Abuse and Gender Relates to HIV Risk Practices among Urban-Dwelling African Americans

Purpose

Previous research has demonstrated that HIV risk practices often differ based on gender and on whether or not people experienced sexual abuse during their formative (i.e., childhood and adolescence) years. The interaction of these two factors, which is the focus of this paper, has received limited attention.

Methods

Based on a model derived from Social Disorganization Theory and Syndemics Theory, interviews were conducted between 2009 and 2012 with 1,864 African American adults residing in Atlanta, Georgia in 80 strategically-chosen consensus block groups.

Results

Based on multiple regression and structural equation analyses, the interaction of sexual abuse and gender was found to be a significant predictor of involvement in (un)protected sex. The interaction of sexual abuse and gender also was related to condom use self-efficacy, which was one of the strongest factors underlying (un)protected sex.

Conclusion

The relationship of sexual abuse history and gender is relevant in the understanding of HIV risk practices. The interaction of these factors with one another and with other relevant influences that shape people's HIV risk profiles is complex. The Syndemics Theory approach used to conceptualize the relationships among relevant variables in this study is an effective way of trying to understand and address HIV risk practices.

Prediction of HIV Sexual Risk Behaviors Among Disadvantaged African American Adults Using a Syndemic Conceptual Framework

The focus of this paper is on HIV sexual risk taking among a community-based sample of disadvantaged African American adults. The objective is to examine multiple factors associated with sexual HIV risk behaviors within a syndemic conceptual framework. Face-to-face, computer-assisted, structured interviews were conducted with 1535 individuals in Atlanta, Georgia. Bivariate analyses indicated a high level of relationships among the HIV sexual risks and other factors. Results from multivariate models indicated that gender, sexual orientation, relationship status, self-esteem, condom use self-efficacy, sex while the respondent was high, and sex while the partner was high were significant predictors of condomless sex. Additionally, a multivariate additive model of risk behaviors indicated that the number of health risks significantly increased the risk of condomless sex. This intersection of HIV sexual risk behaviors and their associations with various other behavioral, socio-demographic, and psychological functioning factors help explain HIV risk-taking among this sample of African American adults and highlights the need for research and practice that accounts for multiple health behaviors and problems.

HIV Testing and HIV Service Delivery to Populations at High Risk Attending Sexually Transmitted Disease Clinics in the United States, 2011-2013

OBJECTIVES

We evaluated HIV testing and service delivery in Centers for Disease Control and Prevention (CDC)-funded sexually transmitted disease (STD) clinics.

METHODS

We assessed HIV testing, HIV positivity, receipt of HIV test results, linkage to medical care, and referral services from 61 health department jurisdictions from 2011 to 2013.

RESULTS

In 2013, 18.6% (621 010) of all CDC-funded HIV-testing events were conducted in STD clinics, and 0.8% were newly identified as HIV-positive. In addition, 27.3% of all newly identified HIV-positive persons and 30.1% of all newly identified HIV-positive men who have sex with men were identified in STD clinics. Linkage to care within any time frame was 63.8%, and linkage within 90 days was 55.3%. Although there was a decrease in first-time HIV testers in STD clinics from 2011 to 2013, identification of new positives increased.

CONCLUSIONS

Although linkage to care and referral to partner services could be improved, STD clinics appear successful at serving populations disproportionately affected by HIV. These clinics may reach persons who may not otherwise seek HIV testing or medical services and provide an avenue for service provision to these populations.

Substance use, mental illness, and familial conflict non-negotiation among HIV-positive African-Americans: latent class regression and a new syndemic framework

We evaluated a synergistic epidemic (syndemic) of substance use, mental illness, and familial conflict non-negotiation among HIV-positive injection drug users (IDU). Baseline BEACON study data was utilized. Latent class analyses identified syndemic classes. These classes were regressed on sex, viral suppression, and acute care non-utilization. Females were hypothesized to have higher syndemic burden, and worse health outcomes than males. Nine percent of participants had high substance use/mental illness prevalence (Class 4); 23 % had moderate levels of all factors (Class 3); 25 % had high mental illness (Class 2); 43 % had moderate substance use/mental illness (Class 1; N = 331). Compared to Classes 1-3, Class 4 was mostly female (p < .05), less likely to achieve viral suppression, and more likely to utilize acute care (p < .05). Interventions should target African-American IDU females to improve their risk of negative medical outcomes. Findings support comprehensive syndemic approaches to HIV interventions, rather than singular treatment methods.

Who Do Smokers Feel Ought to Be Responsible for Informing People about the Dangers Associated with Smoking and Regulating Smoking Behaviors?

PURPOSE

The focus of this paper is to examine the extent to which a community-based sample of current cigarette smokers believes it to be the responsibility of outside persons and agencies to inform the public about the dangers of smoking and/or to regulate smoking behaviors (herein termed REGULATE). Also investigated is how REGULATE relates to smokers' attitudes toward cigarette smoking and actual smoking practices, and whether REGULATE matters when the influence of other key variables is taken into account.

METHOD

Questionnaire-based interviews were conducted with a community-based sample of 485 adult current cigarette smokers recruited from the Atlanta, Georgia metropolitan area. Active and passive recruiting approaches were used, along with a targeted sampling strategy.

RESULTS

Participants were divided in their beliefs pertaining to REGULATE. Their beliefs were related consistently to smoking-related attitudes but much less to actual smoking behaviors. Four factors (greater religiosity, older age of first purchasing a cigarette, lower levels of depression, and sexual abuse history) were found to underlie REGULATE. Structural equation analysis revealed that REGULATE is an influential measure to consider when trying to understand overall attitudes toward smoking and actual smoking behaviors.

CONCLUSION

REGULATE is an important variable to consider when aiming to understand the factors associated with how people feel about their smoking practices, including actual cigarette use. It may be construed as a proxy measure for locus of control; and the implications of this are discussed.

Sexual partnership characteristics of African American women who have sex with women; impact on sexually transmitted infection risk

BACKGROUND

African American women who have sex with women (WSW) are emerging as a population at risk for sexually transmitted infections (STIs). The objectives of this study were to explore partnership characteristics for a cohort of African American WSW and evaluate those characteristics as potential risk factors for STIs. In addition, we aimed to determine STI diagnoses and identify predictors of STI infection.

METHODS

Women who have sex with women presenting to a sexually transmitted disease clinic in Birmingham, AL, completed a questionnaire and were tested for bacterial vaginosis, trichomoniasis, chlamydia, gonorrhea, Mycoplasma genitalium, syphilis, HIV, and herpes simplex virus type 2.

RESULTS

A total of 163 women were enrolled: 78 WSW and 85 women who have sex with women and men (WSWM) (based on report of past year sexual behavior). Both WSW and WSWM reported similar numbers of female partners over the lifetime, past year, and past month; however, WSWM reported significantly more lifetime male partners, thus having a higher overall number of sexual partners. Women who have sex with women and men were more likely to report new or casual partner(s), group sex, history of STIs, and sex with partner(s) known to have STIs. Overall, WSWM were more likely to have a current diagnosis of bacterial vaginosis, a current diagnosis of a curable STI, or a diagnosis of a noncurable STI (85% vs. 56%, P < 0.01).

CONCLUSIONS

African American WSW are not a homogeneous group, and their sexual health may be directly or indirectly influenced by male partners. A better understanding of the distinctions and differences between African American WSW and WSWM will enable health care providers to improve the quality of care provided.

Depression and social support among women living with the substance abuse, violence, and HIV/AIDS syndemic: a qualitative exploration

BACKGROUND

Intimate partner violence (IPV), HIV/AIDS, and substance use are described as the SAVA "syndemic" among low-income urban women because of their intersecting and synergistic presence in these women's lives. Depressive symptoms are significantly associated with these SAVA factors and although social support is potentially protective for depression, little is understood about its impact on depression associated with the SAVA syndemic.

METHODS

This paper investigates how women living with SAVA experience and describe depressive symptoms, and examines how the types of social support they access impact their experiences of SAVA and depressive symptoms. Qualitative, in-depth interviews were conducted with 24 HIV-positive, low-income, urban women who experienced IPV and used cocaine or heroin in their lifetime. Interviews were analyzed based on study aims, principles of thematic content analysis, and grounded theory.

RESULTS

Women identified multiple SAVA factors as catalysts for depression and noted their synergistic effect on depressive symptoms, which were both a trigger for and a result of drug use. Women accessed varying sources of social support to address their SAVA factors and associated symptoms of depression, relying on informal sources for instrumental support related to IPV and formal sources for support related to HIV, drug use, and depression.

CONCLUSIONS

These findings have important implications for health providers who serve SAVA-affected women, and suggest that comprehensively addressing all SAVA factors (and IPV in particular) and improving their access to quality social support at critical times is essential to improve their mental health.

Syndemic vulnerability, sexual and injection risk behaviors, and HIV continuum of care outcomes in HIV-positive injection drug users

Limited investigations have been conducted on syndemics and HIV continuum of care outcomes. Using baseline data from a multi-site, randomized controlled study of HIV-positive injection drug users (n = 1,052), we examined whether psychosocial factors co-occurred, and whether these factors were additively associated with behavioral and HIV continuum of care outcomes. Experiencing one type of psychosocial problem was significantly (p < 0.05) associated with an increased odds of experiencing another type of problem. Persons with 3 or more psychosocial problems were significantly more likely to report sexual and injection risk behaviors and were less likely to be adherent to HIV medications. Persons with 4 or more problems were less likely to be virally suppressed. Reporting any problems was associated with not currently taking HIV medications. Our findings highlight the association of syndemics not only with risk behaviors, but also with outcomes related to the continuum of care for HIV-positive persons.

Psychological symptoms are associated with both abstinence and risky sex among men with HIV

Sexual abstinence is often deemed the "safest behavior" in HIV prevention, but is sometimes associated with psychological symptoms (e.g., depression) just as sexually risky behavior is. This study explored whether sexual abstinence and risky sexual behavior among men with HIV were associated with similar constellations of psychological symptoms. Prior research has not addressed this issue because abstinent people often are not included in the sample or, when data are analyzed, researchers combine abstinent people with sexually active people who practice safer sex. Past research also neglects the co-morbidity of psychological symptoms. A latent class analysis of the psychological symptoms (assessed with the Symptom Check List 90-R; Derogatis, 1994) of 140 men with HIV, mostly from rural New England, revealed three latent classes: men who were asymptomatic on all symptom domains (28.8 %), men who were symptomatic on all domains (34.1 %), and men who were symptomatic on internalizing domains (37.1 %), but were asymptomatic on the externalizing symptoms of hostility and paranoid ideation. Logistic regression showed that sexual behavior during the past 90 days of men in the all symptom class and the internalizing symptoms class was similar, with abstinence and risky sex predominating, and safer sex being relatively uncommon for both classes. The sexual behavior of men in the asymptomatic class differed, with safer sex being relatively more likely to occur compared to the symptomatic classes. These findings suggest that the psychological symptom profile of sexually abstinent people places them at risk for inconsistent condom use should they engage in sexual behavior.

Improving mental health among people living with HIV: a review of intervention trials in low- and middle-income countries

People living with HIV (PLWH) experience greater psychological distress than the general population. Evidence from high-incomes countries suggests that psychological interventions for PLWH can improve mental health symptoms, quality of life, and HIV care engagement. However, little is known about the effectiveness of mental health interventions for PLWH in low and middle-income countries (LMICs), where the large majority of PLWH reside. This systematized review aims to synthesize findings from mental health intervention trials with PLWH in LMICs to inform the delivery of mental health services in these settings. A systematic search strategy was undertaken to identify peer-reviewed published papers of intervention trials addressing negative psychological states or disorders (e.g., depression, anxiety) among PLWH in LMIC settings. Search results were assessed against pre-established inclusion and exclusion criteria. Data from papers meeting criteria were extracted for synthesis. Twenty-six papers, published between 2000 and 2014, describing 22 unique interventions were identified. Trials were implemented in sub-Saharan Africa (n=13), Asia (n=7), and the Middle East (n=2), and addressed mental health using a variety of approaches, including cognitive-behavioral (n=18), family-level (n=2), and pharmacological (n=2) treatments. Four randomized controlled trials reported significant intervention effects in mental health outcomes, and eleven preliminary studies demonstrated promising findings. Among the limited mental health intervention trials with PLWH in LMICs, few demonstrated efficacy. Mental health interventions for PLWH in LMICs must be further developed and adapted for resource-limited settings to improve effectiveness.

Optimism and education buffer the effects of syndemic conditions on HIV status among African American men who have sex with men

The present study sought to replicate effects of the number of syndemic psychosocial health conditions on sexual risk behavior and HIV infection among a sample of high-risk African American men who have sex with men (MSM) and to identify resilience factors that may buffer these effects. We used baseline data from an HIV risk-reduction trial to examine whether a higher number of syndemic conditions was associated with higher rates of self-reported sexual risk behavior and HIV infection. Using logistic regression models, we tested for interactions between number of syndemic conditions and several potential resilience factors to identify buffering effects. Replicating previous studies, we found significant associations between numbers of syndemic conditions and higher rates of sexual risk behavior and HIV infection. Surprisingly, we also replicated a previous finding (Stall et al., Am J Public Health, 93(6):939-942, 2003) that the effects of syndemic burden on HIV status fell off at the highest levels of syndemic conditions. Among a variety of potential resilience factors, two-optimism and education-buffered the syndemic effect on HIV prevalence. This is, to our knowledge, the first paper to identify resilience factors buffering against syndemic effects among MSM. It also constitutes a significant contribution to the literature regarding prevention among black MSM. These results point to the need to identify HIV-positive black MSM and provide effective treatment for them and to develop interventions addressing both syndemic and resilience factors.

Comparing the life concerns of prescription opioid and heroin users

This study explored life concerns of prescription opioid (PO) and heroin users. Persons entering opioid detoxification rated their level of concern about 43 health and welfare items. Using exploratory factor analysis and conceptual rationale, we identified ten areas of concern. Participants (N=529) were 69.9% male, 87.5% non-Hispanic Caucasian, and 24.2% PO users. Concern about drug problems was perceived as the most serious concern, followed by money problems, relationship problems, mental health, and cigarette smoking. PO users expressed significantly lower concern about drug problems (p=.017) and transmissible diseases (p<.001), but were more concerned about alcohol use (p<.001) than heroin users. There were no significant differences with regard to the other 7 areas of concern. Recognition of the daily worries of opioid dependent persons could allow providers to better tailor their services to the context of their patients' lives.

Co-occurring psychosocial problems and HIV risk among women attending drinking venues in a South African township: a syndemic approach

BACKGROUND

In South Africa, women comprise the majority of HIV infections. Syndemics, or co-occurring epidemics and risk factors, have been applied in understanding HIV risk among marginalized groups.

PURPOSE

The purposes of this study are to apply the syndemic framework to examine psychosocial problems that co-occur among women attending drinking venues in South Africa and to test how the co-occurrence of these problems may exacerbate risk for HIV infection.

METHOD

Five hundred sixty women from a Cape Town township provided data on multiple psychosocial problems, including food insufficiency, depression, abuse experiences, problem drinking, and sexual behaviors.

RESULTS

Bivariate associations among the syndemic factors showed a high degree of co-occurrence and regression analyses showed an additive effect of psychosocial problems on HIV risk behaviors.

CONCLUSIONS

These results demonstrate the utility of a syndemic framework to understand co-occurring psychosocial problems among women in South Africa. HIV prevention interventions should consider the compounding effects of psychosocial problems among women.

Childhood sexual abuse and HIV-related risks among men who have sex with men in Washington, DC

Childhood sexual abuse (CSA) has been reported to be disproportionately higher among men who have sex with men (MSM) than among heterosexual men; it has also been found to be significantly positively associated with HIV status and HIV risk factors, including unprotected anal intercourse. The purpose of this study was to assess the correlates of CSA in a sample of community-recruited MSM, investigate race as a potential effect modifier, and describe the independent association between CSA and HIV infection in Washington, DC. A total of 500 MSM were recruited by venue-based sampling in 2008 as part of the National HIV Behavioral Surveillance. More than one-half of MSM identified as White, while one-third identified as Black. CSA was reported by 17.5 % of the 451 MSM, with the first instance of abuse occurring at a median age of 8.3 (interquartile range = 5.0, 11.0). In multivariable analysis, HIV-positive men were significantly more likely to report a history of CSA compared to HIV-negative men after adjusting for intimate partner violence in the last 12 months, having been arrested in the last 12 months, and depressive symptoms. HIV-positive MSM had more than four times the odds of reporting CSA after controlling for other correlates (aOR = 4.19; 95 % CI 2.26, 7.75). Despite hypothesizing that race modified the effect of CSA on HIV infection we found this was not the case in this sample. More research is needed to investigate the potential pathway between a history of CSA and HIV infection, and how this contributes to driving the HIV epidemic among MSM in Washington, DC.

Early life emotional neglect and HIV risk taking among men using the Internet to find other men for unprotected sex

PURPOSE

Using a Syndemics Theory conceptual model, this study examines the relationship between emotional neglect experiences during childhood and/or adolescence and involvement in HIV risk taking in a sample of adult men who actively seek partners for unprotected sex via the Internet.

METHODS

The study was based on a national random sample of 332 MSM who use the Internet to seek men with whom they can engage in unprotected sex. Data collection was conducted via telephone interviews between January 2008 and May 2009. Structural equation analysis was undertaken to examine the specific nature of the relationships involved in understanding HIV risk practices.

RESULTS

Emotional neglect was highly prevalent among the men participating in this study. Emotional neglect experiences were not found to be related directly to involvement in HIV risk taking in adulthood. Emotional neglect, was found to be an important variable in the overall structural equation. Its effect on HIV risk taking was indirect, operating principally by having a negative impact upon self-esteem, which in turn had a negative effect on attitudes toward condom use, which in turn were related strongly and directly to risk taking.

CONCLUSIONS

Childhood experiences with emotional neglect are relevant to understanding HIV risk practices among MSM in adulthood, but the relationship is not as simple as usually conceptualized. Rather, emotional neglect appears to impact risk taking indirectly, through its effects on mental health functioning, which in turn affects risk-related attitudes.