Associations of discomfort intolerance, discomfort avoidance, and cannabis and alcohol use among persons with chronic pain receiving prescription buprenorphine for opioid use disorder.

BACKGROUND: Chronic pain and non-prescribed substance use are associated with lower retention in opioid use disorder (OUD) treatment. We examined the associations of perceived capacity to tolerate uncomfortable physical sensations (discomfort intolerance and discomfort avoidance) and cannabis and alcohol use among persons with chronic pain receiving prescription buprenorphine for OUD. METHODS: This study utilizes baseline data from 163 persons with chronic pain receiving prescription buprenorphine for OUD enrolled in the Treating Opioid use, Persistent Pain, and Sadness (TOPPS) intervention trial. We used negative-binomial regression models, adjusted for age, education, gender, race/ethnicity, pain interference, depression, generalized anxiety disorder, and average cigarettes smoked/day to estimate the associations of discomfort tolerance and discomfort avoidance with frequency of cannabis and alcohol use. RESULTS: Participants (n=163) were on average 45 years old (standard deviation=10.6) and predominantly White (86 %, n=141). Forty-one percent (n=66) used cannabis and 24 % (n=30) used alcohol use in the past 30 days. In adjusted models, discomfort intolerance was positively associated with days of cannabis use (IRR = 1.11, p =.016) and days of alcohol use (IRR = 1.14, p =.022). Discomfort avoidance was not associated with cannabis or alcohol use. CONCLUSION: Individuals with chronic pain receiving prescribed buprenorphine for treatment of OUD with lower tolerance for physical discomfort may augment pain management with cannabis and alcohol. Given the intersections between substance use and retention in care for OUD, future work should extend this preliminary work by exploring these relationships over time and in experimental settings. Clinical Trial # NCT03698669.

Structure and Antigenicity of the Porcine Astrovirus 4 Capsid Spike.

Porcine astrovirus 4 (PoAstV4) has been recently associated with respiratory disease in pigs. In order to understand the scope of PoAstV4 infections and to support the development of a vaccine to combat PoAstV4 disease in pigs, we designed and produced a recombinant PoAstV4 capsid spike protein for use as an antigen in serological assays and for potential future use as a vaccine antigen. Structural prediction of the full-length PoAstV4 capsid protein guided the design of the recombinant PoAstV4 capsid spike domain expression plasmid. The recombinant PoAstV4 capsid spike was expressed in Escherichia coli, purified by affinity and size-exclusion chromatography, and its crystal structure was determined at 1.85 Å resolution, enabling structural comparisons to other animal and human astrovirus capsid spike structures. The recombinant PoAstV4 capsid spike protein was also used as an antigen for the successful development of a serological assay to detect PoAstV4 antibodies, demonstrating that the recombinant PoAstV4 capsid spike retains antigenic epitopes found on the native PoAstV4 capsid. These studies lay a foundation for seroprevalence studies and the development of a PoAstV4 vaccine for swine.

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

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

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

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

Association of Medicaid expansion with health insurance, unmet need for medical care and substance use disorder treatment among people who inject drugs in 13 US states.

BACKGROUND AND AIMS: Impoverished people who inject drugs (PWID) are at the epicenter of US drug-related epidemics. Medicaid expansion is designed to reduce cost-related barriers to care by expanding Medicaid coverage to all US adults living at or below 138% of the federal poverty line. This study aimed to measure whether Medicaid expansion is (1) positively associated with the probability that participants are currently insured; (2) inversely related to the probability of reporting unmet need for medical care due to cost in the past year; and (3) positively associated with the probability that they report receiving substance use disorder (SUD) treatment in the past year, among PWID subsisting at ≤ 138% of the federal poverty line. DESIGN: A two-way fixed-effects model was used to analyze serial cross-sectional observational data. SETTING: Seventeen metro areas in 13 US states took part in the study. PARTICIPANTS: Participants were PWID who took part in any of the three waves (2012, 2015, 2018) of data gathered in the Center for Disease Control and Prevention's National HIV Behavioral Surveillance (NHBS), were aged ≤ 64 years and had incomes ≤ 138% of the federal poverty line. For SUD treatment analyses, the sample was further limited to PWID who used drugs daily, a proxy for SUD. MEASUREMENTS: State-level Medicaid expansion was measured using Kaiser Family Foundation data. Individual-level self-report measures were drawn from the NHBS surveys (e.g. health insurance coverage, unmet need for medical care because of its cost, SUD treatment program participation). FINDINGS: The sample for the insurance and unmet need analyses consisted of 19 946 impoverished PWID across 13 US states and 3 years. Approximately two-thirds were unhoused in the past year; 41.6% reported annual household incomes < $5000. In multivariable models, expansion was associated with a 19.0 [95% confidence interval (CI) = 9.0, 30.0] percentage-point increase in the probability of insurance coverage, and a 9.0 (95% CI = -15.0, -0.2) percentage-point reduction in the probability of unmet need. Expansion was unrelated to SUD treatment among PWID who used daily (n = 17 584). CONCLUSIONS: US Medicaid expansion may curb drug-related epidemics among impoverished people who inject drugs by increasing health insurance coverage and reducing unmet need for care. Persisting non-financial barriers may undermine expansion's impact upon substance use disorder treatment in this sample.

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

OBJECTIVES: We examined substance use hotline operator certainty of each US state and Washington, DC's endorsement of buprenorphine (initiation and continuation) prescribing via telemedicine. METHODS: Between March and May 2021, we called hotlines in 50 US states and Washington, DC, requesting information on whether practitioners in that state could initiate or continue buprenorphine treatment for opioid use disorder (OUD) via telephone or video conference. We compared operator responses to state implementation of buprenorphine telemedicine initiation. This study was designated as not human subjects research by the Boston University Institutional Review Board. RESULTS: We spoke with operators in 47 states and Washington, DC. Operators could not be reached in Alaska, California, and Montana. Most operators were uncertain (don't know, probably yes, probably no) whether the state permitted buprenorphine initiation (81%, n = 39) or continuation (83%, n = 40) via telemedicine. Practitioners could initiate buprenorphine prescribing via telemedicine in 7 states (100%) where operators were certain practitioners could initiate buprenorphine, 1 state (100%) where the operator was certain practitioners could not, and 6 states (86%) where operators indicated practitioners probably could not. CONCLUSIONS: Most US states and Washington, DC, expanded the role of telemedicine in OUD treatment. However, most operators expressed uncertainty and sometimes communicated inaccurate information regarding whether practitioners could initiate buprenorphine treatment via telemedicine. There is an urgent need for policy mandates institutionalizing the role of telemedicine, and of buprenorphine specifically, in OUD treatment and for resources to train and support substance use hotline operators in this evolving policy environment.

Structure and immunogenicity of the murine astrovirus capsid spike.

Human astroviruses (HAstVs) are small, non-enveloped icosahedral RNA viruses that are a significant cause of diarrhoea in young children. Despite their worldwide prevalence, HAstV pathogenesis studies and vaccine development remain challenging due to the lack of an animal model for HAstV infection. The recent development of a murine astrovirus (MuAstV) infection model in mice provides the opportunity to test proof-of-concept vaccines based on MuAstV antigens. To help establish a system in which an astrovirus capsid spike-based vaccine could be tested in vivo, we designed and produced a recombinant MuAstV capsid spike protein based on predicted secondary structure homology to HAstV spike proteins. The recombinant MuAstV spike can be expressed with high efficiency in Escherichia coli and retains antigenicity to polyclonal antibodies elicited by MuAstV infection. We determined the crystal structure of the MuAstV spike to 1.75 Å and assessed its structural conservation with HAstV capsid spike. Despite low sequence identity between the MuAstV and HAstV spikes and differences in their overall shapes, they share related structural folds. Additionally, we found that vaccination with MuAstV spike induced anti-MuAstV-spike antibodies, highlighting that the recombinant spike is immunogenic. These studies lay a foundation for future in vivo MuAstV challenge studies to test whether MuAstV spike can be the basis of an effective vaccine.

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

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

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

BACKGROUND: Direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) is well tolerated, cost-effective, and yields high sustained virologic response rates, yet it has remained financially inaccessible to many patients. METHODS: Participants of the Women's Interagency HIV Study (an observational US cohort) with human immunodeficiency virus (HIV) and HCV (RNA+) reporting no prior hepatitis C treatment were followed for DAA initiation (2015-2019). We estimated risk ratios (RRs) of the relationship between time-varying health insurance status and DAA initiation, adjusting for confounders with stabilized inverse probability weights. We also estimated weighted cumulative incidences of DAA initiation by health insurance status. RESULTS: A total of 139 women (74% Black) were included; at baseline, the median age was 55 years and 86% were insured. Most had annual household incomes ≤$18 000 (85%); advanced liver fibrosis (21%), alcohol use (45%), and recreational drug use (35%) were common. Across 439 subsequent semiannual visits, 88 women (63%) reported DAA initiation. Compared with no health insurance, health insurance increased the likelihood of reporting DAA initiation at a given visit (RR, 4.94; 95% confidence limit [CL], 1.92 to 12.8). At 2 years, the weighted cumulative incidence of DAA initiation was higher among the insured (51.2%; 95% CL, 43.3% to 60.6%) than the uninsured (3.5%; 95% CL, 0.8% to 14.6%). CONCLUSIONS: Accounting for clinical, behavioral, and sociodemographic factors over time, health insurance had a substantial positive effect on DAA initiation. Interventions to increase insurance coverage should be prioritized to increase HCV curative therapy uptake for persons with HIV.

Medicaid expansion and opioid overdose mortality among socioeconomically disadvantaged populations in the US: A difference in differences analysis.

BACKGROUND: Opioid-related overdoses are a major cause of mortality in the US. Medicaid Expansion is posited to reduce opioid overdose-related mortality (OORM), and may have a particularly strong effect among people of lower socioeconomic status. This study assessed the association between state Medicaid Expansion and county-level OORM rates among individuals with low educational attainment. METHODS: This quasi-experimental study used lagged multilevel difference-in-difference models to test the relationship of state Medicaid Expansion to county-level OORM rates among people with a high-school diploma or less. Longitudinal (2008-2018) OORM data on 2978 counties nested in 48 states and the District of Columbia (DC) were drawn from the National Center for Health Statistics. The state-level exposure was a time-varying binary-coded variable capturing pre- and post-Medicaid Expansion under the Affordable Care Act (an "on switch"-type variable). The main outcome was annual county-level OORM rates among low-education adults adjusted for potential underreporting of OORM. FINDINGS: The adjusted county-level OORM rates per 100,000 among the study population rose on average from 10.26 (SD = 13.56) in 2008-14.51 (SD = 18.20) in 2018. In the 1-year lagged multivariable model that controlled for policy and sociodemographic covariates, the association between state Medicaid Expansion and county-level OORM rates was statistically insignificant. CONCLUSIONS: We found no evidence that expanding Medicaid eligibility reduced OORM rates among adults with lower educational attainment. Future work should seek to corroborate our findings and also identify - and repair - breakdowns in mechanisms that should link Medicaid Expansion to reduced overdoses.

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

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

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

PURPOSE: Research examining the association between crime and health outcomes has been hampered by a lack of reliable small-area (e.g., census tract or census block group) crime data. Our objective is to assess the accuracy of synthetically estimated crime indices for use in health research by using preterm birth as a case study. METHODS: We used violent crime data reported by 47 law enforcement agencies in 15 counties in Atlanta, Georgia and compared them with commercially estimated crime rates from the same year to assess (1) how two measures of crime were correlated and (2) if the associations between violent crime rate indices and preterm birth (PTB) varied as a function of the source of crime index. To assess the association between violent crime and PTB, we used multilevel logistic regression and controlled for potential individual- and neighborhood-level confounders. RESULTS: Violent crime, both estimated and observed, was positively correlated with poverty, neighborhood proportion Black, and neighborhood deprivation index; however, the association was stronger using estimated rates as compared with observed crime rates. The association between living in a high violent crime neighborhood and PTB was only consistent for white women across the two crime indices after covariate adjustment. For Black women, the association between living in a high violent crime neighborhood and PTB is systematically underestimated across all models when the estimated crime rate is used. CONCLUSIONS: There is evidence that model-estimated crime rates are not reliable proxies for crime in an urban area even when appropriate confounders are adjusted for.

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

BACKGROUND: People with HIV are disproportionately coinfected with hepatitis C virus (HCV) and experience accelerated liver-related mortality. Direct-acting antivirals (DAAs) yield high sustained virologic response (SVR) rates, but uptake is suboptimal. This study characterizes the DAA-era HCV treatment cascade and barriers among US men and women with or at risk for HIV. METHODS: We constructed HCV treatment cascades using the Women's Interagency HIV Study (women, 6 visits, 2015-2018, n = 2447) and Multicenter AIDS Cohort Study (men, 1 visit, 2015-2018, n = 2221). Cascades included treatment-eligible individuals (ie, HCV RNA-positive or reported DAAs). Surveys captured self-reported clinical (eg, CD4), patient (eg, missed visits), system (eg, appointment access), and financial/insurance barriers. RESULTS: Of 323/92 (women/men) treatment eligible, most had HIV (77%/70%); 69%/63% were black. HIV-positive women were more likely to attain cascade outcomes than HIV-negative women (39% vs 23% initiated, 21% vs 12% SVR); similar discrepancies were noted for men. Black men and substance users were treated less often. Women initiating treatment (vs not) reported fewer patient barriers (14%/33%). Among men not treated, clinical barriers were prevalent (53%). CONCLUSIONS: HIV care may facilitate HCV treatment linkage and barrier navigation. HIV-negative individuals, black men, and substance users may need additional support. CLINICAL TRIALS REGISTRATION: NCT00000797 (Women's Interagency HIV Study); NCT00046280 (Multicenter AIDS Cohort Study).

Strategies for increasing impact, engagement, and accessibility in HIV prevention programs: suggestions from women in urban high HIV burden counties in the Eastern United States (HPTN 064).

BACKGROUND: Merely having the tools to end HIV is insufficient. Effectively ending the epidemic necessitates addressing barriers that impede engagement in biomedical and behavioral prevention and wide scale implementation and utilization of existing interventions. This qualitative study identifies suggestions for increasing access to, engagement in, and impact of HIV prevention among women living in cities in high HIV burden counties in the eastern US. METHODS: Data analyzed for the current study were collected via a qualitative sub-study within the HIV Prevention Trials Network Study 064 (HPTN 064), a multisite observational cohort study designed to estimate HIV incidence among women residing in communities with elevated HIV prevalence who also reported personal or partner characteristics associated with increased risk of HIV acquisition. Focus group and interview participants in the qualitative sub-study (N = 288) were from four cities in the eastern US. RESULTS: Thematic analyses revealed four themes describing women's most frequently stated ideas for improving prevention efforts: 1) Promote Multilevel Empowerment, 2) Create Engaging Program Content, 3) Build "Market Demand", and 4) Ensure Accessibility. We conducted additional analyses to identify contradictory patterns in the data, which revealed an additional three themes: 1) Address Structural Risk Factors, 2) Increase Engagement via Pleasure Promotion, 3) Expand Awareness of and Access to Prevention Resources. CONCLUSIONS: Findings may be useful for enhancing women's engagement in and uptake of behavioral and biomedical HIV prevention resources, improving policy, and addressing multilevel risk factors. TRIAL REGISTRATION: Clinicaltrials.gov: NCT00995176 , prospectively registered.

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

BACKGROUND: African American women bear disproportionate human immunodeficiency virus (HIV) burden in the United States, yet are often underrepresented in clinical research. Community engagement may decrease research mistrust and increase participation. We describe strategies used to engage community partners and female participants in a multisite HIV incidence study, HIV Prevention Trials Network (HPTN) 064. OBJECTIVES: HPTN 064 assessed HIV incidence among women in 10 geographic areas chosen for both high prevalence of HIV and poverty. METHODS: Women were recruited using venue-based sampling and followed for six to 12 months. Recruitment and engagement approaches aligned with the National Institutes of Health (NIH) Director's Council of Public Representatives (COPR) Community Engagement Framework's. RESULTS: Results showed engagement activities increased rapport and established new partnerships with community stakeholders. Study sites engaged 56 community organizations with 2,099 women enrolled in 14 months. Final retention was 94%. CONCLUSIONS: The COPR model maximized inclusiveness and participation of African American women impacted by HIV, supported recruitment and retention, and was the cornerstone of community engagement.

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

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

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

PURPOSE: Voting may play a critical role in the allocation of social and structural resources to communities, which in turn shapes neighborhood environments, and ultimately, an individual's sexually transmitted infection (STI) risk. We assessed relationships among county-level voter turnout and felony voter disenfranchisement, and STIs. METHODS: This cross-sectional multilevel analysis included 666 women in Alabama, Florida, Georgia, Mississippi, and North Carolina enrolled in the Women's Interagency HIV Study between 2013 and 2015. Having a baseline bacterial STI (chlamydia, gonorrhea, trichomoniasis, or early syphilis) was determined by laboratory testing. We used generalized estimating equations to test relationships between county-level voter turnout in the 2012 general election, county-level percentage of felony disenfranchised voters, and STI prevalence. RESULTS: Eleven percent of participants had an STI. Higher voter turnout corresponded to lower STI prevalence (prevalence ratio = 0.84, 95% confidence interval = 0.73-0.96 per 4 percentage point higher turnout). Greater felony voter disenfranchisement corresponded to higher STI prevalence (prevalence ratio = 1.89, 95% confidence interval = 1.10-3.24 per 4 percentage point higher disenfranchisement). CONCLUSIONS: STI prevalence was inversely associated with voter turnout and positively associated with felony voter disenfranchisement. Research should assess causality and mechanisms through which civic engagement shapes sexual health. Expanding political participation, including eliminating discriminatory voting laws, could influence sexual health.

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

BACKGROUND: Using data from HIV Prevention Trials Network 064, a multisite, observational cohort study conducted to estimate HIV incidence rates among women living in areas of high poverty and HIV prevalence in the United States, we examined the use of HIV risk characteristics to predict emotional abuse, physical violence, and forced sex. METHODS: Participants included 2099 women, 18-44 years of age, who reported unprotected vaginal or anal sex with a male partner and an additional personal or perceived male partner HIV risk characteristic in the past 6 months. Adjusting for time-varying covariates, generalized estimating equations were used to assess the ability of HIV risk characteristics to predict violence 6 months later. RESULTS: Reported analyses were limited to the 1980 study participants who reported having a male sex partner at that assessment. Exchanging sex, perceived partner concurrency, and perceived partner incarceration were significantly predictive of emotional abuse 6 months later (adjusted odds ratio [AOR]: 1.60; 1.59; 1.34, respectively). Prior sexually transmitted infection diagnosis, exchanging sex, and binge drinking were significantly predictive of physical violence 6 months later (AOR: 1.62; 1.71; 1.47, respectively). None of the variables measured was significantly predictive of forced sex. CONCLUSIONS: Strategies that address reducing violence against women should be studied further in the context of HIV prevention programs.