Brief Report: Substance Use Care Continuum in Women With and Without HIV in the Southern United States

BACKGROUND

Substance use (SU) contributes to poor outcomes among persons living with HIV. Women living with HIV (WWH) in the United States are disproportionately affected in the South, and examining SU patterns, treatment, and HIV outcomes in this population is integral to addressing HIV and SU disparities.

METHODS

WWH and comparable women without HIV (WWOH) who enrolled 2013-2015 in the Women's Interagency HIV Study Southern sites (Atlanta, Birmingham/Jackson, Chapel Hill, and Miami) and reported SU (self-reported nonmedical use of drugs) in the past year were included. SU and treatment were described annually from enrollment to the end of follow-up. HIV outcomes were compared by SU treatment engagement.

RESULTS

At enrollment, among 840 women (608 WWH, 232 WWOH), 18% (n = 155) reported SU in the past year (16% WWH, 24% WWOH); 25% (n = 38) of whom reported SU treatment. Over time, 30%, 21%, and 18% reported SU treatment at 1, 2, and 3 years, respectively, which did not significantly differ by HIV status. Retention in HIV care did not differ by SU treatment. Viral suppression was significantly higher in women who reported SU treatment only at enrollment ( P = 0.03).

CONCLUSIONS

We identified a substantial gap in SU treatment engagement, with only a quarter reporting treatment utilization, which persisted over time. SU treatment engagement was associated with viral suppression at enrollment but not at other time points or with retention in HIV care. These findings can identify gaps and guide future strategies for integrating HIV and SU care for WWH.

Examining the Effect of SARS-CoV-2 Pandemic-Induced Stress and Anxiety on Humoral Immunity in Health Care Workers

OBJECTIVE

The effect of stress on vaccine-induced humoral immunity and therapeutic interventions to mitigate pandemic-related stress remain underexplored.

METHOD

Participants in a longitudinal cohort study ( n = 189) completed a validated measure, GAD-7, and 10-instrument stress measure to assess stress and anxiety after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. Serum was collected to obtain SARS-CoV-2 antibody titer levels.

RESULTS

Participants experienced increased stress due to the SARS-CoV-2 pandemic with a positive correlation between GAD-7 scores and peak antibody titers overall; however, there was a negative association with scores commensurate with severe anxiety. Health care workers and younger participants were more significantly affected by anxiety.

CONCLUSIONS

Mild anxiety levels may have immune-enhancing effects, whereas severe anxiety may cause antibody generation reduction. Mental health-focused interventions are imperative for younger adults and health care workers. Young adults may be more resilient to increased stress levels.

An Overview of Miami CDEIPI and a Showcase of Team Science and Cutting-Edge Research Driven by Students

BACKGROUND

The Miami-CFAR Diversity, Equity & Inclusion Pathway Initiative (Miami CDEIPI) is designed to promote a diverse scientific workforce that reflects the communities at the highest risk of HIV in South Florida.

SETTING AND METHODS

The focus of the Miami CDEIPI is to help train the next generation of Underrepresented Minorities (URM) and Black, Indigenous, People of Color (BIPOC) in HIV/AIDS-related research through a team science experience. The Miami CDEIPI objectives are to facilitate the interaction of URM/BIPOC students with the network of CFAR-affiliated investigators and to enable these students to access the cutting-edge technologies at the Miami-CFAR and the Sylvester Comprehensive Cancer Center and other resources at the University of Miami.

RESULTS

Five URM/BIPOC students supported by the program in year 1 have been carrying out projects in collaboration with mentors at their parent institution and Miami-CFAR investigators. The students used the state-of-the-art laboratories and core facilities. They began their research with a proposal designed to integrate the cutting-edge technologies now available to them. Their training included participation in Miami-CFAR-sponsored activities such as seminars, an annual conference, and a national HIV workshop. Candidates in the Miami CDEIPI are in the process of developing their research proposals, integrating cutting-edge technologies into their doctoral dissertation research. Their projects are now in the completion phase.

CONCLUSIONS

The Miami CDEIPI focuses its resources on one of the conspicuous gaps in the career paths of URM/BIPOC researchers-the dearth of leading URM/BIPOC scientists in the field. The Miami CDEIPI provides a professional network that supports the participation of URM/BIPOC trainees in innovative research and career skill training.

A Note on Preexposure Prophylaxis Preferences Among Women Who Inject Drugs

ABSTRACT

We informed women who inject drugs about different preexposure prophylaxis (PrEP) formulations; they then ranked their preferences. Daily oral PrEP was most preferred, followed by injectable PrEP and vaginal rings/gels, especially among women of color. Multiple PrEP options should be discussed with women who inject drugs to increase uptake.

Geographic Disparities in Availability of Spanish-Language PrEP Services Among Latino Sexual Minority Men in South Florida

Latino sexual minority men (LSMM) experience barriers in accessing HIV pre-exposure prophylaxis (PrEP), such as lack of proximate culturally-appropriate PrEP navigation services. We examined associations between LSMM's immigration status and Spanish-language PrEP service availability. LSMM clinically indicated for PrEP were recruited from October 2018 to August 2019 in South Florida and completed an interviewer-administered questionnaire. PrEP service navigators in South Florida were identified using the CDC PrEP Directory. We constructed network service areas of 1-, 2-, and 5-miles from Spanish-speaking PrEP navigators. We used multilevel logistic regression to examine associations of individual (i.e., age, income, immigration status, network density) and zip code-level (i.e., population density, poverty, HIV risk) measures with availability of Spanish-language PrEP navigation services. A total of 131 participants clustered into 60 zip codes in South Florida. Latin American-born LSMM reported higher immigration and discrimination stress, and were 91% less likely to have PrEP navigation service availability, relative to LSMM born in the US. Zip code-level HIV incidence was associated with higher service availability within a 1-mile network of Spanish-speaking PrEP navigators. Spanish-language PrEP navigation services were available in high-HIV incidence zip codes; however, Latin American-born LSMM experienced reduced availability. Immigration and discrimination stress may explain lack of availability.

"No matter what, we just work with the trauma…": Mental Health Therapists' Care of Diverse Sexual and Gender Identity Citizens in Cambodia

The convergence of trauma symptomatology, mental health symptoms, family and social difficulties, and intersectionality of diverse sexual and gender minority (SGM) individual issues is complex, multi-faceted, and challenging for the individuals in Cambodia who suffer them and for the therapists in Cambodia who meet individuals in treatment. We documented and analyzed the perspectives of mental health therapists in the context of a randomized control trial (RCT) intervention within the Mekong Project in Cambodia. The research questions explored perceptions of therapists' care of mental health clients, therapist wellbeing, and experiences of navigating within a research environment in which SGM citizens with mental health concerns receive treatment. The larger study enrolled 150 Cambodian adults, among which 69 identified as SGM. Three key patterns emerged across our interpretations. Clients seek help when symptoms interfere with daily life, therapists care for clients and themselves, and integrated research and practice is integral yet sometimes paradoxical. Therapists did not identify differences in terms of how they work with SGM clients compared with non-SGM clients. Future studies are warranted to examine a reciprocal academic-research partnership in which we examine therapists' work alongside rural community members, evaluate the process of embedding and fortifying peer supports within educational systems, and study the wisdom of traditional and Buddhist healers to address the discrimination and violence that citizens who identify as SGM disproportionately suffer. National Library of Medicine (U.S.). (2020). Trauma Informed Treatment Algorithms for Novel Outcomes (TITAN). Identifier NCT04304378.

1414. Substance Use Treatment Utilization Among Women with and at Risk for HIV

Background

Substance use (SU) contributes to poor health outcomes , yet limited data exist to inform strategies to optimize SU treatment among people with HIV (PWH). We describe SU and SU treatment utilization among women with and at risk for HIV in the Women’s Interagency HIV Study (WIHS).

Methods

We included data from participants enrolled in 10 WIHS sites from 2013-2020. Current SU was defined as self-reported, non-medical use of drugs in the past year, excluding use of only marijuana. SU treatment utilization was determined by self-reported use of a drug treatment program in the past year. Multivariable regression models were used to determine associations between participant characteristics and SU treatment.

Results

Among 2559 women (1802 HIV+, 757 HIV-), 66% (n= 1690) reported lifetime SU (65% HIV+, 69% HIV-), and 14% (n=367) reported current SU (13% HIV+, 18% HIV-). Among women with current SU, 71% reported crack/cocaine, 40% opioids, 12% any intravenous drug, 6.5% tranquilizers, and 6.5% methamphetamines. Of these women, 77% reported smoking cigarettes, 52% marijuana use, and 27% using >7 drinks/week. Among women with current SU, 42% (n=155) reported any treatment in the past year (40% HIV+, 45% HIV-); the most common treatments were methadone (64%), narcotics anonymous (29%), inpatient (28%), and outpatient programs (16%). Among women with opioid use (n= 147), 67% reported methadone use in the past year compared to only 5% using buprenorphine/naloxone. In multivariable analysis, HIV seropositivity and concurrent alcohol or marijuana use were associated with lower odds of SU treatment, and visit with a psychiatrist/counselor with higher odds of treatment (Table). In a separate model including only women with HIV, SU treatment was not associated with having an HIV care visit or viral suppression. Table- part 1Table - part 2

Conclusion

In the WIHS cohort, SU treatment utilization was higher than expected, especially for methadone use, reflecting the resilience of a population which is known to face stigma and barriers to treatment. Still, our analysis highlights opportunities for accessing SU treatment in the context of HIV care for women with HIV, such as the need to prioritize providing buprenorphine/naloxone in HIV care settings.

Disclosures

Steven Shoptaw, PhD, Alkermes Inc: Grant/Research Support|Gilead Sciences, Inc: Grant/Research Support Adaora A. Adimora, MD, MPH, Gilead: Advisor/Consultant|Gilead: Grant/Research Support|Merck: Advisor/Consultant|Merck: Grant/Research Support Ellen Eaton, MD, MPH, Gilead HIV Research Scholar: Grant/Research Support|Gilead HIV research scholar: Grant/Research Support.

The association between egocentric sexual networks and sexual meeting venues with PrEP conversation and encouragement for use among Latinx men who have sex with men

Despite the increasing availability of pre-exposure prophylaxis (PrEP), Latinx men who have sex with men (LMSM) are not receiving PrEP-related information. To understand the influence of LMSM sexual networks on PrEP-related conversations and encouragement to use PrEP, this cross-sectional egocentric network study characterized the PrEP-related communication of 130 LMSM egos with 507 sexual partners (alters). Participants were recruited using respondent-driven sampling methods from a Miami-Dade County community-health organization. Egocentric-level data were collected from 2018-2019 and analyzed using multilevel modeling. Of egos, 30% reported using PrEP. Closeness between participants and sexual partners played a role in PrEP conversation and encouragement. Participants believed they would have less success convincing sexual partners to use PrEP if partners were older. Participants perceived higher likelihood to talk about PrEP or success in encouraging alters to use PrEP if, relative to meeting sexual partners on Grindr, they met at a friend's party, gay-centric community event, or school/work. Given that increased closeness and in-person sexual partner meeting venues are associated with PrEP information dissemination and encouragement, social network-based interventions can capitalize on PrEP navigators who run network visualizations, and with this information develop a longitudinal plan to increase PrEP conversation and encouragement as needed for each network.

Individual Differences in CD4/CD8 T-Cell Ratio Trajectories and Associated Risk Profiles Modeled From Acute HIV Infection

OBJECTIVE

We examined individual differences in CD4/CD8 T-cell ratio trajectories and associated risk profiles from acute HIV infection (AHI) through 144 weeks of antiretroviral therapy (ART) using a data-driven approach.

METHODS

A total of 483 AHI participants began ART during Fiebig I-V and completed follow-up evaluations for 144 weeks. CD4+, CD8+, and CD4/CD8 T-cell ratio trajectories were defined followed by analyses to identify associated risk variables.

RESULTS

Participants had a median viral load (VL) of 5.88 copies/ml and CD4/CD8 T-cell ratio of 0.71 at enrollment. After 144 weeks of ART, the median CD4/CD8 T-cell ratio was 1.3. Longitudinal models revealed five CD4/CD8 T-cell ratio subgroups: group 1 (3%) exhibited a ratio >1.0 at all visits; groups 2 (18%) and 3 (29%) exhibited inversion at enrollment, with normalization 4 and 12 weeks after ART, respectively; and groups 4 (31%) and 5 (18%) experienced CD4/CD8 T-cell ratio inversion due to slow CD4+ T-cell recovery (group 4) or high CD8+ T-cell count (group 5). Persistent inversion corresponded to ART onset after Fiebig II, higher VL, soluble CD27 and TIM-3, and lower eosinophil count. Individuals with slow CD4+ T-cell recovery exhibited higher VL, lower white blood cell count, lower basophil percent, and treatment with standard ART, as well as worse mental health and cognition, compared with individuals with high CD8+ T-cell count.

CONCLUSIONS

Early HIV disease dynamics predict unfavorable CD4/CD8 T-cell ratio outcomes after ART. CD4+ and CD8+ T-cell trajectories contribute to inversion risk and correspond to specific viral, immune, and psychological profiles during AHI. Adjunctive strategies to achieve immune normalization merit consideration.

HIV patients’ perceptions of a potential multi-component mindfulness-based smoking cessation smartphone application intervention

Objectives

Cigarette smoking rates among people living with HIV (PLWH) in the US is triple that of the general population. PLWH smokers are a high-risk group for smoking-related health disparities and should be a prime focus for smoking cessation efforts. Our team has developed a novel evidence-based Mindfulness Training (MT) smoking cessation smartphone application (app), “Craving-to-Quit.” Using qualitative focus groups among PLWH smokers, this study aims to tailor and optimize the app’s content and design to PLWH’s unique psychosocial profile and needs.

Methods

We conducted 8 focus groups among PLWH smokers (n = 59; 47.5% females; ≥18 years) to gain insight into participants’ perceptions about the app, MT, and the feasibility and acceptability of adding two additional strategies (CM: Contingency Management; self-monitoring of anti-retroviral therapies intake [ART]) to further optimize the app. Participants were asked to practice MTs and watch videos from the app presented on a screen in the conference room to discuss their experience. Sessions were audio-taped, transcribed verbatim, and analyzed thematically using NVivo.

Results

Most participants were non-Hispanic black (67.8%), on a federal health insurance program (61.0%). Participants considered it easy to learn the app and thought that MT is helpful in reducing stress and motivating quit attempts and were supportive of adding CM and recommended providing $20-$50 weekly cash incentives to help in quitting. Participants felt that adding self-monitoring of ART is helpful but were concerned about confidentiality in case they lost their phone. Participants recommended making the app cost-free and adding information about smoking cessation medications and the negative effects of smoking among PLWH.

Conclusions

Findings will guide the development of a novel multi-component smoking cessation intervention app integrating MT, CM, and ART self-monitoring strategies. This intervention has the potential to address several barriers to quitting in PLWH. Further clinical research is needed to test this intervention.

Efficacy of a Family-Based Intervention for HIV Prevention with Hispanic Adolescents with Same Gender Sexual Behaviors

Despite the availability of efficacious and effective family-based interventions, such interventions are scarce for sexual minority adolescents, particularly among ethnic/racial minorities. Prior to creating an entirely new intervention, a prudent first step may be to determine if existing interventions are efficacious in reducing risk behaviors in sexual minority adolescents. This study assesses the relative efficacy of a general, family-based intervention (Familias Unidas) on improving substance and condom use outcomes among Hispanic adolescents with same gender sexual behaviors (HASGB). Data across five distinct trials of Familias Unidas were synthesized. HASGB were randomized either to an intervention (n = 94) or control condition (n = 100). Mediation analyses tested for intervention efficacy on past 90-day substance (cigarette/alcohol/illicit drug) use and condomless sex at last intercourse in HASGB participants and whether family functioning indicators-parent-adolescent communication, positive parenting, and parental monitoring of peers-mediated the effects. Post hoc analyses explored the moderating role of study target population based on prior risk. Familias Unidas did not impact substance use but significantly reduced condomless sex postintervention relative to the control condition. Hypothesized mediators did not explain this effect. Post hoc analyses indicated that the effect was significant in studies that recruited based on prior risk but not studies that recruited universal samples. Our results suggest that a general, family-based intervention may have positive effects on condom use in HASGB, particularly those with prior indicated risk. Identifying intervention components that drive this effect in addition to developing tailored content for HASGB is needed.

Comparing Social Media and In-Person Recruitment: Lessons Learned From Recruiting Substance-Using, Sexual and Gender Minority Adolescents and Young Adults for a Randomized Control Trial

BACKGROUND

Recruiting large samples of diverse sexual and gender minority adolescent and young adults (AYAs) into HIV intervention research is critical to the development and later dissemination of interventions that address the risk factors for HIV transmission among substance-using, sexual and gender minority AYAs.

OBJECTIVE

This paper aimed to describe the characteristics of the samples recruited via social media and in-person methods and makes recommendations for strategies to recruit substance-using, sexual and gender minority AYAs, a hardly reached population that is a priority for HIV prevention research.

METHODS

Using data from a randomized control trial of an HIV and substance use intervention with sexual and gender minority AYAs, aged 15 to 29 years in southeastern Michigan (n=414), we examined demographic and behavioral characteristics associated with successful recruitment from a range of virtual and physical venues.

RESULTS

We found that paid advertisements on Facebook, Instagram, and Grindr offered the largest quantity of eligible participants willing to enroll in the trial. Instagram offered the largest proportion of transgender masculine participants, and Grindr offered the largest proportion of Black/African American individuals. Although we attempted venue-based recruitment at clubs, bars, community centers, and AIDS service organizations, we found it to be unsuccessful for this specific hardly reached population. Social media and geobased dating applications offered the largest pool of eligible participants.

CONCLUSIONS

Understanding factors associated with successful recruitment has the potential to inform effective and efficient strategies for HIV prevention research with substance-using, sexual and gender AYAs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02945436; https://clinicaltrials.gov/ct2/show/NCT02945436.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/resprot.9414.

The Association Between Social and Spatial Closeness With PrEP Conversations Among Latino Men Who Have Sex With Men

BACKGROUND

US Latino men who have sex with men (LMSM) are a group at highest risk for HIV. One driver of HIV among LMSM is inadequate access to pre-exposure prophylaxis (PrEP) information. The social network theory of homophily suggests that sharing similar sociodemographic factors could influence PrEP conversations within networks. This study aimed to determine how the effects of homophily across sociodemographic, immigration, cultural, and PrEP-related factors are associated with PrEP-related communication.

SETTING

This study was conducted in Miami-Dade County, FL.

METHODS

Data collected between August 2018 and October 2019 included 10 sociocentric friendship groups of 13 LMSM (N = 130). Participants were recruited using respondent-driven sampling by a community-based organization in Miami. We used the multiple regression quadratic assignment procedure to identify the effects of homophily and relationship characteristics on PrEP-related conversations using R software.

RESULTS

More frequent PrEP-related conversations were associated with dyadic friendships characterized by homophily on knowledge of PrEP effectiveness, heterophily on depressive symptom severity, home addresses proximity, friend closeness, and interaction frequency. Past PrEP-related conversation frequency also increased based on heterophily on the Latino cultural value of familism (ie, emotional support to family). Racial homophily, heterophily on severity of depressive symptoms, home addresses proximity, friendship closeness, and frequency of interactions increased likelihood to encourage a friend to use PrEP.

DISCUSSION

Social and spatial closeness and homophily play a role in PrEP-related conversations. Information from social networks contextualized in geographic settings can be elucidated to contribute toward the design of novel opportunities to end HIV.

The Beat Goes On: Stimulant Use and HIV in the Era of COVID-19

Background

Evidence suggests that economic, social, and psychological circumstances brought about by the COVID-19 pandemic may have a serious impact on behavioral health. Men who have sex with men (MSM) are disproportionally impacted by HIV and stimulant use, the co-occurrence of which heightens HIV transmission risk and undermines nationwide treatment strategies as prevention efforts for ending the HIV epidemic. There is a paucity of information regarding the potential impact of the COVID-19 pandemic on the substance use and HIV medication adherence in this key vulnerable population—MSM who use stimulants and are living with HIV.

Objective

The aim of this qualitative study was to identify ways in which the COVID-19 pandemic has affected stimulant use and antiretroviral therapy (ART) adherence among a sample of MSM living with HIV.

Methods

Two focus groups were conducted in August 2020 via videoconferencing technology compliant with the Health Insurance Portability and Accountability Act. Potential participants from an established research participant registry at State University of New York Downstate Health Sciences University were invited and screened for study participation on the basis of inclusion criteria. A semistructured interview guide was followed. A general inductive approach was used to analyze the data. Findings in two general areas of interest, the impact of the COVID-19 pandemic on stimulant use and ART adherence, emerged directly from the raw data.

Results

A total of 12 ethnically diverse participants over the age of 25 years took part in the study. Results were heterogeneous in terms of the effects of the pandemic on both stimulant use and ART adherence among MSM living with HIV. Some men indicated increased or sustained stimulant use and ART adherence, and others reported decreased stimulant use and ART adherence. Reasons for these behavioral changes ranged from concerns about their own health and that of their loved ones to challenges brought about by the lack of daily structure during the lockdown phase of the pandemic and emotion regulation difficulties.

Conclusions

The COVID-19 pandemic has had a differential impact on stimulant use and ART medication adherence among MSM living with HIV. The reasons for behavioral change identified in this study may be salient intervention targets to support ART medication adherence and lower stimulant use among MSM in the aftermath of the of the COVID-19 pandemic, as well as beyond.

"PrEP just isn't my priority": Adherence challenges among women who inject drugs participating in a pre-exposure prophylaxis (PrEP) demonstration project in Philadelphia, PA USA

Pre-exposure prophylaxis (PrEP) has the ability to curb HIV transmission among women if they are highly adherent (e.g. 6/7 weekly doses). In a recent PrEP demonstration project with 95 women who inject drugs (WWID) in Philadelphia, PA, USA, PrEP uptake was high but adherence was low. This qualitative study draws upon the Behavioral Model for Vulnerable Populations (BMVP) to describe how the context of 23 WWID's lives challenged PrEP adherence using narrative data from in-depth interviews. Content analysis suggests that women's need to organize their day around predisposing survival needs made it difficult to prioritize PrEP. Adherence was further challenged by dis-enabling structural forces such as entry into institutions that do not provide PrEP (e.g., drug treatment and correctional facilities) and medication diversion to illicit marketplaces. Overtime, women's perceived need for PrEP was dynamic: in periods they characterized as risky, women considered PrEP highly beneficial and described enhanced motivation to adhere. In periods of low perceived risk, women were less committed to continuing daily PrEP in the context of their competing survival needs. In sum, WWID faced challenges to PrEP adherence that correspond to all of the BMVP domains. To optimize PrEP for WWID, multi-level programs are needed that address the determinants that both increase HIV susceptibility and undermine adherence.

Joint effects of alcohol and stimulant use disorders on self-reported sexually transmitted infections in a prospective study of Cambodian female entertainment and sex workers

Female entertainment and sex workers (FESW) have high rates of alcohol and amphetamine-type stimulant (ATS) use, increasing risk for HIV/sexually transmitted infections (STI), and other negative outcomes. A prospective cohort of 1,198 FESW in a HIV/ATS use prevention intervention in Cambodia was assessed for alcohol and stimulant use disorders (AUD and SUD) using the Alcohol and Substance Use Involvement (ASSIST) scale. STI history was measured by self-report at baseline and at quarterly follow-up visits. Participants were asked if they had been diagnosed with an STI by a medical provider in the past 3 months. Marginal structural models were used to estimate joint effects of AUD and SUD on recent STI. At baseline, one-in-four screened AUD positive and 7% screened positive for SUD. At 18-months, 26% reported ≥1 recent STI. Accounting for time-varying and other known confounders, the adjusted odds ratio (AOR) for recent STI associated with AUD alone and SUD alone were 2.8 (95% CI:1.5-5.1) and 3.5 (95% CI:1.1-11.3), respectively. The AOR for joint effects of AUD and SUD was 5.7 (95% CI:2.2-15.2). AUD and SUD are independently and jointly associated with greater odds of STI among Cambodian FESW. Further research is critical for understanding how AUD and SUD potentiate biological and behavioural pathways that influence STI acquisition and to inform HIV risk-reduction interventions in FESW.

Internalizing Symptoms and Externalizing Behaviors in Latinx Adolescents with Same Sex Behaviors in Miami

Sexual minorities report poorer mental health relative to heterosexual counterparts, but this is underexplored in Latinx youth. This study compares internalizing symptoms and externalizing behaviors in Latinx adolescents with Same Sex Behaviors (LASSB) to their Latinx adolescent peers who did not report same sex behaviors (non-LASSB). It also explores the moderating role of biculturalism on the relationship between internalizing symptoms and externalizing behaviors, and same-sex behaviors. Individual-level baseline data (Total N=1,634; LASSB n=195) from five trials of a preventive intervention for Latinx adolescents were synthesized. Normal and clinical levels of internalizing symptoms and externalizing behaviors were determined, and logistic regression models were conducted to determine the odds of LASSB reporting these behaviors relative to non-LASSB. Additional adjusted models tested for the moderating effect of biculturalism. LASSB reported significantly higher odds of normal levels of all externalizing behaviors and clinical levels of anxious/depressed compared to non-LASSB. Biculturalism significantly moderated the association between same-sex behavior and clinical levels of internalizing behaviors; however, in subgroup analyses among LASSB, biculturalism did not significantly predict any of these behaviors. Latinx adolescents exhibited mental health disparities by same-sex behavior. Biculturalism may be an important indicator for describing these disparities in LASSB and should be further explored.

Problem opioid use and HIV primary care engagement among hospitalized people who use drugs and/or alcohol

BACKGROUND

There is growing public health concern around the potential impact of the opioid crisis on efforts to eradicate HIV. This secondary analysis seeks to determine if those who report opioids as their primary problem drug compared to those who report other drugs and/or alcohol differ in engagement in HIV primary care among a sample of hospitalized people with HIV (PWH) who use drugs and/or alcohol, a traditionally marginalized and difficult to engage population key to ending the HIV epidemic.

SETTING AND PARTICIPANTS

A total of 801 participants (67% male; 75% Black, non-Hispanic; mean age 44.2) with uncontrolled HIV and reported drug and/or alcohol use were recruited from 11 hospitals around the U.S. in cities with high HIV prevalence from 2012 to 2014 for a multisite clinical trial to improve HIV viral suppression.

METHODS

A generalized linear model compared those who reported opioids as their primary problem drug to those who reported other problem drugs and/or alcohol on their previous engagement in HIV primary care, controlling for age, sex, race, education, income, any previous drug and/or alcohol treatment, length of time since diagnosis, and study site.

RESULTS

A total of 95 (11.9%) participants reported opioids as their primary problem drug. In adjusted models, those who reported opioids were significantly less likely to have ever engaged in HIV primary care than those who reported no problem drug use (adjusted risk ratio, ARR = 0.84, 95% Confidence Interval, CI 0.73, 0.98), stimulants (ARR = 0.84, 95% CI 0.74, 0.95), and polydrug use but no alcohol (ARR = 0.79, 95% CI 0.68, 0.93). While not statistically significant, the trend in the estimates of the remaining drug and/or alcohol categories (alcohol, cannabis, polydrug use with alcohol, and [but excluding the estimate for] other), point to a similar phenomena-those who identify opioids as their primary problem drug are engaging in HIV primary care less.

CONCLUSIONS

These findings suggest that for hospitalized PWH who use drugs and/or alcohol, tailored and expanded efforts are especially needed to link those who report problem opioid use to HIV primary care. Trial registration This study was funded by National Institutes of Health (NIH) grant: U10-DA01372011 (Project HOPE-Hospital Visit as Opportunity for Prevention and Engagement for HIV-Infected Drug Users; Metsch); which is also a registered clinical trial under the Clinical Trials Network (CTN-0049). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Acceptability and feasibility of a brief substance use intervention for adolescents in Cape Town, South Africa: A pilot study

Substance use is prevalent among South African adolescents, but few interventions exist to reduce risk of harm. This study assesses the feasibility, acceptability and preliminary effects of a brief intervention for reducing adolescent substance use and other risk behaviours. This single-arm feasibility test recruited 30 substance-using adolescents and their primary caregiver. Participants received separate interventions (2 sessions for adolescents, 1 session for caregivers), with a subsample randomly selected for post-intervention interviews. Feasibility was measured by the proportion of eligible adolescents who were enrolled and retained in the study. Interviews explored acceptability, and changes in outcomes from baseline to 1-month follow-up assessed preliminary effects of the intervention. Thirty of 43 (69.8%) eligible adolescents and their caregivers were enrolled, with 29 adolescents (96.7%) and 28 caregivers (93.3%) completing the intervention. Twenty-eight adolescents (93.3%) and 29 caregivers (96.7%) were retained at follow-up. Frequency of alcohol, cannabis use and delinquent-type behaviours decreased significantly from baseline to follow-up. Participants appreciated the intervention content and delivery and felt that it facilitated behaviour change. Suggestions for improving the intervention were provided. This study found that the intervention is feasible, acceptable and had promising effects on adolescent behaviour. Efficacy must be established with a randomised controlled trial.

Racial Disparities in Mortality Among American Film Celebrities: A Wikipedia-Based Retrospective Cohort Study

Background

In the United States, well-documented racial disparities in health outcomes are frequently attributed to racial bias and socioeconomic inequalities. However, it remains unknown whether racial disparities in mortality persist among those with higher socioeconomic status (SES) and occupational prestige.

Objective

As the celebrity population is generally characterized by high levels of SES and occupational prestige, this study aimed to examine survival differences between black and white film celebrities.

Methods

Using a Web-based, open-source encyclopedia (ie, Wikipedia), data for 5829 entries of randomly selected American film actors and actresses born between 1900 and 2000 were extracted. A Kaplan-Meier survival curve was conducted using 4356 entries to compare the difference in survival by race. A Cox semiparametric regression analysis examined whether adjusting for year of birth, gender, and cause of death influenced differences in survival by race.

Results

Most celebrities were non-Hispanic white (3847/4352, 88.4%), male (3565/4352, 81.9%), and born in the United States (4187/4352, 96.2%). Mean age at death for black celebrities (64.1; 95% CI 60.6-67.5 years) was 6.4 years shorter than that for white celebrities (70.5; 95% CI 69.6-71.4 years; P<.001). Black celebrities had a faster all-cause mortality rate using Kaplan-Meier survival function estimates and a log-rank test. However, in a Cox semiparametric regression, there was no longer a significant difference in survival times between black and white celebrities (hazard ratio 1.07; 95% CI 0.87-1.31).

Conclusions

There is some evidence that racial disparities in all-cause mortality may persist at higher levels of SES, but this association was no longer significant in adjusted analyses. Further research is needed to examine if racial disparities in mortality are diminished at higher levels of SES among more representative populations.

1289. Douching and Rectal Inflammation in Sexual Minority Men: Implications for HIV Acquisition

Background

Rectal douching is the practice of rinsing the anus and rectum prior to, or after, anal sex. Among gay, bisexual, and other men who have sex with men (sexual minority men), rectal douching is likely to enhance HIV acquisition by amplifying inflammation of the rectal mucosa. This study evaluated the association of rectal douching with rectal inflammation among sexual minority men at risk for HIV infection.

Methods

HIV uninfected sexual minority men who reported receptive anal intercourse in the past 3 months (N = 197) were recruited from four STI clinics in South Florida, the leading region for new HIV infections among sexual minority men in the United States. A brief survey assessed rectal douching practices and sexual behaviors in the previous 3 months. Rectal inflammation was assessed by measuring 13 human rectal inflammatory cytokines/chemokines in rectal swabs using the LEGENDplex Human Inflammation Panel in a sample of 38 participants who reported douching and condomless receptive anal intercourse (CRAI).

Results

Average age was 35.8 years (SD=15.4). The sample was multi-ethnic: 42% Caucasian, 38% Hispanic/Latino, 13% Black/African American, and 7% other ethnic minority. Approximately two-thirds of participants (65%) reported any rectal douching in the past 3 months and the median number times participants douched was five. Participants who douched had more CRAI partners (Cohen’s d = 0.4587; P < 0.01), and more CRAI partners to ejaculation (Cohen’s d = 0.4813; P < 0.01) compared with participants who did not douche. Participants who reported douching five or more times in the past 3 months displayed significantly higher levels of IL-8 (Cohen’s d = 0.79; P = 0.02) than those who douched less than five times.

Conclusion

Among sexual minority men who engage in CRAI, more frequent douching is associated with higher levels of rectal inflammation. Assessment of rectal douching should be included when evaluating HIV prevention interventions among sexual minority men, as those who douche are more likely to engage in CRAI and are at higher risk for acquisition of HIV and other sexually transmitted infection. Further mechanistic studies are needed to assess the role of rectal douching in promoting rectal inflammation.

Disclosures

All authors: No reported disclosures.

Structural interventions and social suffering: Responding to amphetamine-type stimulant use among female entertainment and sex workers in Cambodia

BACKGROUND

In Cambodia, HIV infection remains high among female entertainment and sex workers (FESW) and the use of amphetamine-type stimulants (ATS) is an independent risk factor for unprotected sex and sexually transmitted infections among this group. For decades public health approaches to HIV prevention in low and middle income countries (LMIC) have attempted to target the macro-power relations that shape risk behaviour with structural interventions. Recent research has highlighted that interventions that combine ATS risk reduction, in the form of financial incentives for abstinence, with existing HIV prevention programmes, may also play an important role. However, whether this approach goes far enough as a response to structural drivers of risk requires further examination.

METHODS

Semi-structured in-depth interviews were conducted with 30 FESW (mean age 25 years) from five provinces in Cambodia, as part of formative research for the implementation of the Cambodia Integrated HIV and Drug Prevention (CIPI) trial. The aim was to explore the contexts and drivers of ATS use. Data were analysed using grounded theory.

RESULTS

In addition to increasing occupational functionality, ATS were used to control pervasive feelings of 'sadness' in relation to the lived experience of poverty, family and relationship problems. Feeling sad could be viewed as an expression of social suffering, in response to competing priorities and seemingly inescapable constraints imposed by a lack of options for income generation, gender inequalities and stigma. Participants expressed interest in microenterprise (ME) opportunities, particularly vocational training, that could create new work opportunities beyond sex work and ATS use.

CONCLUSION

In addition to reducing ATS use, HIV prevention interventions need to target sources of sadness and social suffering as drivers of risk among FESW in this context. The inclusion of ME opportunities in HIV prevention, to alleviate social suffering, warrants further investigation through qualitative and ethnographic research.

Proportion and predictors of loss to follow-up in a longitudinal cohort study of female entertainment and sex workers in Cambodia

We examined the proportion and correlates of loss to follow-up (LTFU) among female entertainment and sex workers (FESWs) in a longitudinal HIV prevention intervention trial in Cambodia. The Cambodia Integrated HIV and Drug Prevention Intervention trial tested a comprehensive package of interventions aimed at reducing amphetamine-type stimulant use and HIV risk among FESWs in ten provinces. The present study estimated the proportion of women LTFU and assessed factors associated with LTFU. Logistic regression analyses were used. Of a total 596 women enrolled, the cumulative proportion of LTFU was 29.5% (n = 176) between zero- and 12-month follow-up. In multivariate analyses, women with no living children (adjusted odds ratio [AOR] 1.6; 95% confidence interval [CI]: 1.1, 2.3) and those who experienced recent food insecurity (AOR 1.7; 95%CI: 1.1, 2.7) were more likely to be LTFU. Women who were members of the SMARTgirl HIV prevention programme for ≥ 6 months compared to non-members were less likely to be LTFU (AOR 0.3; 95%CI: 0.2, 0.6). LTFU was moderately high in this study and similar to other studies, indicating a need for strategies to retain this population in HIV prevention programmes and research. Interventions aimed at stabilizing women's lives, including reducing food insecurity and creating communities of engagement for FESWs, should be considered.

Intervention to Increase HIV Testing Among Substance-Using Young Men Who Have Sex With Men: Protocol for a Randomized Controlled Trial

BACKGROUND

Young men who have sex with men (YMSM) and transgender people in the Detroit Metro Area are the only risk group for whom the incidence of HIV and sexually transmitted infections (STI) has increased since 2000, with HIV incidence nearly doubling among youth. Substance use (including alcohol), which is relatively frequent among YMSM and transgender people, creates barriers to the optimal delivery of HIV prevention and care services. Standard HIV counseling, testing, and referral (CTR) is limited in providing strategies to identify and address substance use. Hence, in its current form, CTR may not be serving the prevention needs of substance-using YMSM and transgender people. Brief counseling interventions, grounded in principles of motivational interviewing, may offer a mechanism to meet the HIV prevention and care needs of substance-using YMSM and transgender people.

OBJECTIVE

This prospective, 4-arm, factorial randomized controlled trial aims to examine the efficacy of an motivational interviewing-based substance use brief intervention (SUBI) on participants' substance use and engagement in HIV prevention.

METHODS

The research implements a prospective randomized controlled trial (Project Swerve) of 600 YMSM and transgender people recruited both online and in person. Eligibility criteria include participants who (1) are between the ages of 15 to 29 years, (2) live in the Detroit Metro Area, (3) self-identify as a man or transgender man or woman, (4) have had sexual contact with a man in the 6 months before enrollment, (5) self-report binge drinking or any substance use in the 3 months before enrollment, and (6) self-report an unknown or negative HIV status upon enrollment. Participants are randomized to receive, 3-months apart starting at baseline, 2 individual sessions. Sessions are CTR-only, SUBI-only, CTR followed by SUBI, or SUBI followed by CTR.

RESULTS

Project Swerve was launched in April 2017 and enrollment is ongoing.

CONCLUSIONS

Incorporating a SUBI that utilizes the principles of motivational interviewing into HIV CTR provides an opportunity to tailor counseling services for YMSM and transgender people to address additional client barriers to HIV and STI testing.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02945436; http://clinicaltrials.gov/ct2/show/NCT02945436 (Archived by WebCite at http://www.webcitation.org/6yFyOK57w).

HIV Pre-exposure Prophylaxis (PrEP) Uptake and Retention Among Men Who Have Sex with Men in a Community-Based Sexual Health Clinic

In a community-based clinic serving men who have sex with men in San Francisco, California, this study characterized key steps of the pre-exposure prophylaxis (PrEP) cascade and identified correlates of retention in care. In total, 344 patients were evaluated for PrEP. Three-fourths (78%) of those who sought PrEP services initiated PrEP. The overall cumulative incidence of discontinuing PrEP at 13 months was 38%. Men with a sexually transmitted infection (STI) were 44% less likely to be retained (adjusted hazard ratio [aHR] 0.56, 95% confidence interval [0.33-0.95]). Comprehensive retention efforts for men with STIs are crucial to optimize the benefits of PrEP.

Engagement with health care providers as a mediator between social capital and quality of life among a sample of people living with HIV in the United States: Path-analysis

Background

Social capital is “features of social organizations—networks, norms, and as trust that facilitate coordination and cooperation for mutual benefit”. People with high social capital have lower mortality and better health outcomes. Although utilization of social networks has grown, social capital continues to be a complex concept in relation to health promotion. This study examined 1) associations between social capital and quality of life (QoL), 2) factors of social capital leading to higher QoL among people living with HIV (PLWH), 3) role of health care providers (HCP) as a mediator between social capital and QoL.

Methods

This is a secondary analysis of the International Nursing HIV Network for HIV/AIDS Research. This cross-sectional study included 1673 PLWH from 11 research sites in the United States in 2010. Using path analysis, we examined the independent effect of social capital on QoL, and the mediating effect of PLWH engagement with HCP.

Results

The majority of participants were male (71.2%), and 45.7% were African American. Eighty-nine percent of the participants were on antiretroviral therapy. Social capital consisted of three factors — social connection, tolerance toward diversity, and community participation — explaining 87% of variance of social capital. Path analysis (RMSEA = 0, CFI = 1) found that social connection, followed by tolerance toward diversity, were the principal domain of social capital leading to better QoL (std. beta = 0.50, std. error = 0.64, p<.05). Social capital was positively associated with QoL (p<.05). About 11% of the protective effect of social capital on QoL was mediated by engagement with HCP (p<.05).

Conclusions

This study emphasizes importance of social connections and mediating role of HCP in improving QoL for PLWH. To develop social capital effectively, interventions should focus on strengthening PLWH's social connections and engagement to HCP.

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Social capital improves quality of life.

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Social capital has three factors: social connection, community participation, and tolerance towards diversity.

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Social connection is seminal domain of social capital to improve quality of life for people living with HIV.

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Engagement with health care provider mediates the relationships between social capital and quality of life.

Utilization of a Sobering Center for Acute Alcohol Intoxication

OBJECTIVE

The objective was to describe the population utilizing a sobering center for public alcohol intoxication and compare between single-visit users, repeat users, and high users.

METHODS

We conducted a secondary analysis of 1,271 adults cared for in a sobering center from July 2014 to June 2015. We divided the population into three groups-single use (one visit), repeat users (two to five visits), and high (six or more) users-and evaluated demographics, lifetime health diagnoses utilizing the Elixhauser Comorbidity Index, rates of public service utilization including ambulance and emergency department, and related costs.

RESULTS

The population was primarily male, middle-aged, and ethnically diverse. Compared to single-visit users (n = 869), repeat (n = 287) and high users (n = 115) were older, were more likely to be currently homeless, and had spent more time homeless. Repeat and high users had significantly higher rates of hypertension, liver disease, diabetes, depression, psychoses, and drug abuse diagnoses compared to single-visit users. In addition to sobering visits, utilization of ambulance and ED and related costs were significantly greater for the high users compared to repeat and single-visit users.

CONCLUSIONS

From an overall heterogeneous population, more frequent utilizers of the sobering center, both high and repeat users compared to low users, had significantly greater prevalence of chronic disorders, service utilization, and homelessness. Findings indicate that a sobering center can have a prominent role in the care for those with acute alcohol intoxication, particularly those individuals with chronic public intoxication who are likewise homeless. Further longitudinal research could offer important insights as to the population served over time, investigating changes in utilization and efforts toward health and housing stabilization.

Importance of substance use and violence in psychosocial syndemics among women with and at-risk for HIV

Women in the US continue to be affected by HIV through heterosexual contact. Sexual risk behaviors among women have been associated with a syndemic, or a mutually reinforcing set of conditions, including childhood sexual abuse (CSA), depression, substance use, violence, and financial hardship. Baseline data from a cohort of women with and at-risk for HIV (N = 620; 52% HIV+) were analyzed with Poisson regression to assess evidence for additive, independent and interactive effects among syndemic conditions in relation to reported sexual risk behaviors (e.g., unprotected and transactional sex) over the past 6 months, controlling for age and HIV status. The number of syndemic conditions was incrementally associated with more types of sexual risk behaviors. For example, women with all five syndemic conditions reported 72% more types of risk behaviors over 6 months, as compared to women without any syndemic conditions. Compared to women with no syndemic conditions, women with three syndemic conditions reported 34% more and women with one syndemic condition reported 13% more types of risk behaviors. Endorsing substance use in the past 6 months, reporting CSA, and experiencing violence as an adult were independently associated with 49%, 12%, and 8% more types of risk behaviors, respectively compared to women without these conditions. Endorsing both substance use and violence was associated with 27% more types of risk behaviors. These associations were not moderated by HIV status. Understanding specific relationships and interactions are needed to more effectively prioritize limited resources in addressing the psychosocial syndemic associated with sexual risk behavior among women with and at-risk for HIV. Our results identify interrelated psychosocial factors that could be targeted by intervention studies aiming to reduce high-risk sex in this population.

Qualitative research and implementation science: Informing the acceptability and implementation of a trial of a conditional cash transfer intervention designed to reduce drug use and HIV risk

HIV risk remains high among Cambodian female entertainment and sex workers, driven by amphetamine-type substance use and sexual risk. Conditional cash transfer is an evidence-based approach to reduce stimulant use and optimize HIV/AIDS prevention, but questions remain regarding implementation in resource-limited settings. We conducted formative qualitative research to enhance acceptability of a conditional cash transfer intervention aimed at reducing amphetamine-type substance use and HIV risk among female entertainment/sex workers and inform implementation as part of a large cluster randomized trial. We conducted in-depth interviews with 30 female entertainment/sex workers. Interviews were digitally recorded and conducted and transcribed in Khmer. English transcripts were read for emerging themes and an initial coding scheme was developed. Data were coded using open and axial coding to clarify and consolidate initial themes. While most participants expressed enthusiasm for the intervention, financial and transportation issues emerged as key barriers to participation. The proposed incentive of USD$1 per screen was regarded as unacceptable and participants identified a need for transportation assistance. Participants also expressed concerns about directly observed urine specimen collection. Finally, while most participants found the 4-week aftercare program acceptable, the need for enjoyable as well as educational content was emphasized. Revisions to the protocol taking these data into account were made to optimize the acceptability of the intervention and the implementation of the trial. Findings identified key concerns and preferences that were taken into account in the final trial protocol. In particular, financial and transportation issues were identified as critical barriers to participation, with the potential to impact both intervention uptake and trial feasibility. Results demonstrate the value of formative qualitative research for clinical trial planning and implementation, particularly in settings where little is known about acceptability of interventions or willingness to participate.

Pharmacology, physiology and performance: occupational drug use and HIV risk among female entertainment and sex workers in Cambodia

BACKGROUND

In Cambodia, HIV prevalence among female entertainment and sex workers (FESW) is up to twenty times higher than in the general population. Use of amphetamine-type stimulants (ATS) has been associated with increased risk of HIV and other sexually transmitted infections in key populations, including FESW. While one in four Cambodian FESW report recent ATS use, little attention has been paid to how the occupational contexts of sex work shape patterns of use. Currently, no HIV prevention interventions target ATS use in this population.

METHODS

We conducted in-depth interviews with FESW (n = 30) with the goal of exploring experiences and motivations for ATS use and informing the development of a conditional cash transfer (CCT) intervention designed to reduce ATS use and HIV risk. Interviews were conducted and transcribed in Khmer and translated into English. Interview narratives were read and re-read and emerging themes reviewed and refined to develop an initial coding scheme. Data were formally coded using both open and axial coding to clarify and consolidate initial themes.

RESULTS

The most common driver of ATS use among FESW was increased functionality. ATS was seen as a performance enhancer, acting as an appetite suppressant and enabling women to meet the physiological demands of sex work, including long working hours, multiple clients and extended sexual transactions. While our results are consistent with studies linking ATS use to heightened sexual risk, via unprotected and/or prolonged sex, for women in the current study, the negative consequences of ATS use were outweighed by perceived functional benefits.

CONCLUSIONS

FESW in Cambodia harness the pharmacological properties of ATS to meet the physiological demands of sex work in a context of limited economic opportunities. There is an urgent need to both provide Cambodian women with options for income generation that do not risk their health and to better regulate the conditions of sex work to provide safer working environments. Structural and economic interventions, including CCT programmes, combined with awareness and enforcement of sex workers' rights, are also necessary to facilitate harm reduction and occupational health and work safety within the Cambodian sex and entertainment industry.

Adversity and syndemic production among men participating in the multicenter AIDS cohort study: a life-course approach

OBJECTIVES

We tested a theory of syndemic production among men who have sex with men (MSM) using data from a large cohort study.

METHODS

Participants were 1551 men from the Multicenter AIDS Cohort Study enrolled at 4 study sites: Baltimore, Maryland-Washington, DC; Chicago, Illinois; Los Angeles, California; and Pittsburgh, Pennsylvania. Participants who attended semiannual visits from April 1, 2008, to March 31, 2009, completed an additional survey that captured data about events throughout their life course thought to be related to syndemic production.

RESULTS

Using multivariate analysis, we found that the majority of life-course predictor variables (e.g., victimization, internalized homophobia) were significantly associated with both the syndemic condition and the component psychosocial health outcomes (depressive symptoms, stress, stimulant use, sexual compulsivity, intimate partner violence). A nested negative binomial analysis showed that the overall life course significantly explained variability in the syndemic outcomes (χ(2) = 247.94; P < .001; df = 22).

CONCLUSIONS

We identified life-course events and conditions related to syndemic production that may help to inform innovative interventions that will effectively disentangle interconnecting health problems and promote health among MSM.

Entopic overexpression of Ascl2 does not accelerate tumourigenesis in ApcMin mice

OBJECTIVE

Expression of the Wnt target gene ASCL2 is elevated in 78% of intestinal neoplasia datasets (Oncomine), suggesting a role for deregulated ASCL2 in the aetiology of intestinal tumourigenesis. Furthermore, ectopic expression of Ascl2 has previously been shown to lead to hyperplasia in the mouse. However, elevated levels of ASCL2 does not have an impact on the overall survival or recurrence-free survival rates in colorectal cancer patients. Here the authors use a novel mouse model to analyse the role of Ascl2 in intestinal tumourigenesis and address the controversy surrounding the relevance of this gene to the aetiology of colorectal cancer.

DESIGN

The authors have generated a mouse possessing a transgene carrying the Ascl2 gene together with its endogenous promoter and regulatory regions, thereby elevating Ascl2 expression in an authentic manner. The authors have further intercrossed these Ascl2 overexpressers to the classic Apc(Min) model, to study the consequence of elevated Ascl2 expression in intestinal tumourigenesis.

RESULTS

Here the authors genetically demonstrate that elevated expression of Ascl2 in a Wnt signalling dependent manner specifically in the stem cell compartment of the intestine neither increases tumour formation nor diminishes survival in a well established intestinal tumour model, the Apc(min) mouse.

CONCLUSION

The authors conclude that ectopic expression of Ascl2 is more important in the aetiology of neoplasia than overexpression of Ascl2.

Changes in stimulant drug use over time in the MACS: evidence for resilience against stimulant drug use among men who have sex with men

Stimulant drug use is associated with numerous health problems among men who have sex with men (MSM). This paper describes how stimulant drug use changes over a four and one-half year period from 2003 until 2008. Participants were 2,389 men (17,222 person-visits) from The Multicenter AIDS Cohort Study (MACS)-an ongoing, prospective study of HIV infection among MSM. Group-based trajectory analyses of data from these men over the study period yielded a four groups solution: consistent users (9.8%), men whose use increased (5.4%), men whose use declined (6.9%), and abstinent or rarely-using men (77.9%). There were significant differences between groups in terms of demographic, behavioral risk and HIV serostatus. Men who increased or decreased stimulant drug use over time reported congruent changes in sexual risk taking. The fact that sexual risk levels parallel stimulant drug use over time suggests that finding ways to lower rates of stimulant drug use among MSM could be a tool in HIV prevention.

Physicians' diagnoses of psychiatric disorders for people with chronic fatigue syndrome

OBJECTIVE

To examine rates of psychiatric diagnoses given by patients' primary or regular physicians to persons with chronic fatigue syndrome (CFS), persons with psychiatrically explained fatigue, and a control group. Physicians' psychiatric diagnosis and participants' self-reported psychiatric diagnoses were compared to lifetime psychiatric diagnoses as measured by a structured psychiatric interview.

METHOD

Participants were recruited as part of a community-based epidemiology study of chronic fatigue syndrome. Medical records of 23 persons with chronic fatigue syndrome, 25 persons with psychiatrically explained chronic fatigue, and 19 persons without chronic fatigue (controls) were examined to determine whether their physician had given a diagnosis of mood, anxiety, somatoform, or psychotic disorder. Lifetime psychiatric status was measured using the Structured Clinical Interview for the DSM-IV (SCID). Participants' self reports of specific psychiatric disorders were assessed as part of a detailed medical questionnaire.

RESULTS

Physicians' diagnosis of a psychiatric illness when at least one psychiatric disorder was present ranged from 40 percent in the psychiatrically explained group, 50 percent in the control group, and 64.3 percent in the CFS group. Participants in the psychiatrically explained group were more accurate than physicians in reporting the presence of a psychiatric disorder, and in accurately reporting the presence of a mood or anxiety disorder.

CONCLUSIONS

The present investigation found underrecognition of psychiatric illness by physicians, with relatively little misdiagnosis of psychiatric illness. Physicians had particular difficulty assessing psychiatric disorder in those patients whose chronic fatigue was fully explained by a psychiatric disorder. Results emphasized the importance of using participant self report as a screening for psychiatric disorder.