An Exploration of Geographic Access to Substance Use Treatment Programs and Violence Against Women

Violence against women (VAW) is a significant public health and human rights issue, with an estimated 736 million women globally experiencing VAW. Consistent evidence demonstrates that substance use is associated with VAW and that participation in substance use treatment programs is associated with reduction in substance use-related violence. While evidence demonstrates the ability to address VAW through substance use treatment programs, less attention has been paid to geographic access to substance use programs. If these programs are geographically inaccessible, particularly to marginalized populations, many people will not get the help they need. This study seeks to explore the relationship between geographic access to substance use treatment programs on VAW. Using data from the HIV Prevention Trials Network (HPTN) 064 study, longitudinal multilevel models were used to assess the relationship between neighborhood-level social determinants, with a specific focus on geographic access to Substance Abuse and Mental Health Services Administration (SAMHSA) certified drug and alcohol treatment programs and VAW. The study included 1910 women, ages 18 to 44, living in select geographic areas with high-ranked prevalence of HIV and poverty. The findings of this study indicate that among women who reside in census tracts with high prevalence rates of HIV: (1) substance use increases VAW; (2) VAW decreases as geographic access to SAMHSA-certified drug and alcohol treatment facilities increases; and (3) when looking at specific types of VAW, emotional and physical abuse decreases as geographic access to substance use treatment increases. Policies and programs to increase access to substance use treatment should be explored and evaluated, and more programs are needed that address the intersectionality of substance use and VAW.

Missed Opportunities: Substance Use Hotline Operator Uncertainty of State Buprenorphine Prescribing via Telemedicine

OBJECTIVES

We examined substance use hotline operator certainty of each US state and Washington, DC's endorsement of buprenorphine (initiation and continuation) prescribing via telemedicine.

METHODS

Between March and May 2021, we called hotlines in 50 US states and Washington, DC, requesting information on whether practitioners in that state could initiate or continue buprenorphine treatment for opioid use disorder (OUD) via telephone or video conference. We compared operator responses to state implementation of buprenorphine telemedicine initiation. This study was designated as not human subjects research by the Boston University Institutional Review Board.

RESULTS

We spoke with operators in 47 states and Washington, DC. Operators could not be reached in Alaska, California, and Montana. Most operators were uncertain (don't know, probably yes, probably no) whether the state permitted buprenorphine initiation (81%, n = 39) or continuation (83%, n = 40) via telemedicine. Practitioners could initiate buprenorphine prescribing via telemedicine in 7 states (100%) where operators were certain practitioners could initiate buprenorphine, 1 state (100%) where the operator was certain practitioners could not, and 6 states (86%) where operators indicated practitioners probably could not.

CONCLUSIONS

Most US states and Washington, DC, expanded the role of telemedicine in OUD treatment. However, most operators expressed uncertainty and sometimes communicated inaccurate information regarding whether practitioners could initiate buprenorphine treatment via telemedicine. There is an urgent need for policy mandates institutionalizing the role of telemedicine, and of buprenorphine specifically, in OUD treatment and for resources to train and support substance use hotline operators in this evolving policy environment.

Health Insurance and Initiation of Direct-Acting Antivirals for Hepatitis C in US Women With Human Immunodeficiency Virus

BACKGROUND

Direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) is well tolerated, cost-effective, and yields high sustained virologic response rates, yet it has remained financially inaccessible to many patients.

METHODS

Participants of the Women's Interagency HIV Study (an observational US cohort) with human immunodeficiency virus (HIV) and HCV (RNA+) reporting no prior hepatitis C treatment were followed for DAA initiation (2015-2019). We estimated risk ratios (RRs) of the relationship between time-varying health insurance status and DAA initiation, adjusting for confounders with stabilized inverse probability weights. We also estimated weighted cumulative incidences of DAA initiation by health insurance status.

RESULTS

A total of 139 women (74% Black) were included; at baseline, the median age was 55 years and 86% were insured. Most had annual household incomes ≤$18 000 (85%); advanced liver fibrosis (21%), alcohol use (45%), and recreational drug use (35%) were common. Across 439 subsequent semiannual visits, 88 women (63%) reported DAA initiation. Compared with no health insurance, health insurance increased the likelihood of reporting DAA initiation at a given visit (RR, 4.94; 95% confidence limit [CL], 1.92 to 12.8). At 2 years, the weighted cumulative incidence of DAA initiation was higher among the insured (51.2%; 95% CL, 43.3% to 60.6%) than the uninsured (3.5%; 95% CL, 0.8% to 14.6%).

CONCLUSIONS

Accounting for clinical, behavioral, and sociodemographic factors over time, health insurance had a substantial positive effect on DAA initiation. Interventions to increase insurance coverage should be prioritized to increase HCV curative therapy uptake for persons with HIV.

Accuracy Differences in Cannabis Retailer Information Ascertained from Webservices and Government-Maintained State Registries Across US States Legalizing the Sale of Cannabis in 2019

Cannabis retailer locations used to investigate geographic cannabis access are frequently ascertained from two sources: 1) webservices which provide locations of cannabis retailers (e.g., Yelp) or 2) government-maintained registries. Characterizing the operating status and location information accuracy of cannabis retailer data sources on a state-by-state level can inform research examining the health implications of cannabis legalization policies. This study ascertained cannabis retailer name and location from webservices and government-maintained registries for 26 states and the District of Columbia legalizing cannabis sales in 2019. Validation subsamples were created using state-level sequential sampling. Phone surveys were conducted by trained researchers for webservice samples (n=790, November 2019 - May 2020) and government-maintained registry (n=859, February - June 2020) to ascertain information about operating status and location. Accuracy was calculated as the percent agreement among subsample and phone survey data. For operating status and location, webservice derived data was 78% (614/790) and 79% (484/611) accurate, whereas government-maintained registry derived data was 76% (657/859) and 95% (622/655) accurate, respectively. Fifty-nine percent (15/27) of states and the District of Columbia had over 80% accuracy for operating status and 48% (13/27) states had over 80% accuracy for location information with both data sources. However, government-maintained registry derived information was more accurate in 33% (9/27) states for operating status and 41% (11/27) states for location information. Both data sources had similar operating status accuracy. Research using spatial analysis may prefer government-maintained registry derived data due to high location information accuracy, whereas studies looking at broad trends across states may prefer webservice derived. State level COVID-19 restrictions had minimal impact on ascertainment of cannabis retailer operating status and location information via phone survey derived from webservices and government-maintained registries.

Direct-Acting Antiviral Hepatitis C Treatment Cascade and Barriers to Treatment Initiation Among US Men and Women With and Without HIV

BACKGROUND

People with HIV are disproportionately coinfected with hepatitis C virus (HCV) and experience accelerated liver-related mortality. Direct-acting antivirals (DAAs) yield high sustained virologic response (SVR) rates, but uptake is suboptimal. This study characterizes the DAA-era HCV treatment cascade and barriers among US men and women with or at risk for HIV.

METHODS

We constructed HCV treatment cascades using the Women's Interagency HIV Study (women, 6 visits, 2015-2018, n = 2447) and Multicenter AIDS Cohort Study (men, 1 visit, 2015-2018, n = 2221). Cascades included treatment-eligible individuals (ie, HCV RNA-positive or reported DAAs). Surveys captured self-reported clinical (eg, CD4), patient (eg, missed visits), system (eg, appointment access), and financial/insurance barriers.

RESULTS

Of 323/92 (women/men) treatment eligible, most had HIV (77%/70%); 69%/63% were black. HIV-positive women were more likely to attain cascade outcomes than HIV-negative women (39% vs 23% initiated, 21% vs 12% SVR); similar discrepancies were noted for men. Black men and substance users were treated less often. Women initiating treatment (vs not) reported fewer patient barriers (14%/33%). Among men not treated, clinical barriers were prevalent (53%).

CONCLUSIONS

HIV care may facilitate HCV treatment linkage and barrier navigation. HIV-negative individuals, black men, and substance users may need additional support.

CLINICAL TRIALS REGISTRATION

NCT00000797 (Women's Interagency HIV Study); NCT00046280 (Multicenter AIDS Cohort Study).

Building Partnerships and Stakeholder Relationships for HIV Prevention: Longitudinal Cohort Study Focuses on Community Engagement

BACKGROUND

African American women bear disproportionate human immunodeficiency virus (HIV) burden in the United States, yet are often underrepresented in clinical research. Community engagement may decrease research mistrust and increase participation. We describe strategies used to engage community partners and female participants in a multisite HIV incidence study, HIV Prevention Trials Network (HPTN) 064.

OBJECTIVES

HPTN 064 assessed HIV incidence among women in 10 geographic areas chosen for both high prevalence of HIV and poverty.

METHODS

Women were recruited using venue-based sampling and followed for six to 12 months. Recruitment and engagement approaches aligned with the National Institutes of Health (NIH) Director's Council of Public Representatives (COPR) Community Engagement Framework's.

RESULTS

Results showed engagement activities increased rapport and established new partnerships with community stakeholders. Study sites engaged 56 community organizations with 2,099 women enrolled in 14 months. Final retention was 94%.

CONCLUSIONS

The COPR model maximized inclusiveness and participation of African American women impacted by HIV, supported recruitment and retention, and was the cornerstone of community engagement.

Associations between population density and clinical and sociodemographic factors in women living with HIV in the Southern United States

To explore the associations of urbanicity with clinical/behavioral outcomes and sociodemographic factors among women living with HIV in the Southern United States, 523 participants of the Women's Interagency HIV Study were classified into population density quartiles. Rural-Urban Commuting Area codes revealed that 7% resided in areas where >30% commute to urban areas, 2% resided in small towns or rural areas, and 91% resided in varying densities of urban areas. Although women in lower density, mostly suburban areas reported higher socioeconomic indicators such as advanced education and greater annual household income, larger proportions of women in the lowest density quartile perceived discrimination in health care settings and agreed with several internalized HIV stigma scale items. Women in the lower quartiles had higher CD4 counts, while those in the lowest quartile were more likely to have a suppressed HIV viral load, report being employed, and not report a history of drug use or current heavy alcohol use. More research is needed to understand the interplay between population density and mechanisms contributing to HIV control as well as increased internalized stigma and perceived discrimination, along with how to target interventions to improve outcomes for individuals with HIV across urban, suburban, and rural areas.

Measuring small-area violent crime: a comparison of observed versus model-estimated crime rates and preterm birth

PURPOSE

Research examining the association between crime and health outcomes has been hampered by a lack of reliable small-area (e.g., census tract or census block group) crime data. Our objective is to assess the accuracy of synthetically estimated crime indices for use in health research by using preterm birth as a case study.

METHODS

We used violent crime data reported by 47 law enforcement agencies in 15 counties in Atlanta, Georgia and compared them with commercially estimated crime rates from the same year to assess (1) how two measures of crime were correlated and (2) if the associations between violent crime rate indices and preterm birth (PTB) varied as a function of the source of crime index. To assess the association between violent crime and PTB, we used multilevel logistic regression and controlled for potential individual- and neighborhood-level confounders.

RESULTS

Violent crime, both estimated and observed, was positively correlated with poverty, neighborhood proportion Black, and neighborhood deprivation index; however, the association was stronger using estimated rates as compared with observed crime rates. The association between living in a high violent crime neighborhood and PTB was only consistent for white women across the two crime indices after covariate adjustment. For Black women, the association between living in a high violent crime neighborhood and PTB is systematically underestimated across all models when the estimated crime rate is used.

CONCLUSIONS

There is evidence that model-estimated crime rates are not reliable proxies for crime in an urban area even when appropriate confounders are adjusted for.

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.

Associations between county-level voter turnout, county-level felony voter disenfranchisement, and sexually transmitted infections among women in the Southern United States

PURPOSE

Voting may play a critical role in the allocation of social and structural resources to communities, which in turn shapes neighborhood environments, and ultimately, an individual's sexually transmitted infection (STI) risk. We assessed relationships among county-level voter turnout and felony voter disenfranchisement, and STIs.

METHODS

This cross-sectional multilevel analysis included 666 women in Alabama, Florida, Georgia, Mississippi, and North Carolina enrolled in the Women's Interagency HIV Study between 2013 and 2015. Having a baseline bacterial STI (chlamydia, gonorrhea, trichomoniasis, or early syphilis) was determined by laboratory testing. We used generalized estimating equations to test relationships between county-level voter turnout in the 2012 general election, county-level percentage of felony disenfranchised voters, and STI prevalence.

RESULTS

Eleven percent of participants had an STI. Higher voter turnout corresponded to lower STI prevalence (prevalence ratio = 0.84, 95% confidence interval = 0.73-0.96 per 4 percentage point higher turnout). Greater felony voter disenfranchisement corresponded to higher STI prevalence (prevalence ratio = 1.89, 95% confidence interval = 1.10-3.24 per 4 percentage point higher disenfranchisement).

CONCLUSIONS

STI prevalence was inversely associated with voter turnout and positively associated with felony voter disenfranchisement. Research should assess causality and mechanisms through which civic engagement shapes sexual health. Expanding political participation, including eliminating discriminatory voting laws, could influence sexual health.

Associations Between Neighborhood Characteristics, Social Cohesion, and Perceived Sex Partner Risk and Non-Monogamy Among HIV-Seropositive and HIV-Seronegative Women in the Southern U.S

Neighborhood social and physical factors shape sexual network characteristics in HIV-seronegative adults in the U.S. This multilevel analysis evaluated whether these relationships also exist in a predominantly HIV-seropositive cohort of women. This cross-sectional multilevel analysis included data from 734 women enrolled in the Women's Interagency HIV Study's sites in the U.S. South. Census tract-level contextual data captured socioeconomic disadvantage (e.g., tract poverty), number of alcohol outlets, and number of non-profits in the census tracts where women lived; participant-level data, including perceived neighborhood cohesion, were gathered via survey. We used hierarchical generalized linear models to evaluate relationships between tract characteristics and two outcomes: perceived main sex partner risk level (e.g., partner substance use) and perceived main sex partner non-monogamy. We tested whether these relationships varied by women's HIV status. Greater tract-level socioeconomic disadvantage was associated with greater sex partner risk (OR 1.29, 95% CI 1.06-1.58) among HIV-seropositive women and less partner non-monogamy among HIV-seronegative women (OR 0.69, 95% CI 0.51-0.92). Perceived neighborhood trust and cohesion was associated with lower partner risk (OR 0.83, 95% CI 0.69-1.00) for HIV-seropositive and HIV-seronegative women. The tract-level number of alcohol outlets and non-profits were not associated with partner risk characteristics. Neighborhood characteristics are associated with perceived sex partner risk and non-monogamy among women in the South; these relationships vary by HIV status. Future studies should examine causal relationships and explore the pathways through which neighborhoods influence partner selection and risk characteristics.

HIV Risk Characteristics Associated with Violence Against Women: A Longitudinal Study Among Women in the United States

BACKGROUND

Using data from HIV Prevention Trials Network 064, a multisite, observational cohort study conducted to estimate HIV incidence rates among women living in areas of high poverty and HIV prevalence in the United States, we examined the use of HIV risk characteristics to predict emotional abuse, physical violence, and forced sex.

METHODS

Participants included 2099 women, 18-44 years of age, who reported unprotected vaginal or anal sex with a male partner and an additional personal or perceived male partner HIV risk characteristic in the past 6 months. Adjusting for time-varying covariates, generalized estimating equations were used to assess the ability of HIV risk characteristics to predict violence 6 months later.

RESULTS

Reported analyses were limited to the 1980 study participants who reported having a male sex partner at that assessment. Exchanging sex, perceived partner concurrency, and perceived partner incarceration were significantly predictive of emotional abuse 6 months later (adjusted odds ratio [AOR]: 1.60; 1.59; 1.34, respectively). Prior sexually transmitted infection diagnosis, exchanging sex, and binge drinking were significantly predictive of physical violence 6 months later (AOR: 1.62; 1.71; 1.47, respectively). None of the variables measured was significantly predictive of forced sex.

CONCLUSIONS

Strategies that address reducing violence against women should be studied further in the context of HIV prevention programs.

Post-traumatic Stress Disorder Symptoms and Mental Health over Time among Low-Income Women at Increased Risk of HIV in the U.S

Women living in poverty suffer more post-traumatic stress disorder (PTSD) symptoms than do members of the general population; however we know little about factors associated with changes in their PTSD symptoms over time. Using data from HPTN 064, a cohort of women from low-income, high-HIV-prevalence communities across six eastern states (n=1,860), we assessed the prevalence of and changes in PTSD symptoms over 12 months and the effect of potential predictors on symptom acquisition and remission (via the Primary Care-PTSD symptoms scale). Forty-three percent screened positive for PTSD symptoms. Those reporting food insecurity, ongoing abuse, depressive symptoms, or binge drinking were more likely to acquire PTSD symptoms. Those with ongoing abuse or depressive symptoms were less likely to experience PTSD symptom remission. Findings suggest a need to integrate programs to reduce abuse, depression, and economic hardship with those that address sexual health risks among women living in low-income, high-HIV-prevalence neighborhoods.

Public Housing Relocations and Relationships of Changes in Neighborhood Disadvantage and Transportation Access to Unmet Need for Medical Care

INTRODUCTION

Cross-sectional research suggests that neighborhood characteristics and transportation access shape unmet need for medical care. This longitudinal analysis explores relationships of changes in neighborhood socioeconomic disadvantage and trans- portation access to unmet need for medical care.

METHODS

We analyzed seven waves of data from African American adults (N = 172) relocating from severely distressed public housing complexes in Atlanta, Georgia. Surveys yielded individual-level data and admin- istrative data characterized census tracts. We used hierarchical generalized linear models to explore relationships.

RESULTS

Unmet need declined from 25% pre-relocation to 12% at Wave 7. Post-relocation reductions in neighborhood disadvantage were inversely associated with reductions in unmet need over time (OR = 0.71, 95% CI = 0.51-0.99). More frequent transportation barriers predicted unmet need (OR = 1.16, 95% CI = 1.02-1.31).

CONCLUSION

These longitudinal findings support the importance of neighborhood environments and transportation access in shaping unmet need and suggest that improvements in these exposures reduce unmet need for medical care in this vulnerable population.

Social causation and neighborhood selection underlie associations of neighborhood factors with illicit drug-using social networks and illicit drug use among adults relocated from public housing

Theories of social causation and social influence, which posit that neighborhood and social network characteristics are distal causes of substance use, are frequently used to interpret associations among neighborhood characteristics, social network characteristics and substance use. These associations are also hypothesized to result from selection processes, in which substance use determines where people live and who they interact with. The potential for these competing selection mechanisms to co-occur has been underexplored among adults. This study utilizes path analysis to determine the paths that relate census tract characteristics (e.g., economic deprivation), social network characteristics (i.e., having ≥ 1 illicit drug-using network member) and illicit drug use, among 172 African American adults relocated from public housing in Atlanta, Georgia and followed from 2009 to 2014 (7 waves). Individual and network-level characteristics were captured using surveys. Census tract characteristics were created using administrative data. Waves 1 (pre-relocation), 2 (1st wave post-relocation), and 7 were analyzed. When controlling for individual-level sociodemographic factors, residing in census tracts with prior economic disadvantage was significantly associated with illicit drug use at wave 1; illicit drug use at wave 1 was significantly associated with living in economically-disadvantaged census tracts at wave 2; and violent crime at wave 2 was associated with illicit drug-using social network members at wave 7. Findings from this study support theories that describe social causation and neighborhood selection processes as explaining relationships of neighborhood characteristics with illicit drug use and illicit drug-using social networks. Policies that improve local economic and social conditions of neighborhoods may discourage substance use. Future studies should further identify the barriers that prevent substance users from obtaining housing in less disadvantaged neighborhoods.

Changing Places and Partners: Associations of Neighborhood Conditions With Sexual Network Turnover Among African American Adults Relocated From Public Housing

Neighborhood conditions and sexual network turnover have been associated with the acquisition of HIV and other sexually transmitted infections (STIs). However, few studies investigate the influence of neighborhood conditions on sexual network turnover. This longitudinal study used data collected across 7 visits from a predominantly substance-misusing cohort of 172 African American adults relocated from public housing in Atlanta, Georgia, to determine whether post-relocation changes in exposure to neighborhood conditions influence sexual network stability, the number of new partners joining sexual networks, and the number of partners leaving sexual networks over time. At each visit, participant and sexual network characteristics were captured via survey, and administrative data were analyzed to describe the census tracts where participants lived. Multilevel models were used to longitudinally assess the relationships of tract-level characteristics to sexual network dynamics over time. On average, participants relocated to neighborhoods that were less economically deprived and violent, and had lower alcohol outlet densities. Post-relocation reductions in exposure to alcohol outlet density were associated with fewer new partners joining sexual networks. Reduced perceived community violence was associated with more sexual partners leaving sexual networks. These associations were marginally significant. No post-relocation changes in place characteristics were significantly associated with overall sexual network stability. Neighborhood social context may influence sexual network turnover. To increase understanding of the social-ecological determinants of HIV/STIs, a new line of research should investigate the combined influence of neighborhood conditions and sexual network dynamics on HIV/STI transmission over time.

Relationships between neighbourhood characteristics and current STI status among HIV-infected and HIV-uninfected women living in the Southern USA: a cross-sectional multilevel analysis

OBJECTIVES

Neighbourhood characteristics (eg, high poverty rates) are associated with STIs among HIV-uninfected women in the USA. However, no multilevel analyses investigating the associations between neighbourhood exposures and STIs have explored these relationships among women living with HIV infection. The objectives of this study were to: (1) examine relationships between neighbourhood characteristics and current STI status and (2) investigate whether the magnitudes and directions of these relationships varied by HIV status in a predominantly HIV-infected cohort of women living in the Southern USA.

METHODS

This cross-sectional multilevel analysis tests relationships between census tract characteristics and current STI status using data from 737 women enrolled at the Women's Interagency HIV Study's southern sites (530 HIV-infected and 207 HIV-uninfected women). Administrative data (eg, US Census) described the census tract-level social disorder (eg, violent crime rate) and social disadvantage (eg, alcohol outlet density) where women lived. Participant-level data were gathered via survey. Testing positive for a current STI was defined as a laboratory-confirmed diagnosis of chlamydia, gonorrhoea, trichomoniasis or syphilis. Hierarchical generalised linear models were used to determine relationships between tract-level characteristics and current STI status, and to test whether these relationships varied by HIV status.

RESULTS

Eleven per cent of participants tested positive for at least one current STI. Greater tract-level social disorder (OR=1.34, 95% CI 0.99 to 1.87) and social disadvantage (OR=1.34, 95% CI 0.96 to 1.86) were associated with having a current STI. There was no evidence of additive or multiplicative interaction between tract-level characteristics and HIV status.

CONCLUSIONS

Findings suggest that neighbourhood characteristics may be associated with current STIs among women living in the South, and that relationships do not vary by HIV status. Future research should establish the temporality of these relationships and explore pathways through which neighbourhoods create vulnerability to STIs.

TRIAL REGISTRATION NUMBER

NCT00000797; results.

Perceptions of Community HIV/STI Risk Among U.S Women Living in Areas with High Poverty and HIV Prevalence Rates

Although studies have consistently demonstrated that women at high risk for HIV and non-HIV sexually transmitted infections (STIs) tend to underestimate their individual risk, little is known about how women at risk perceive their community's HIV/STI risk. We explored perceptions of community HIV/STI risk among U.S. women living in areas with high poverty and HIV prevalence rates as part of a qualitative substudy of the Women's HIV SeroIncidence Study. Semi-structured focus groups were conducted. Data were coded and analyzed using the constant comparative method. Participants expressed the perception that their communities were at elevated HIV/STI risk, mostly due to contextual and structural factors such as lack of access to health care and education. Findings suggest that HIV prevention messages that target U.S. women at high risk for HIV may be strengthened by addressing the high perceived community HIV/STI risk driven by structural factors.

Confidentiality considerations for use of social-spatial data on the social determinants of health: Sexual and reproductive health case study

Understanding whether and how the places where people live, work, and play are associated with health behaviors and health is essential to understanding the social determinants of health. However, social-spatial data which link a person and their attributes to a geographic location (e.g., home address) create potential confidentiality risks. Despite the growing body of literature describing approaches to protect individual confidentiality when utilizing social-spatial data, peer-reviewed manuscripts displaying identifiable individual point data or quasi-identifiers (attributes associated with the individual or disease that narrow identification) in maps persist, suggesting that knowledge has not been effectively translated into public health research practices. Using sexual and reproductive health as a case study, we explore the extent to which maps appearing in recent peer-reviewed publications risk participant confidentiality. Our scoping review of sexual and reproductive health literature published and indexed in PubMed between January 1, 2013 and September 1, 2015 identified 45 manuscripts displaying participant data in maps as points or small-population geographic units, spanning 26 journals and representing studies conducted in 20 countries. Notably, 56% (13/23) of publications presenting point data on maps either did not describe approaches used to mask data or masked data inadequately. Furthermore, 18% (4/22) of publications displaying data using small-population geographic units included at least two quasi-identifiers. These findings highlight the need for heightened education for researchers, reviewers, and editorial teams. We aim to provide readers with a primer on key confidentiality considerations when utilizing linked social-spatial data for visualizing results. Given the widespread availability of place-based data and the ease of creating maps, it is critically important to raise awareness on when social-spatial data constitute protected health information, best practices for masking geographic identifiers, and methods of balancing disclosure risk and scientific utility. We conclude with recommendations to support the preservation of confidentiality when disseminating results.

People and places: Relocating to neighborhoods with better economic and social conditions is associated with less risky drug/alcohol network characteristics among African American adults in Atlanta, GA

BACKGROUND

Few studies assess whether place characteristics are associated with social network characteristics that create vulnerability to substance use.

METHODS

This longitudinal study analyzed 7 waves of data (2009-2014) from a predominantly substance-using cohort of 172 African American adults relocated from public housing complexes in Atlanta, GA, to determine whether post-relocation changes in exposure to neighborhood conditions were associated with four network characteristics related to substance use: number of social network members who used illicit drugs or alcohol in excess in the past six months ("drug/alcohol network"), drug/alcohol network stability, and turnover into and out of drug/alcohol networks. Individual- and network-level characteristics were captured via survey and administrative data were used to describe census tracts where participants lived. Multilevel models were used to assess relationships of census tract-level characteristics to network outcomes over time.

RESULTS

On average, participants relocated to census tracts that had less economic disadvantage, social disorder, and renter-occupied housing. Post-relocation reductions in exposure to economic disadvantage were associated with fewer drug/alcohol network members and less turnover into drug/alcohol networks. Post-relocation improvements in exposure to multiple census tract-level social conditions and reductions in perceived community violence were associated with fewer drug/alcohol network members, less turnover into drug/alcohol networks, less drug/alcohol network stability, and more turnover out of drug/alcohol networks.

CONCLUSION

Relocating to neighborhoods with less economic disadvantage and better social conditions may weaken relationships with substance-using individuals.

Sexual Behaviors of US Women at Risk of HIV Acquisition: A Longitudinal Analysis of Findings from HPTN 064

We describe the sexual behaviors of women at elevated risk of HIV acquisition who reside in areas of high HIV prevalence and poverty in the US. Participants in HPTN 064, a prospective HIV incidence study, provided information about individual sexual behaviors and male sexual partners in the past 6 months at baseline, 6- and 12-months. Independent predictors of consistent or increased temporal patterns for three high-risk sexual behaviors were assessed separately: exchange sex, unprotected anal intercourse (UAI) and concurrent partnerships. The baseline prevalence of each behavior was >30 % among the 2,099 participants, 88 % reported partner(s) with >1 HIV risk characteristic and both individual and partner risk characteristics decreased over time. Less than high school education and food insecurity predicted consistent/increased engagement in exchange sex and UAI, and partner's concurrency predicted participant concurrency. Our results demonstrate how interpersonal and social factors may influence sustained high-risk behavior by individuals and suggest that further study of the economic issues related to HIV risk could inform future prevention interventions.

Changes in Exposure to Neighborhood Characteristics are Associated with Sexual Network Characteristics in a Cohort of Adults Relocating from Public Housing

Ecologic and cross-sectional multilevel analyses suggest that characteristics of the places where people live influence their vulnerability to HIV and other sexually-transmitted infections (STIs). Using data from a predominately substance-misusing cohort of African-American adults relocating from US public housing complexes, this multilevel longitudinal study tested the hypothesis that participants who experienced greater post-relocation improvements in economic disadvantage, violent crime, and male:female sex ratios would experience greater reductions in perceived partner risk and in the odds of having a partner who had another partner (i.e., indirect concurrency). Baseline data were collected from 172 public housing residents before relocations occurred; three waves of post-relocation data were collected every 9 months. Participants who experienced greater improvements in community violence and in economic conditions experienced greater reductions in partner risk. Reduced community violence was associated with reduced indirect concurrency. Structural interventions that decrease exposure to violence and economic disadvantage may reduce vulnerability to HIV/STIs.

Regression to the mean and changes in risk behavior following study enrollment in a cohort of U.S. women at risk for HIV

PURPOSE

Reductions in risk behaviors are common following enrollment in human immunodeficiency virus (HIV) prevention studies. We develop methods to quantify the proportion of change in risk behaviors that can be attributed to regression to the mean versus study participation and other factors.

METHODS

A novel model that incorporates both regression to the mean and study participation effects is developed for binary measures. The model is used to estimate the proportion of change in the prevalence of "unprotected sex in the past 6 months" that can be attributed to study participation versus regression to the mean in a longitudinal cohort of women at risk for HIV infection who were recruited from ten U.S. communities with high rates of HIV and poverty. HIV risk behaviors were evaluated using audio computer-assisted self-interviews at baseline and every 6 months for up to 12 months.

RESULTS

The prevalence of "unprotected sex in the past 6 months" declined from 96% at baseline to 77% at 12 months. However, this change could be almost completely explained by regression to the mean.

CONCLUSIONS

Analyses that examine changes over time in cohorts selected for high- or low- risk behaviors should account for regression to the mean effects.

Prevalence and correlates of knowledge of male partner HIV testing and serostatus among African-American women living in high poverty, high HIV prevalence communities (HPTN 064)

Knowledge of sexual partners' HIV infection can reduce risky sexual behaviors. Yet, there are no published studies to-date examining prevalence and characteristics associated with knowledge among African-American women living in high poverty communities disproportionately affected by HIV. Using the HIV Prevention Trial Network's (HPTN) 064 Study data, multivariable logistic regression was used to examine individual, partner, and partnership-level determinants of women's knowledge (n = 1,768 women). Results showed that women's demographic characteristics alone did not account for the variation in serostatus awareness. Rather, lower knowledge of partner serostatus was associated with having two or more sex partners (OR = 0.49, 95 % CI 0.37-0.65), food insecurity (OR = 0.68, 95 % CI 0.49-0.94), partner age >35 years (OR = 0.68, 95 % CI 0.49-0.94), and partner concurrency (OR = 0.63, 95 % CI 0.49-0.83). Access to financial support (OR = 1.42, 95 % CI 1.05-1.92) and coresidence (OR = 1.43, 95 % CI 1.05-1.95) were associated with higher knowledge of partner serostatus. HIV prevention efforts addressing African-American women's vulnerabilities should employ integrated behavioral, economic, and empowerment approaches.

Multilevel challenges to engagement in HIV care after prison release: a theory-informed qualitative study comparing prisoners' perspectives before and after community reentry

Background

Although prison provides the opportunity for HIV diagnosis and access to in-prison care, following release, many HIV-infected inmates experience clinical setbacks, including nonadherence to antiretrovirals, elevations in viral load, and HIV disease progression. HIV-infected former inmates face numerous barriers to successful community reentry and to accessing healthcare. However, little is known about the outcome expectations of HIV-infected inmates for release, how their post-release lives align with pre-release expectations, and how these processes influence engagement in HIV care following release from prison.

Methods

We conducted semi-structured interviews (24 pre- and 13 post-release) with HIV-infected inmates enrolled in a randomized controlled trial of a case management intervention to enhance post-release linkage to care. Two researchers independently coded data using a common codebook. Intercoder reliability was strong (kappa = 0.86). We analyzed data using Grounded Theory methodology and Applied Thematic Analysis. We collected and compared baseline sociodemographic and behavioral characteristics of all cohort participants who did and did not participate in the qualitative interviews using Fisher’s Exact Tests for categorical measures and Wilcoxon rank-sum tests for continuous measures.

Results

Most participants were heterosexual, middle-aged, single, African American men and women with histories of substance use. Substudy participants were more likely to anticipate living with family/friends and needing income assistance post-release. Most were taking antiretrovirals prior to release and anticipated needing help securing health benefits and medications post-release. Before release, most participants felt confident they would be able to manage their HIV. However, upon release, many experienced intermittent or prolonged periods of antiretroviral nonadherence, largely due to substance use relapse or delays in care initiation. Substance use was precipitated by stressful life experiences, including stigma, and contact with drug-using social networks. As informed by the Social Cognitive Theory and HIV Stigma Framework, findings illustrate the reciprocal relationships among substance use, experiences of stigma, pre- and post-release environments, and skills needed to engage in HIV care.

Conclusion

These findings underscore the need for comprehensive evidence-based interventions to prepare inmates to transition from incarceration to freedom, particularly those that strengthen linkage to HIV care and focus on realities of reentry, including stigma, meeting basic needs, preventing substance abuse, and identifying community resources.

Substance use patterns and factors associated with changes over time in a cohort of heterosexual women at risk for HIV acquisition in the United States

BACKGROUND

Substance use is associated with HIV sexual risk behaviors, yet few studies have examined substance use patterns longitudinally. We evaluated the types and frequency of substances used over a six-month period among U.S. women at risk for HIV acquisition.

METHODS

Women reporting unprotected sex with a man in the previous six months and at least one other personal or partner HIV risk characteristic enrolled in a multisite cohort study and completed interviews about substance use at study visits. Prevalence and frequency of substance use at the baseline and six-month visits were compared and correlates of decreased substance use at the six-month visit were assessed.

RESULTS

Of 2099 women enrolled, 1882 had substance use data at baseline and six-months. Of these, 76.1% reported using at least one drug or binge drinking in the previous six months; 37.5% were frequent and 38.6% non-frequent substance users. Binge drinking was most frequently reported (63.3%), followed by cocaine (25.0%) and opioids (16.5%). Fifty-five percent of opiate users and 30% of cocaine users reported daily/almost daily use. At the six-month visit, 40.5% reported a decrease in frequency of use. Adjusting for income and type of drug used, poly-substance users were less likely to decrease frequency of use compared to those who only used one substance.

CONCLUSION

A substantial decrease in frequency of substance use over time was observed in this cohort. Poly-substance users were less likely to reduce frequency of use over time, suggesting that specific substance use interventions targeting these users are warranted.

Venue-based recruitment of women at elevated risk for HIV: an HIV Prevention Trials Network study

BACKGROUND

The challenge of identifying and recruiting U.S. women at elevated risk for HIV acquisition impedes prevention studies and services. HIV Prevention Trials Network (HPTN) 064 was a U.S. multisite, longitudinal cohort study designed to estimate HIV incidence among women living in communities with prevalent HIV and poverty. Venue-based sampling (VBS) methodologies and participant and venue characteristics are described.

METHODS

Eligible women were recruited from 10 U.S. communities with prevalent HIV and poverty using VBS. Participant eligibility criteria included age 18-44 years, residing in a designated census tract/zip code, and self-report of at least one high-risk personal and/or male sexual partner characteristic associated with HIV acquisition (e.g., incarceration history). Ethnography was conducted to finalize recruitment areas and venues.

RESULTS

Eight thousand twenty-nine women were screened and 2,099 women were enrolled (88% black, median age 29 years) over 14 months. The majority of participants were recruited from outdoor venues (58%), retail spaces (18%), and social service organizations (13%). The proportion of women recruited per venue category varied by site. Most participants (73%) had both individual and partner characteristics that qualified them for the study; 14% were eligible based on partner risk only.

CONCLUSION

VBS is a feasible and effective approach to rapidly recruit a population of women at enhanced risk for HIV in the United States. Such a recruitment approach is needed in order to engage women most at risk and requires strong community engagement.

Retention strategies and factors associated with missed visits among low income women at increased risk of HIV acquisition in the US (HPTN 064)

Women at high-risk for HIV acquisition often face challenges that hinder their retention in HIV prevention trials. These same challenges may contribute to missed clinical care visits among HIV-infected women. This article, informed by the Gelberg-Andersen Behavioral Model for Vulnerable Populations, identifies factors associated with missed study visits and describes the multifaceted retention strategies used by study sites. HPTN 064 was a multisite, longitudinal HIV seroincidence study in 10 US communities. Eligible women were aged 18-44 years, resided in a census tract/zipcode with high poverty and HIV prevalence, and self-reported ≥1 personal or sex partner behavior related to HIV acquisition. Multivariate analyses of predisposing (e.g., substance use) and enabling (e.g., unmet health care needs) characteristics, and study attributes (i.e., recruitment venue, time of enrollment) identified factors associated with missed study visits. Retention strategies included: community engagement; interpersonal relationship building; reduction of external barriers; staff capacity building; and external tracing. Visit completion was 93% and 94% at 6 and 12 months. Unstable housing and later date of enrollment were associated with increased likelihood of missed study visits. Black race, recruitment from an outdoor venue, and financial responsibility for children were associated with greater likelihood of attendance. Multifaceted retention strategies may reduce missed study visits. Knowledge of factors associated with missed visits may help to focus efforts.

The aftermath of public housing relocations: relationships between changes in local socioeconomic conditions and depressive symptoms in a cohort of adult relocaters

USA is experiencing a paradigm shift in public housing policy: while policies used to place people who qualified for housing assistance into spatially concentrated housing complexes, they now seek to geographically disperse them, often to voucher-subsidized rental units in the private market. Programs that relocate residents from public housing complexes tend to move them to neighborhoods that are less impoverished and less violent. To date, studies have reached conflicting findings about the relationship between public housing relocations and depression among adult relocaters. The present longitudinal multilevel analysis tests the hypothesis that pre-/postrelocation improvements in local economic conditions, social disorder, and perceived community violence are associated with declines in depressive symptoms in a cohort of African-American adults; active substance misusers were oversampled. We tested this hypothesis in a cohort of 172 adults who were living in one of seven public housing complexes scheduled for relocation and demolition in Atlanta, GA; by design, 20% were dependent on substances and 50% misused substances but were not dependent. Baseline data captured prerelocation characteristics of participants; of the seven census tracts where they lived, three waves of postrelocation data were gathered approximately every 9 months thereafter. Surveys were administered at each wave to assess depressive symptoms measured using the Center for Epidemiologic Studies Depression Scale (CES-D), perceived community violence, and other individual-level covariates. Participants' home addresses were geocoded to census tracts at each wave, and administrative data sources were used to characterize tract-level economic disadvantage and social disorder. Hypotheses were tested using multilevel models. Between waves 1 and 2, participants experienced significant improvements in reported depressive symptoms and perceived community violence and in tract-level economic disadvantage and social disorder; these reductions were sustained across waves 2-4. A 1 standard deviation improvement in economic conditions was associated with a 1-unit reduction in CES-D scores; the magnitude of this relationship did not vary by baseline substance misuse or gender. Reduced perceived community violence also predicted lower CES-D scores. Our objective measure of social disorder was unrelated to depressive symptoms. We found that relocaters who experienced greater pre-/postrelocation improvements in economic conditions or in perceived community violence experienced fewer depressive symptoms. Combined with past research, these findings suggest that relocation initiatives should focus on the quality of the places to which relocaters move; future research should also identify pathways linking pre-/postrelocation changes in place characteristics to changes in mental health.

HIV acquisition among women from selected areas of the United States: a cohort study

BACKGROUND

Women account for 23% of newly diagnosed HIV infections in the United States, but there are few recent, well-characterized cohorts of U.S. women in whom behavior characteristics and HIV acquisition have been well-described.

OBJECTIVE

To evaluate HIV incidence and describe behaviors among U.S. women residing in areas of high HIV prevalence.

DESIGN

Multisite, longitudinal cohort of women who had HIV rapid testing and audio computer-assisted self-interviews at baseline and every 6 months for up to 12 months. (ClinicalTrials.gov: NCT00995176)

SETTING

10 urban and periurban communities with high HIV prevalence and poverty rates, located in the northeastern and southeastern United States.

PATIENTS

Venue-based sampling was used to recruit women aged 18 to 44 years who recently had unprotected sex and had 1 or more additional personal or partner risk factors and no self-reported previous HIV diagnosis.

MEASUREMENTS

HIV prevalence and incidence, frequency of HIV risk behaviors, and health status perceptions.

RESULTS

Among 2099 high-risk women (85.9% black and 11.7% of Hispanic ethnicity), 32 (1.5%) were diagnosed with HIV infection at enrollment. Annual HIV incidence was 0.32% (95% CI, 0.14% to 0.74%). Older age, substance use, and knowing a partner had HIV were associated with HIV prevalence. Ten women died during the study (0.61% per year).

LIMITATIONS

Longitudinal assessment of risk behaviors was limited to a maximum of 12 months. There were few incident HIV infections, precluding identification of characteristics predictive of HIV acquisition.

CONCLUSION

This study enrolled a cohort of women with HIV incidence substantially higher than the Centers for Disease Control and Prevention national estimate in the general population of U.S. black women. Concerted efforts to improve preventive health care strategies for HIV and overall health status are needed for similar populations.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Challenges of a hidden epidemic: HIV prevention among women in the United States

HIV/AIDS trends in the United States depict a concentrated epidemic with hot spots that vary by location, poverty, race/ethnicity, and transmission mode. HIV/AIDS is a leading cause of death among US women of color; two-thirds of new infections among women occur in black women, despite the fact that black women account for just 14% of the US female population. The gravity of the HIV epidemic among US women is often not appreciated by those at risk and by the broader scientific community. We summarize the current epidemiology of HIV/AIDS among US women and discuss clinical, research, and public health intervention components that must be brought together in a cohesive plan to reduce new HIV infections in US women. Only by accelerating research and programmatic efforts will the hidden epidemic of HIV among US women emerge into the light and come under control.