Leveraging pooled medical examiner records to surveil complex and emerging patterns of polysubstance use in the United States

BACKGROUND

The United States (US) is an extreme global outlier for drug-related death rates. However, data describing drug-related deaths are generally available only on an 8-13-month lag. Furthermore, granular details about substance-involvement are often not available, which particularly stymies efforts to track fatal polysubstance and novel psychoactive substance use. Detailed medical examiner records provide a powerful source of information for drug-related death surveillance, but have been underutilized.

METHODS

We pooled medical examiner data from five US states and 14 counties that together comprise 18% of the US population to examine demographic, geographic, and drug-specific trends in polysubstance drug-related deaths. We employed mixed effects logistic regression to identify demographic factors associated with polysubstance rather than single substance drug-related deaths. We assessed the correlations between drug classes and described geographic variation in the prevalence of specific drugs and the presence of novel and emerging psychoactive substances.

RESULTS

Our sample included 73,077 drug-related deaths from 2012 through early 2022. Nearly two-thirds of drug-related deaths were polysubstance-involved, with the number and percentage growing annually. High percentages of polysubstance drug-related deaths were observed in both urban and rural jurisdictions. After adjusting for year and jurisdiction, female, American Indian and Alaska Native, and White individuals had the most elevated odds of polysubstance drug-related deaths. Drug-related deaths involving benzodiazepines or opioids, whether pharmaceutical or illicit, and other pharmaceutical drugs were most likely to have polysubstance involvement, while methamphetamine-involved deaths were least likely to involve multiple substances. Strong correlations were observed between prescription opioids and prescription benzodiazepines, fentanyl and xylazine, and designer benzodiazepines and novel synthetic opioids.

CONCLUSIONS

Analysis of detailed medical examiner records reveals the breadth and complexity of polysubstance drug-related deaths in the US. Future efforts to use this unique resource can improve population-based surveillance of drug-related deaths to better tailor interventions and solutions to this critical health crisis.

Charting the fourth wave: Geographic, temporal, race/ethnicity and demographic trends in polysubstance fentanyl overdose deaths in the United States, 2010-2021

AIMS

To characterize polysubstance death in the United States during the transition to the fourth wave of the drug overdose crisis. To characterize co-involved substances in fatal overdose involving synthetic opioids (mainly illicitly manufactured fentanyl analogues) by year, state, and intersectional sociodemographic groups.

DESIGN

Population-based study of national death records.

SETTING

United States.

PARTICIPANTS/CASES

All people who died from drug overdose in the United States between 2010 and 2021.

MEASUREMENTS

Percentage of all fatal overdose involving fentanyls, stimulants, and other drugs. Most commonly co-involved substances in fentanyl overdose by state and year. Percentage of fatal fentanyl overdose co-involving stimulants by state and year. Percentage of fatal fentanyl overdose co-involving stimulants by intersectional region, race/ethnicity, age, and sex.

FINDINGS

The percent of US overdose deaths involving both fentanyl and stimulants increased from 0.6% (n = 235) in 2010 to 32.3% (34 429) in 2021, with the sharpest rise starting in 2015. In 2010, fentanyl was most commonly found alongside prescription opioids, benzodiazepines, and alcohol. In the Northeast this shifted to heroin-fentanyl co-involvement in the mid-2010s, and nearly universally to cocaine-fentanyl co-involvement by 2021. Universally in the West, and in the majority of states in the South and Midwest, methamphetamine-fentanyl co-involvement predominated by 2021. The proportion of stimulant involvement in fentanyl-involved overdose deaths rose in virtually every state 2015-2021. Intersectional group analysis reveals particularly high rates for older Black and African American individuals living in the West.

CONCLUSIONS

By 2021 stimulants were the most common drug class found in fentanyl-involved overdoses in every state in the US. The rise of deaths involving cocaine and methamphetamine must be understood in the context of a drug market dominated by illicit fentanyls, which have made polysubstance use more sought-after and commonplace. The widespread concurrent use of fentanyl and stimulants, as well as other polysubstance formulations, presents novel health risks and public health challenges.

Drug-related deaths among housed and homeless individuals in the UK and the USA: comparative retrospective cohort study

BACKGROUND

The UK and USA currently report their highest number of drug-related deaths since records began, with higher rates among individuals experiencing homelessness.

AIMS

Given that overdose prevention in homeless populations may require unique strategies, we evaluated whether substances implicated in death differed between (a) housed decedents and those experiencing homelessness and (b) between US and UK homeless populations.

METHOD

We conducted an internationally comparative retrospective cohort study utilising multilevel multinomial regression modelling of coronial/medical examiner-verified drug-related deaths from 1 January 2012 to 31 December 2021. UK data were available for England, Wales and Northern Ireland; US data were collated from eight county jurisdictions. Data were available on decedent age, sex, ethnicity, housing status and substances implicated in death.

RESULTS

Homeless individuals accounted for 16.3% of US decedents versus 3.4% in the UK. Opioids were implicated in 66.3 and 50.4% of all studied drug-related deaths in the UK and the USA respectively. UK homeless decedents had a significantly increased risk of having only opioids implicated in death compared with only non-opioids implicated (relative risk ratio RRR = 1.87, 95% CI 1.76-1.98, P < 0.001); conversely, US homeless decedents had a significantly decreased risk (RRR = 0.37, 95% CI 0.29-0.48, P < 0.001). Methamphetamine was implicated in two-thirds (66.7%) of deaths among US homeless decedents compared with 0.4% in the UK.

CONCLUSIONS

Both the rate and type of drug-related deaths differ significantly between homeless and housed populations in the UK and USA. The two countries also differ in drugs implicated in death. Targeted programmes for country-specific implicated drug profiles appear warranted.

Fentanyl, heroin, and methamphetamine-based counterfeit pills sold at tourist-oriented pharmacies in Mexico: An ethnographic and drug checking study

BACKGROUND

Fentanyl- and methamphetamine-based counterfeit prescription drugs have driven escalating overdose death rates in the US, however their presence in Mexico has not been assessed. Our ethnographic team has conducted longitudinal research focused on illicit drug markets in Northern Mexico since 2018. In 2021-2022, study participants described the arrival of new, unusually potent tablets sold as ostensibly controlled substances, without a prescription, directly from pharmacies that cater to US tourists.

AIMS

To characterize the availability of counterfeit and authentic controlled substances at pharmacies in Northern Mexico available to English-speaking tourists without a prescription.

METHODS

We employed an iterative, exploratory, mixed methods design. Longitudinal ethnographic data was used to characterize tourist-oriented micro-neighborhoods and guide the selection of n=40 pharmacies in n=4 cities in Northern Mexico. In each pharmacy, samples of "oxycodone", "Xanax", and "Adderall" were sought as single pills, during English-language encounters, after which detailed ethnographic accounts were recorded. We employed immunoassay-based testing strips to check each pill for the presence of fentanyls, benzodiazepines, amphetamines, and methamphetamines. We used Fourier-Transform Infrared Spectroscopy to further characterize drug contents.

RESULTS

Of n=40 pharmacies, one or more of the requested controlled substances could be obtained with no prescription (as single pills or in bottles) at 28 (70.0%) and as single pills at 19 (47.5%). Counterfeit pills were obtained at 11 pharmacies (27.5%). Of n=45 samples sold as one-off controlled substances, 18 were counterfeit. 7 of 11 (63.6%) samples sold as "Adderall" contained methamphetamine, 8 of 27 (29.6%) samples sold as "Oxycodone" contained fentanyl, and 3 "Oxycodone" samples contained heroin. Pharmacies providing counterfeit drugs were uniformly located in tourist-serving micro-neighborhoods, and generally featured English-language advertisements for erectile dysfunction medications and "painkillers". Pharmacy employees occasionally expressed concern about overdose risk and provided harm reduction guidance.

DISCUSSION

The availability of fentanyl-, heroin-, and methamphetamine-based counterfeit medications in tourist-oriented independent pharmacies in Northern Mexico represents a public health risk, and occurs in the context of 1) the normalization of medical tourism as a response to rising unaffordability of healthcare in the US, 2) plummeting rates of opioid prescription in the US, affecting both chronic pain patients and the availability of legitimate pharmaceuticals on the unregulated market, 3) the rise of fentanyl-based counterfeit opioids as a key driver of the fourth, and deadliest-to-date, wave of the opioid crisis. It was not possible to distinguish counterfeit medications based on appearance of pills or geography of pharmacies, because identically-appearing authentic and counterfeit versions were often sold in close geographic proximity. Nevertheless, people who consume drugs may be more trusting of controlled substances purchased directly from pharmacies. Due to Mexico's limited opioid overdose surveillance infrastructure, the current death rate from these substances remains unknown.

Longitudinal changes in co-involved drugs, comorbidities, and demographics of methamphetamine-related deaths in Los Angeles County

INTRODUCTION

We conducted a population-based observational study of all medical examiner cases in Los Angeles County from January 2012 through June 2021 in which methamphetamine was listed as a cause of or contributing factor to death (n = 6125). We aimed to characterize demographics, comorbidities, and co-involved substances in methamphetamine-related deaths longitudinally in Los Angeles County, California.

METHODS

We used detailed death record data to manually classify fatalities by involvement of each organ system, opioids, alcohol, cocaine, other drugs or medications, and external/traumatic causes. Primary outcomes included: the number of methamphetamine-involved deaths, demographics of decedents, percentage of methamphetamine deaths also involving other drugs, and percentage of methamphetamine deaths involving different organ systems. We performed Mann Kendall tests of trends to identify statistically significant longitudinal changes.

RESULTS

During the study period, the percentage of methamphetamine-related deaths involving opioids significantly increased from 16 % in 2012 to 54 % in 2021 (p < 0.001). Concurrently, the percentage involving cardiovascular causes significantly decreased from 47 % to 26 % (p < 0.05). Methamphetamine-related deaths in LAC increasingly affected people experiencing homelessness, for whom the percentage tripled from 13 % in 2012 to 35 % in 2021. The share of decedents under 40 years old increased from 33 % to 41 %. The percentage of Black or African American decedents increased over five-fold from 3 % to 17 %.

CONCLUSIONS

Methamphetamine-related deaths involving opioids more than tripled in Los Angeles County from 2012 to 2021, reflecting the drug supply's shift to illicit fentanyl. More than a quarter involved cardiovascular causes. These findings have implications for treatment and prevention, including scaling up contingency management, distributing naloxone to people who primarily use stimulants, and including cardiovascular care alongside these interventions directly targeted to reduce harms of methamphetamine use.

Polysubstance use and lived experience: new insights into what is needed

PURPOSE OF REVIEW

During the current overdose crisis in the United States and Canada, both polysubstance use and interventions involving people with lived experience of substance use disorder have grown. This review investigates the intersection of these topics to recommend best practices.

RECENT FINDINGS

We identified four themes from the recent literature. These are ambivalence about the term lived experience and the practice of using private disclosure to gain rapport or credibility; efficacy of peer participation; promoting equitable participation by fairly compensating staff hired for their lived experience; challenges unique to the current polysubstance-dominated era of the overdose crisis. People with lived experience make important contributions to research and treatment, especially given the additional challenges that polysubstance use creates above and beyond single substance use disorder. The same lived experience that can make someone an excellent peer support worker also often comes with both trauma related to working with people struggling with substance use and lack of opportunities for career advancement.

SUMMARY

Policy priorities for clinicians, researchers and organizations should include steps to foster equitable participation, such as recognizing expertise by experience with fair compensation; offering career advancement opportunities; and promoting self-determination in how people describe themselves.

Twenty-Year Trends in Drug Overdose Fatalities Among Older Adults in the US

This study uses data from the US Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research database to assess 20-year trends in drug overdose fatalities among older adults in the US.

US drug overdose mortality rose faster among hispanics than non-hispanics from 2010 to 2021

BACKGROUND

Historically, overdose mortality rates among Hispanics have been lower than non-Hispanics. The purpose of this analysis was to characterize the U.S. overdose crisis among Hispanics compared to non-Hispanics.

METHODS

We used the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiological Research (WONDER) platform to obtain drug overdose mortality rates per 100,000 population between 2010 and 2021 for Hispanics and non-Hispanics. We examined the relative percent change and specific drug involvement (2010-2021) and state-level disparities (2010-2020) among Hispanics versus non-Hispanics. We calculated rate ratios by state and annual percent change in total and for each specific drug. Statistical analyses were performed using R software version 4.0.3 (R Project for Statistical Computing).

RESULTS

Nationally, from 2010 to 2021, Hispanic overdose rates rose from 5.6 to 21.7 per 100,000, an increase of 287.5 % compared to 13.5-35.1 per 100,000, an increase of 160 % among non-Hispanics. The average annual percent change was 12 % for Hispanics and 9 % for non-Hispanics. The three most common drug classes involved in overdose deaths among both groups included: Fentanyls and synthetic opioids; cocaine; and prescription opioids. Hispanic overdose rates were higher than non-Hispanic rates in New Mexico, Colorado, Massachusetts, and Pennsylvania in 2020, versus only Michigan in 2010.

CONCLUSIONS

We observed disparities in overdose mortality growth among Hispanics compared to non-Hispanics from 2010 to 2021. These disparities highlight the urgency to develop community-centered solutions that take into consideration the social and structural inequalities that exacerbate the effects of the opioid overdose crisis on Hispanic communities.

A COVID-19 Vaccination Program to Promote Uptake and Equity for People Experiencing Homelessness in Los Angeles County

People experiencing homelessness (PEH) have been disproportionately affected by COVID-19, yet their vaccination coverage is lower than is that of the general population. We implemented a COVID-19 vaccination program that used evidence-based and culturally tailored approaches to promote vaccine uptake and equity for PEH in Los Angeles County, California. From February 2021 through February 2022, 33 977 doses of vaccine were administered at 2658 clinics, and 9275 PEH were fully vaccinated. This program may serve as a model for future service delivery in vulnerable populations. (Am J Public Health. 2023;113(2):170-174. https://doi.org/10.2105/AJPH.2022.307147).

Fentanyl, Heroin, and Methamphetamine-Based Counterfeit Pills Sold at Tourist-Oriented Pharmacies in Mexico: An Ethnographic and Drug Checking Study

Background

Our ethnographic team has conducted longitudinal research focused on illicit drug markets in Northern Mexico since 2018. In 2021-2022, study participants described the arrival of new, unusually potent tablets sold as ostensibly controlled substances, without a prescription, directly from pharmacies that cater to US tourists. Concurrently, fentanyl- and methamphetamine-based counterfeit prescription drugs have driven escalating overdose death rates in the US, however their presence in Mexico has not been assessed.

Aims

To characterize the availability of counterfeit and authentic controlled substances at pharmacies in Northern Mexico available to English-speaking tourists without a prescription.

Methods

We employed an iterative, exploratory, mixed methods design. Longitudinal ethnographic data was used to characterize tourist-oriented micro-neighborhoods and guide the selection of n=40 pharmacies in n=4 cities in Northern Mexico. In each pharmacy, samples of "oxycodone", "Xanax", and "Adderall" were sought as single pills, during English-language encounters, after which detailed ethnographic accounts were recorded. We employed immunoassay-based testing strips to check each pill for the presence of fentanyls, benzodiazepines, amphetamines, and methamphetamines. We used Fourier-Transform Infrared Spectroscopy to further characterize drug contents.

Results

Of 40 pharmacies, these controlled substances could be obtained in any form with no prescription at 68.3% and as single pills at 46.3%. Counterfeit pills were obtained at n=11 (26.8%) of pharmacies. Of n=45 samples sold as one-off controlled substances, n=20 were counterfeit including 9 of 11 (81.8%) of samples sold as "Adderall" that contained methamphetamine, and 8 of 27 (29.6%) of samples sold as "Oxycodone" that contained fentanyl, and n=3 'Oxycodone' samples containing heroin. Pharmacies providing counterfeit drugs were uniformly located in tourist-serving micro-neighborhoods, and generally featured English-language advertisements for erectile dysfunction medications and 'painkillers'. Pharmacy employees occasionally expressed concern about overdose risk and provided harm reduction guidance.

Discussion

The availability of fentanyl-, heroin-, and methamphetamine-based counterfeit medications in Northern Mexico represents a public health risk, and occurs in the context of 1) the normalization of medical tourism as a response to rising unaffordability of healthcare in the US, 2) plummeting rates of opioid prescription in the US, affecting both chronic pain patients and the availability of legitimate pharmaceuticals on the unregulated market, 3) the rise of fentanyl-based counterfeit opioids as a key driver of the fourth, and deadliest-to-date, wave of the opioid crisis. It is not possible to distinguish counterfeit medications based on appearance, because identically-appearing authentic and counterfeit versions are often sold in close geographic proximity. Nevertheless, US tourist drug consumers may be more trusting of controlled substances purchased directly from pharmacies. Due to Mexico's limited opioid overdose surveillance infrastructure, the current death rate from these substances remains unknown.

Long-Acting Injectable Therapy for People with HIV: Looking Ahead with Lessons from Psychiatry and Addiction Medicine

Long-acting injectable antiretroviral medications are new to HIV treatment. People with HIV may benefit from a treatment option that better aligns with their preferences, but could also face new challenges and barriers. Authors from the fields of HIV, substance use treatment, and mental health collaborated on this commentary on the issues surrounding equitable implementation and uptake of LAI ART by drawing lessons from all three fields. We employ a socio-ecological framework beginning at the policy level and moving through the community, organizational, interpersonal, and patient levels. We look at extant literature on the topic as well as draw from the direct experience of our clinician-authors.

Sensitivity of health records for self-reported nonfatal drug and alcohol overdose

BACKGROUND AND OBJECTIVES

Public health surveillance for overdose sometimes depends on nonfatal drug overdoses recorded in health records. However, the proportion of total overdoses identified through health record systems is unclear. Comparison of overdoses from health records to those that are self-reported may provide insight on the proportion of nonfatal overdoses that are not identified.

METHODS

We conducted a cohort study linking survey data on overdose from a national survey of Veterans to United States Department of Veterans Affairs (VA) health records, including community care paid for by VA. Self-reported overdose in the prior 3 years was compared to diagnostic codes for overdoses and substance use disorders in the same time period.

RESULTS

The sensitivity of diagnostic codes for overdose, compared to self-report as a reference standard for this analysis, varied by substance: 28.1% for alcohol, 23.1% for sedatives, 12.0% for opioids, and 5.5% for cocaine. There was a notable concordance between substance use disorder diagnoses and self-reported overdose (sensitivity range 17.9%-90.6%).

DISCUSSION AND CONCLUSIONS

Diagnostic codes in health records may not identify a substantial proportion of drug overdoses. A health record diagnosis of substance use disorder may offer a stronger inference regarding the size of the population at risk. Alternatively, screening for self-reported overdose in routine clinical care could enhance overdose surveillance and targeted intervention.

SCIENTIFIC SIGNIFICANCE

This study suggests that diagnostic codes for overdose are insensitive. These findings support consideration of alternative approaches to overdose surveillance in public health.

COVID-19 Mortality Rates in Los Angeles County Among People Experiencing Homelessness, March 2020-February 2021

OBJECTIVE

Understanding COVID-19-related mortality among the large population of people experiencing homelessness (PEH) in Los Angeles County (LA County) may inform public health policies to protect this vulnerable group. We investigated the impact of COVID-19 on PEH compared with the general population in LA County.

METHODS

We calculated crude COVID-19 mortality rates per 100 000 population and mortality rates adjusted for age, race, and sex/gender among PEH and compared them with the general population in LA County from March 1, 2020, through February 28, 2021.

RESULTS

Among adults aged ≥18 years, the crude mortality rate per 100 000 population among PEH was 20% higher than among the general LA County population (348.7 vs 287.6). After adjusting for age, the mortality rate among PEH was 570.7 per 100 000 population. PEH had nearly twice the risk of dying from COVID-19 as people in the general LA County population; PEH aged 18-29 years had almost 8 times the risk of dying compared with their peers in the general LA County population. PEH had a higher risk of mortality than the general population after adjusting for race (standardized mortality ratio [SMR] = 1.4; 95% CI, 1.2-1.6) and sex/gender (SMR = 1.3; 95% CI, 1.1-1.5).

CONCLUSIONS

A higher risk of COVID-19-related death among PEH compared with the general population indicates the need for public health policies and interventions to protect this vulnerable group.

Engaging Same-Day Peer Ambassadors to Increase Coronavirus Disease 2019 Vaccination Among People Experiencing Unsheltered Homelessness in Los Angeles County: A Hybrid Feasibility-Evaluation Study

BACKGROUND

This study aimed to evaluate the feasibility and acceptability of engaging unhoused peer ambassadors (PAs) in coronavirus disease 2019 (COVID-19) vaccination efforts to reach people experiencing unsheltered homelessness in Los Angeles County.

METHODS

From August to December 2021, vaccinated PAs aged ≥18 years who could provide informed consent were recruited during vaccination events for same-day participation. Events were held at encampments, service providers (eg, housing agencies, food lines, and mobile showers), and roving locations around Los Angeles. PAs were asked to join outreach alongside community health workers and shared their experience getting vaccinated, receiving a $25 gift card for each hour they participated. Postevent surveys evaluated how many PAs enrolled and how long they participated. In October 2021, we added a preliminary effectiveness evaluation of how many additional vaccinations were attributable to PAs. Staff who enrolled the PAs estimated the number of additional people vaccinated because of talking with the PA.

RESULTS

A total of 117 PAs were enrolled at 103 events, participating for an average of 2 hours. At events with the effectiveness evaluation, 197 additional people were vaccinated over 167 PA hours ($21.19 gift card cost per additional person vaccinated), accounting for >25% of all vaccines given at these events.

DISCUSSION

Recruiting same-day unhoused PAs is a feasible, acceptable, and preliminarily effective technique to increase COVID-19 vaccination in unsheltered settings. The findings can inform delivery of other health services for people experiencing homelessness.

Development and Validation of Machine Models Using Natural Language Processing to Classify Substances Involved in Overdose Deaths

IMPORTANCE

Overdose is one of the leading causes of death in the US; however, surveillance data lag considerably from medical examiner determination of the death to reporting in national surveillance reports.

OBJECTIVE

To automate the classification of deaths related to substances in medical examiner data using natural language processing (NLP) and machine learning (ML).

DESIGN, SETTING, AND PARTICIPANTS

Diagnostic study comparing different natural language processing and machine learning algorithms to identify substances related to overdose in 10 health jurisdictions in the US from January 1, 2020, to December 31, 2020. Unstructured text from 35 433 medical examiner and coroners' death records was examined.

EXPOSURES

Text from each case was manually classified to a substance that was related to the death. Three feature representation methods were used and compared: text frequency-inverse document frequency (TF-IDF), global vectors for word representations (GloVe), and concept unique identifier (CUI) embeddings. Several ML algorithms were trained and best models were selected based on F-scores. The best models were tested on a hold-out test set and results were reported with 95% CIs.

MAIN OUTCOMES AND MEASURES

Text data from death certificates were classified as any opioid, fentanyl, alcohol, cocaine, methamphetamine, heroin, prescription opioid, and an aggregate of other substances. Diagnostic metrics and 95% CIs were calculated for each combination of feature extraction method and machine learning classifier.

RESULTS

Of 35 433 death records analyzed (decedent median age, 58 years [IQR, 41-72 years]; 24 449 [69%] were male), the most common substances related to deaths included any opioid (5739 [16%]), fentanyl (4758 [13%]), alcohol (2866 [8%]), cocaine (2247 [6%]), methamphetamine (1876 [5%]), heroin (1613 [5%]), prescription opioids (1197 [3%]), and any benzodiazepine (1076 [3%]). The CUI embeddings had similar or better diagnostic metrics compared with word embeddings and TF-IDF for all substances except alcohol. ML classifiers had perfect or near perfect performance in classifying deaths related to any opioids, heroin, fentanyl, prescription opioids, methamphetamine, cocaine, and alcohol. Classification of benzodiazepines was suboptimal using all 3 feature extraction methods.

CONCLUSIONS AND RELEVANCE

In this diagnostic study, NLP/ML algorithms demonstrated excellent diagnostic performance at classifying substances related to overdoses. These algorithms should be integrated into workflows to decrease the lag time in reporting overdose surveillance data.

Community Health Worker Perspectives on Engaging Unhoused Peer Ambassadors for COVID-19 Vaccine Outreach in Homeless Encampments and Shelters

BACKGROUND

COVID-19 vaccination is a priority for people experiencing homelessness. However, there are barriers to vaccine access driven in part by mistrust towards clinicians and healthcare. Community health workers (CHWs) and Peer Ambassadors (PAs) may be able to overcome mistrust in COVID-19 vaccine outreach. An unhoused PA program for COVID-19 vaccine outreach by CHWs was implemented in Los Angeles using a participatory academic-community partnership.

OBJECTIVE

The purpose of this study was to evaluate CHW perspectives on an unhoused PA COVID-19 vaccine outreach program in Los Angeles.

DESIGN

This study used a participatory community conference and qualitative focus groups to understand CHW perspectives on the PA program. The one-day conference was held in November 2021.

PARTICIPANTS

Of the 42 conference participants, 19 CHWs participated in focus groups for two-way knowledge exchange between CHWs and researchers.

APPROACH

Four focus groups were held during the conference, with 4-6 CHWs per group. Each group had a facilitator and two notetakers. Focus group notes were then analyzed using content analysis to derive categories of findings. CHWs reviewed the qualitative analysis to ensure that findings represented their experiences with the PA program.

KEY RESULTS

The five categories of findings from focus groups were as follows: (1) PAs were effective liaisons to their peers to promote COVID-19 vaccines; (2) CHWs recognized the importance of establishing genuine trust and equitable working relationships within CHW/PA teams; (3) there were tradeoffs of integrating unhoused PAs into the existing CHW workflow; (4) CHWs had initial misgivings about the research process; and (5) there were lingering questions about the ethics of "exploiting" the invaluable trust unhoused PAs have with unhoused communities.

CONCLUSIONS

CHWs were in a unique position to empower unhoused PAs to take a leadership role in reaching their peers with COVID-19 vaccines and advocate for long-term employment and housing needs.

COVID-19 Vaccine Acceptability and Financial Incentives among Unhoused People in Los Angeles County: a Three-Stage Field Survey

Unhoused people have higher COVID-19 mortality and lower vaccine uptake than housed community members. Understanding vaccine hesitancy among unhoused people is key for developing programs that address their unique needs. A three-round, rapid, field-based survey was conducted to describe attitudes toward COVID-19 vaccination. Round 1 assessed vaccine brand preference, round 2 assessed intention to accept a financial incentive for vaccination, and round 3 measured vaccine uptake and assessed reasons for vaccine readiness during implementation of a financial incentive program. A total of 5177 individuals were approached at COVID-19 vaccination events for unhoused people in Los Angeles County from May through November 2021. Analyses included 4949 individuals: 3636 (73.5%) unsheltered and 1313 (26.5%) sheltered. Per self-report, 2008 (40.6%) were already vaccinated, 1732 (35%) wanted to get vaccinated, 359 (7.3%) were not yet ready, and 850 (17.2%) did not want to get vaccinated. Brand preference was evenly split among participants (Moderna 31.0%, J&J 35.5%, either 33.5%, p = 0.74). Interest in a financial incentive differed between those who were not yet ready and those who did not want to get vaccinated (43.2% vs. 16.2%, p < 0.01). After implementing a financial incentive program, 97.4% of participants who indicated interest in vaccination were vaccinated that day; the financial incentive was the most cited reason for vaccine readiness (n = 731, 56%). This study demonstrated the utility of an iterative, field-based assessment for program implementation during the rapidly evolving pandemic. Personal engagement, a variety of brand choices, and financial incentives could be important for improving vaccine uptake among unhoused people.

Trends in Drug Overdose Deaths Among US Adolescents, January 2010 to June 2021

This study assesses trends in drug overdose deaths among US adolescents aged 14 to 18 years from January 2010 to June 2021, by substance type and race and ethnicity, using data from the Centers for Disease Control and Prevention WONDER database.

Proportion of U.S. Clinics Offering LGBT-Tailored Mental Health Services Decreased Over Time: A Panel Study of the National Mental Health Services Survey

Our objective was to characterize the proportion of U.S. mental health clinics that offered LGBT-tailored mental health services between 2014 and 2018. We used data from the National Mental Health Services Survey (NMHSS) to construct a mixed logistic model of availability of LGBT-tailored mental health services over time, by region (Northeast, South, Midwest and West), and by facility type (Veterans Administration, inpatient/residential, outpatient, community mental health centers and mixed). Our results show that the overall proportion of mental health clinics that offered LGBT-tailored services decreased from 2014 to 2018. Our results also indicate that Veteran Affairs clinics and facilities in the West and Northeast were most likely to offer LGBT-tailored mental health services. Given the temporal, regional, and facility gaps in LGBT-tailored mental health services availability, more effort should be dedicated to addressing this disparity.

Elevated Mortality Among People Experiencing Homelessness With COVID-19

We reviewed publicly available data from major US health jurisdictions to compare severe acute respiratory syndrome coronavirus 2 case fatality rates in people experiencing homelessness with the general population. The case fatality rate among people experiencing homelessness was 1.3 times (95% CI, 1.1-1.5) that of the general population, suggesting that people experiencing homelessness should be prioritized for vaccination.

Comparative impact of methamphetamine and other drug use on viral suppression among sexual minority men on antiretroviral therapy

BACKGROUND

Substance use decreases the likelihood of achieving undetectable HIV viremia; however, the comparative effects by drug have not been fully described. In this study, we compare the effects of methamphetamine use versus other drugs on viremia in sexual minority men on antiretroviral therapy (ART).

METHODS

HIV-positive participants currently on ART (N = 230) were selected from an ongoing cohort of diverse young sexual minority men (mSTUDY) enrolled from August 2014 to May 2018. Substance use and sociodemographic factors associated with viremia outcomes were assessed using ordinal regression analysis with generalized estimating equations. Viremia outcomes were grouped as undetectable (<20 copies/mL), low level suppressed (21-200 copies/mL), or not suppressed (>200 copies/mL).

RESULTS

The prevalence of drug use across 825 study visits was 73 %, with methamphetamine use most prevalent (50 %). After adjusting for unstable housing and ART adherence, methamphetamine use, either alone (adjusted OR = 1.87; 95 % CI 1.03-3.40) or with other drugs (adjusted OR = 1.82; 95 % CI 1.12-2.95), was associated with higher odds of increasing viremia compared to no drug use. Other drug use excluding methamphetamine did not show a similar association (adjusted OR = 1.29; 95 % CI 0.80-2.09). Among our study population, nearly half the instances of viremia could be reduced if methamphetamine was discontinued (attributable fraction = 46 %; 95 % CI 3-71 %).

CONCLUSIONS

Methamphetamine use, either alone or in combination with other drugs, is associated with failure of viral suppression among sexual minority men on ART independent of adherence and sociodemographic factors. This accounts for nearly half of the observed instances of unsuppressed viremia in this study.

Steep increases in fentanyl-related mortality west of the Mississippi River: Recent evidence from county and state surveillance

BACKGROUND

Overdose deaths from synthetic opioids (e.g., fentanyl) increased 10-fold in the United States from 2013 to 2018, despite such opioids being rare in illicit drug markets west of the Mississippi River. Public health professionals have feared a "fentanyl breakthrough" in western U.S. drug markets could further accelerate overdose mortality. We evaluated the number and nature of western U.S. fentanyl deaths using the most recent data available.

METHODS

We systematically searched jurisdictions west of the Mississippi River for publicly available data on fentanyl-related deaths since 2018, the most recent Centers for Disease Control and Prevention (CDC) statistics. Using mortality data from 2019 and 2020, we identified changes in fentanyl-related mortality rate and proportion of fatal heroin-, stimulant, and prescription pill overdoses involving fentanyl.

RESULTS

Seven jurisdictions had publicly available fentanyl death data through December 2019 or later: Arizona; California; Denver County, CO; Harris County, TX; King County, WA; Los Angeles County, CA; and Dallas-Fort Worth, TX (Denton, Johnson, Parker, and Tarrant counties). All reported increased fentanyl deaths over the study period. Their collective contribution to national synthetic narcotics mortality increased 371 % from 2017 to 2019. Available 2020 data shows a 63 % growth in fentanyl-mortality over 2019. Fentanyl-involvement in heroin, stimulant, and prescription pill deaths has substantially grown.

DISCUSSION

Fentanyl has spread westward, increasing deaths in the short-term and threatening to dramatically worsen the nation's already severe opioid epidemic in the long-term. Increasing the standard dose of naloxone, expanding Medicaid, improving coverage of addiction treatment, and public health educational campaigns should be prioritized.

Structural, Dosing, and Risk Change Factors Affecting Discontinuation of Pre-exposure Prophylaxis (PrEP) in a Large Urban Clinic

Understanding why clients stop taking pre-exposure prophylaxis (PrEP) is critical to improve PrEP delivery and ultimately reduce HIV incidence. We analyzed data from a programmatic evaluation conducted at the Los Angeles LGBT Center from February to May 2018. Of 180 respondents to the emailed survey, 91 had stopped taking PrEP and 11 never started. Among former PrEP users, most common reasons for stopping were entering a monogamous relationship (43%) and side effects (40%). Ten of 11 who never started PrEP reported access barriers (e.g., cost, insurance problems). A quarter of inactive clients re-engaged with PrEP services following the survey and 15% restarted PrEP by October 2018. Improving PrEP retention may require multifaceted interventions-e.g., tailored discussions about stopping and restarting PrEP safely as HIV risk changes, ensuring consistent access to affordable PrEP, and alternative dosing strategies. An emailed survey may be a simple, effective strategy to reengage some PrEP clients.

Physical and Sexual Violence Among Gay, Lesbian, Bisexual, and Questioning Adolescents

This cross-sectional study uses data from the National Youth Risk Behavior Surveys to quantify the risks of physical and sexual violence faced by sexual minority adolescents in the United States from 2014 to 2017.

Association of State Policies Allowing Medical Cannabis for Opioid Use Disorder With Dispensary Marketing for This Indication

IMPORTANCE

Misinformation about cannabis and opioid use disorder (OUD) may increase morbidity and mortality if it leads individuals with OUD to forego evidence-based treatment. It has not been systematically evaluated whether officially designating OUD as a qualifying condition for medical cannabis is associated with cannabis dispensaries suggesting cannabis as a treatment for OUD.

OBJECTIVE

To examine whether state-level policies designating OUD a qualifying condition for medical cannabis are associated with more dispensaries claiming cannabis can treat OUD.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional, mixed-methods study of 208 medical dispensary brands was conducted in 2019 using the brands' online content. The study included dispensaries operating in New Jersey, New York, and Pennsylvania, where OUD is a qualifying condition for medical cannabis, and in Connecticut, Delaware, Maryland, Ohio, and West Virginia, where this policy does not exist.

EXPOSURES

Presence of OUD on the list of qualifying conditions for a state's medical cannabis program.

MAIN OUTCOMES AND MEASURES

Binary indicators of whether online content from the brand said cannabis can treat OUD, can replace US Food and Drug Administration-approved medications for OUD, can be an adjunctive therapy to Food and Drug Administration-approved medications for OUD, or can be used as a substitute for opioids to treat other conditions (eg, chronic pain).

RESULTS

After excluding duplicates, listings for nonexistent dispensaries, and those without online content, 167 brands across 7 states were included in the analysis (44 [26.3%] in states where OUD was a qualifying condition and 123 [73.7%] in adjacent states). A dispensary listed in a directory for West Virginia was not operational; therefore, comparison states were Connecticut, Delaware, Maryland, and Ohio. In policy-exposed states, 39% (95% CI, 23%-55%) more dispensaries claimed cannabis could treat OUD compared with unexposed states (P < .001). For replacing medications for OUD and being an adjunctive therapy, the differences were 14% (95% CI, 2%-26%; P = .002) and 28% (95% CI, 14%-42%; P < .001), respectively. The suggestion that cannabis could substitute for opioids (eg, to treat chronic pain) was made by 25% (95% CI, 9%-41%) more brands in policy-exposed states than adjacent states (P = .002).

CONCLUSIONS AND RELEVANCE

In this study, state-level policies designating OUD as a qualifying condition for medical cannabis were associated with more dispensaries claiming cannabis can treat OUD. In the current policy environment, in which medical claims by cannabis dispensaries are largely unregulated, these advertisements could harm patients. Future research linking these policies to patient outcomes is warranted.

Commentary on Larance et al. (2020): Priorities and concerns of people who use opioids are key to scaling up XR-buprenorphine

Larence et al.’s findings have key implications for XR-buprenorphine guidelines as it becomes available internationally. These are to embrace less-onerous dosing schedules, to consider incorporating into standard-of-care an option to supplement with transmucosal buprenorphine between injections, and to investigate what possibilities XR-buprenorphine opens up for patients wanting to taper off opioid agonist treatment.

Debunking Cannabidiol as a Treatment for COVID-19: Time for the FDA to Adopt a Focused Deterrence Model?

Many cannabidiol (CBD) retailers make unsupported medical claims about their product. In recent years, the U.S. Food and Drug Administration (FDA) has sent warning letters to CBD retailers who promoted CBD to treat Alzheimer’s disease, cancer, diabetes, and other serious conditions for which there is no evidence of its efficacy as a treatment or preventive. Compliance with these warning letters has been low. During the novel coronavirus disease 2019 (COVID-19) pandemic, the FDA has begun sending more strongly worded warning letters that appear to have better compliance in that most of these companies have removed COVID-19-related claims. However, many continue to present other unsupported medical claims on other serious medical conditions like cancer, depression, addiction, and bone fractures, among many others. We argue that adopting a strategy of focused deterrence where the FDA prioritizes enforcement related to COVID-19 claims - but when COVID-19-related claims are found, pursues all other violations by that company - would present an opportunity to efficiently cut down on harmful claims overstating CBD’s benefits.

Age at first HIV test for MSM at a community health clinic in Los Angeles

Young MSM, especially ethnic and racial minority young MSM, bear a disproportionate burden of new HIV infections. This group also has the highest rates of undiagnosed infection and lowest rates of viral suppression. Previous research indicates that young MSM are testing for HIV too late, which may explain why rates of new HIV infection are rising in young Hispanic MSM and not falling in young Black and White MSM despite advances in preventive medications. Analysis of our sample showed an overall average age at first HIV test of approximately 26. The average age at first HIV test was 25.5 years for Black/African American individuals, 24.7 years for Hispanic individuals, and 28 years for White individuals. More testing resources and innovative outreach methods are needed to increase rates of testing among young MSM.

Using Sexual Orientation and Gender Identity to Monitor Disparities in HIV, Sexually Transmitted Infections, and Viral Hepatitis

OBJECTIVES

To quantify sexual orientation and gender identity (SOGI) disparities in incidence of HIV, other sexually transmitted infections (STIs), and viral hepatitis.

METHODS

We performed a records-based study of 19 933 patients visiting a federally qualified health center in Los Angeles, California, between November 2016 and October 2017 that examined HIV, STIs, and viral hepatitis incidence proportions. We created multivariable logistic regression models to examine the association between incidence proportions and SOGI among people living with HIV and HIV-negative patients.

RESULTS

Among those who were HIV-negative at baseline (n = 16 757), 29% tested positive for any STI during the study period, compared with 38% of people living with HIV. Stratified by birth sex, STI positivity was 32% among men and 11% among women. By SOGI, STI positivity was 35% among gay and bisexual cisgender men, 15% among heterosexual cisgender men, 11% among cisgender women, 25% among transgender women, 13% among gay and bisexual transgender men, 3% among heterosexual transgender men, and 26% among nonbinary people.

CONCLUSIONS

Stratifying by SOGI highlighted disparities that are obscured when stratifying by birth sex. Public Health Implications. To monitor and reduce disparities, health jurisdictions should include SOGI data with infectious disease reporting.

The relationship of Medicaid expansion to psychiatric comorbidity care within substance use disorder treatment programs

BACKGROUND

Co-occurring mental health disorders are common among substance use disorder (SUD) patients. Medicaid expansion aimed to reduce barriers to SUD and mental health care and thereby improve treatment outcomes.

METHODS

We estimated change in the proportion of United States SUD treatment sites offering treatment for psychiatric comorbidities following Medicaid expansion as part of implementation of the Affordable Care Act (ACA) in 2014. Using panel data from the 2013-2014, n = 660, and 2016-2017, n = 638, waves of the National Drug Abuse Treatment System Survey (NDATSS), we estimated change in the proportion of sites offering antidepressant medication, other psychiatric medication, behavioral treatment, or any combination thereof for treatment of mental health comorbidities (i.e., beyond services focused on SUD). We modeled the impact of Medicaid expansion as an interaction between year and date of Medicaid expansion. We constructed a mixed-effects linear regression model for each outcome, with the interaction variable as the main exposure, site as a random effect, and site's average duration of treatment, proportion of clients with psychiatric comorbidities, average caseload per treatment prescribing-clinician on staff, type of facility and geographic region as covariates, to estimate a difference-in-differences (D-I-D) equation.

RESULTS

The adjusted D-I-D analysis indicated that the proportion of SUD treatment sites offering antidepressants for psychiatric treatment increased 10% (95% CI 1%, 18%) in the Medicaid expansion sites compared to non-expansion sites. The D-I-D for other psychiatric medications was also 10% (95% 1%, 19%). No significant changes were observed in behavioral treatment or the combination measure. The strongest association between Medicaid expansion and offering medication for mental health comorbidities was the 34% increase observed for residential treatment settings (95% CI 10%, 59%).

CONCLUSION

Availability of psychiatric medication treatment in SUD treatment settings increased following Medicaid expansion, particularly in residential SUD facilities. This policy change has facilitated integrated treatment for the substantial share of SUD treatment patients with mental health comorbidities, with the greatest benefit for patients receiving SUD treatment in residential programs.

HIV Research for Prevention 2018: From Research to Impact Conference Summary and Highlights

The HIV Research for Prevention (HIVR4P) conference is dedicated to advancing HIV prevention research, responding to a growing consensus that effective and durable prevention will require a combination of approaches as well as unprecedented collaboration among scientists, practitioners, and community workers from different fields and geographic areas. The conference theme in 2018, "From Research to Impact," acknowledged an increasing focus on translation of promising research findings into practical, accessible, and affordable HIV prevention options for those who need them worldwide. HIVR4P 2018 was held in Madrid, Spain, on 21-25 October, with >1,400 participants from 52 countries around the globe, representing all aspects of HIV prevention research and implementation. The program included 137 oral and 610 poster presentations. This article presents a brief summary of highlights from the conference. More detailed information, complete abstracts as well as webcasts and daily Rapporteur summaries may be found on the conference website.

Accuracy of Presumptive Gonorrhea Treatment for Gay, Bisexual, and Other Men Who Have Sex with Men: Results from a Large Sexual Health Clinic in Los Angeles, California

PURPOSE

This study analyzed the accuracy of presumptive gonorrhea treatment in a sexual health clinic serving primarily gay, bisexual, and other men who have sex with men (MSM). Treating suspected gonorrhea before laboratory confirmation can reduce symptoms and transmission; however, this strategy can overtreat uninfected individuals, which may promote antimicrobial resistance. We identified differences in accuracy of gonorrhea presumptive treatment by site of infection and presence of signs or symptoms.

METHODS

We conducted a cross-sectional study of gay, bisexual, and other MSM who were treated presumptively for gonorrhea at the Los Angeles LGBT Center between February and July 2015. We calculated positivity of treated patients, proportion of infections treated, and positive predictive value (PPV) of treating gonorrhea presumptively based on signs, symptoms, or exposure at the urethral, rectal, or pharyngeal site.

RESULTS

Of 9141 testing visits, presumptive treatment was provided at 1677 (18%). Overall, gonococcal infections were identified at 31% (n = 527) of visits where presumptive treatment was provided, compared to 9% (n = 657) of visits without presumptive treatment (P < 0.01). Forty-five percent of gonococcal infections were treated presumptively, and treatment was provided at 14% of gonorrhea-negative visits. Seventy-eight percent of urethral, 54% of rectal, and 35% of pharyngeal infections were treated presumptively. PPV was highest for genitourinary signs.

CONCLUSION

Approximately one-third of gay, bisexual, or other MSM treated presumptively for gonorrhea at a sexual health clinic tested positive for gonorrhea. These findings highlight the potential contribution of point-of-care tests in reducing overtreatment resulting from presumptive treatment.

Six policy lessons relevant to cannabis legalization

Background: Cannabis (marijuana) has been legalized for recreational and/or medicinal use in many US states, despite remaining a Schedule-I drug at the federal level. As legalization regimes are established in multiple countries, public health professionals should leverage decades of knowledge from other policy areas (e.g., alcohol and tobacco regulation) to inform cannabis policy.Objectives: Identify policy lessons from other more established policy areas that can inform cannabis policy in the United States, Canada, and any other nations that legalize recreational cannabis.Methods: Narrative review of policy and public health literature.Results: We identified six key lessons to guide cannabis policy. To avoid the harms of "a medical system only in name," medical cannabis programs should either be regulated like medicine or combined with the recreational market. Capping potency of cannabis products can reduce the harms of the drug, including addiction. Pricing policies that promote public health may include minimum unit pricing or taxation by weight. Protecting science and public health from corporate interest can prevent the scenarios we have seen with soda and tobacco lobbies funding studies to report favorable results about their products. Legalizing states can go beyond reducing possession arrests (which can be accomplished without legalization) by expunging prior criminal records of cannabis-related convictions. Finally, facilitating rigorous research can differentiate truth from positive and negative hype about cannabis' effects.Conclusion: Scientists and policymakers can learn from the successes and failures of alcohol and tobacco policy to regulate cannabis products, thereby mitigating old harms of cannabis prohibition while reducing new harms from legalization.

HIV Preexposure Prophylaxis Initiation at a Large Community Clinic: Differences Between Eligibility, Awareness, and Uptake

OBJECTIVES

To characterize uptake of HIV preexposure prophylaxis (PrEP) in a community setting and to identify disparities in PrEP use by demographic and behavioral factors associated with increased HIV risk.

METHODS

We conducted a cross-sectional study of 19 587 men who have sex with men and transgender people visiting a Los Angeles, California, clinic specializing in lesbian, gay, bisexual, and transgender care between August 2015 and February 2018 by using clinical care data.

RESULTS

Seventy percent of patients met PrEP eligibility criteria, while 10% reported PrEP use. Using sex drugs, reporting both condomless anal intercourse and recent sexually transmitted infection, older age, and higher education level were associated with higher odds of PrEP use given eligibility. Latino or Asian race/ethnicity and bisexual orientation were associated with lower odds of PrEP use given eligibility. Higher odds of perceived need were associated with demographic risk factors but PrEP use was not similarly elevated.

CONCLUSIONS

Discrepancies between PrEP eligibility, perceived need, and use reveal opportunities to improve PrEP delivery in community settings. Public Health Implications. Efforts are needed to facilitate PrEP uptake in populations with highest HIV incidence.

App-Based Sexual Partner Seeking and Sexually Transmitted Infection Outcomes: A Cross-Sectional Study of HIV-Negative Men Who Have Sex With Men Attending a Sexually Transmitted Infection Clinic in Los Angeles, California

BACKGROUND

Gay, bisexual, and other men who have sex with men (MSM) face higher rates of sexually transmitted infections (STIs) compared with the general population. The association between venues where sexual partners are met and STI transmission is dynamic and poorly understood, especially among those who use geosocial networking (GSN) apps. This study aimed to determine whether there is a difference in STI incidence between MSM who met their last sexual partner through a GSN app and MSM who met their last partner via other venues.

METHODS

Data were analyzed from HIV-negative MSM attending the Los Angeles LBGT Center between August 2015 and July 2016 (n = 9499). Logistic regression models were used to investigate the relationship between STI incidence and whether or not an individual met his last partner through a GSN app.

RESULTS

No relationship was detected between STI incidence and whether one's last sexual partner was met via GSN app. However, an association was detected between STI incidence and having used GSN apps to meet sexual partners in the past 3 months. A dose-response relationship was observed between the number of venues used to meet partners and testing positive for any STI (adjusted odds ratio, 1.08; 95% confidence interval, 1.02-1.14).

CONCLUSIONS

The relationship between how people meet sexual partners and STI acquisition is much more nuanced than previously thought. Geosocial networking apps do not inherently expose users to high-risk reservoirs of STIs, but further understanding of the complexity of sexual networks and networking methods is warranted, given increasing rates of STIs.

Tobacco-Free Policies and Tobacco Cessation Systems at Health Centers Serving Lesbian, Gay, Bisexual, and Transgender Clients

PURPOSE

LGBT populations have high rates of tobacco use. Health centers serving LGBT clients are an important source of care. The researchers aimed to assess the implementation of recommended systems-level tobacco cessation interventions at these health centers.

METHODS

Using systematic searching, directories, and expert review, we identified health centers serving LGBT clients that provide primary care. We conducted phone-based, semi-structured interviews with administrators (n = 11) between September 2016 and March 2017 regarding implementation of the Clinical Practice Guideline, Treating Tobacco Use and Dependence: 2008 Update (the Guideline). Two authors confirmed saturation and two authors conducted thematic coding.

RESULTS

Eight themes were identified, including clear evidence of systems-level procedures for asking about, advising on, and assessing tobacco use. Interviewees viewed tobacco use as important given existing disparities. However, there was room for improvement in the following areas: (1) Education for staff on tobacco cessation was ad hoc and not formalized; (2) materials and resources for tobacco cessation available in the center varied widely and changed when a staff champion arrived or left; (3) no point person was assigned to coordinate tobacco cessation efforts; and, (4) assessment of tobacco use as a vital sign is not consistent-some centers met meaningful use quality metrics (e.g., once or more in the past 24 months) instead of the Guideline recommendation (every visit). Addressing tobacco use competes with addressing other health risk behaviors.

CONCLUSIONS

Administrators at health centers serving LGBT clients viewed tobacco use as an important issue. However, there was room for improvement in implementation of systems recommended in the Guideline. Targeted outreach is warranted to improve standardization of implementation and promote cessation of tobacco use.

Does HIV pre-exposure prophylaxis use lead to a higher incidence of sexually transmitted infections? A case-crossover study of men who have sex with men in Los Angeles, California

BACKGROUND

Pre-exposure prophylaxis (PrEP) is an effective method for reducing HIV incidence among at-risk populations. However, concerns exist over the potential for an increase in STIs following PrEP initiation. The objective of this study is to compare the STI incidence before and after PrEP initiation within subjects among a cohort of men who have sex with men in Los Angeles, California.

METHODS

The present study used data from patients who initiated PrEP services at the Los Angeles LGBT Center between October 2015 and October 2016 (n=275). A generalised linear mixed model was used with a case-crossover design to determine if there was a significant difference in STIs within subjects 365 days before (before-PrEP period) and 365 days after PrEP initiation (after-PrEP period).

RESULTS

In a generalised linear mixed model, there were no significant differences in urethral gonorrhoea (P=0.95), rectal gonorrhoea (P=0.33), pharyngeal gonorrhoea (P=0.65) or urethral chlamydia (P=0.71) between periods. There were modest increases in rectal chlamydia (rate ratio (RR) 1.83; 95% CI 1.13 to 2.98; P=0.01) and syphilis diagnoses (RR 2.97; 95% CI 1.23 to 7.18; P=0.02).

CONCLUSIONS

There were significant increases in rectal chlamydia and syphilis diagnoses when comparing the periods directly before and after PrEP initiation. However, only 28% of individuals had an increase in STIs between periods. Although risk compensation appears to be present for a segment of PrEP users, the majority of individuals either maintain or decrease their sexual risk following PrEP initiation.

Are Partner Race and Intimate Partner Violence Associated with Incident and Newly Diagnosed HIV Infection in African-American Men Who Have Sex with Men?

Black gay, bisexual, and other men who have sex with men (BMSM) experience a disparate rate of HIV infections among MSM. Previous analyses have determined that STI coinfection and undiagnosed HIV infection partly explain the disparity. However, few studies have analyzed the impact of partner-level variables on HIV incidence among BMSM. Data were analyzed for BMSM who attended the Los Angeles LGBT Center from August 2011 to July 2015 (n = 1974) to identify risk factors for HIV infection. A multivariable logistic regression was used to analyze predictors for HIV prevalence among all individuals at first test (n = 1974; entire sample). A multivariable survival analysis was used to analyze predictors for HIV incidence (n = 936; repeat tester subset). Condomless receptive anal intercourse at last sex, number of sexual partners in the last 30 days, and intimate partner violence (IPV) were significant partner-level predictors of HIV prevalence and incidence. Individuals who reported IPV had 2.39 times higher odds (CI 1.35-4.23) and 3.33 times higher hazard (CI 1.47-7.55) of seroconverting in the prevalence and incidence models, respectively. Reporting Black partners only was associated with increased HIV prevalence, but a statistically significant association was not found with incidence. IPV is an important correlate of both HIV prevalence and incidence in BMSM. Further studies should explore how IPV affects HIV risk trajectories among BMSM. Given that individuals with IPV history may struggle to negotiate safer sex, IPV also warrants consideration as a qualifying criterion among BMSM for pre-exposure prophylaxis (PrEP).

Concordance between self-reported STI history and biomedical results among men who have sex with men in Los Angeles, California

OBJECTIVES

HIV studies and risk assessments among men who have sex with men (MSM) frequently use self-reported STI history as a proxy for true STI history. The objective of our study was to assess the validity of self-reported STI history through comparison with laboratory-confirmed biomedical results.

METHODS

Data were analysed for MSM attending the Los Angeles LGBT Center (the Center) from August 2011 to July 2015. We identified 10 529 unique MSM who received testing for chlamydia, gonorrhoea and/or syphilis and had a later visit in which they self-reported their STI history to a clinic counsellor during a risk assessment.

RESULTS

MSM who had an STI in the past year self-reported their STI history with 51%-56% accuracy, and MSM who had an STI more than a year ago self-reported their STI history with 65%-72% accuracy. Among MSM with any positive STIs at the Center, black/African-American and Hispanic MSM were more likely to inaccurately self-report their positive results for gonorrhoea (adjusted OR (aOR): 1.48, 95% CI 1.09 to 2.01; aOR: 1.39, 95% CI 1.14 to 1.70). Additionally, HIV-positive MSM were more likely to inaccurately self-report their positive results for gonorrhoea (aOR: 1.63, 95% CI 1.22 to 2.18) and/or syphilis (aOR: 2.19, 95% CI 1.08 to 4.47).

CONCLUSIONS

This is the first study that attempts to evaluate the validity of self-reported STI history among MSM. We found that self-reported STI history may not be an appropriate proxy for true STI history in certain settings and minority populations. Clinical guidelines and research studies that rely on self-reported STI history will need to modify their recommendations in light of the limited validity of these data.