Design and Implementation of an Innovative, Rapid Data-Monitoring Strategy for Public Health Emergencies: Pilot of the United States School COVID-19 Mitigation Strategies Project.

During the COVID-19 pandemic, an urgent need existed for near-real-time data collection to better understand how individual beliefs and behaviors, state and local policies, and organizational practices influenced health outcomes. We describe the processes, methods, and lessons learned during the development and pilot testing of an innovative rapid data collection process we developed to inform decision-making during the COVID-19 public health emergency. We used a fully integrated mixed-methods approach to develop a structured process for triangulating quantitative and qualitative data from traditional (cross-sectional surveys, focus groups) and nontraditional (social media listening) sources. Respondents included students, parents, teachers, and key school personnel (eg, nurses, administrators, mental health providers). During the pilot phase (February-June 2021), data from 12 cross-sectional and sector-based surveys (n = 20 302 participants), 28 crowdsourced surveys (n = 26 820 participants), 10 focus groups (n = 64 participants), and 11 social media platforms (n = 432 754 503 responses) were triangulated with other data to support COVID-19 mitigation in schools. We disseminated findings through internal dashboards, triangulation reports, and policy briefs. This pilot demonstrated that triangulating traditional and nontraditional data sources can provide rapid data about barriers and facilitators to mitigation implementation during an evolving public health emergency. Such a rapid feedback and continuous improvement model can be tailored to strengthen response efforts. This approach emphasizes the value of nimble data modernization efforts to respond in real time to public health emergencies.

Behavioral health and treatment-seeking behaviors among deployed vs. non-deployed service members: How impactful is deployment on well-being?

Increasing attention has been dedicated to studying behavioral health of non-deployed military personnel. This investigation explored the impacts of a variety of sociodemographic and health factors on key behavioral health outcomes among active duty personnel. A secondary analysis was conducted using 2014 Defense Health Agency Health Related Behaviors Survey data (unweighted n = 45,762, weighted n = 1,251,606). Three logistic regression models investigated factors associated with reporting symptomatology consistent with depression, anxiety, and stress. We found that after adjusting for sociodemographic and other health variables (e.g., sleep), deployment was associated with stress but not anxiety or depression. Although deployed personnel were more likely to report increased levels of stress overall, few differences with respect to the sources of stressors were identified. While behavioral health screening and treatment needs may differ for non-deployed and deployed personnel, programs to support mental and physical well-being among all service members should be robustly promoted.

Teamwork Is Associated with Reduced Hospital Staff Burnout at Military Treatment Facilities: Findings from the 2019 Department of Defense Patient Safety Culture Survey.

BACKGROUND: A National Academy of Medicine report emphasizes the importance of creating positive work environments to address the negative effects of burnout on health care workers. The purpose of this investigation was to determine the scope of burnout among military hospital personnel and explore the relationship between teamwork, burnout, and patient safety culture. METHODS: A logistic regression analysis investigated the relationship between teamwork and burnout using the 2019 US Department of Defense Patient Safety Culture Survey data from 15,838 military hospital workers. Additional regressions investigated teamwork/burnout relationships among individual work areas and staff positions. RESULTS: About one third of respondents (34.4%) reported experiencing burnout. Work areas most likely to report burnout included many different/other work areas (43.4%), pharmacy (41.8%), and labor and delivery/obstetrics (41.8%). Staff positions most likely to report burnout included pharmacy/pharmacists (39.7%), assistants/technicians/therapists (38.1%), and nurses/nursing (37.6%). Analysis revealed an association between lower burnout and high teamwork, both within (odds ratio [OR] 0.54, 95% confidence interval [CI] 0.48-0.60) and across (OR 0.64, 95% CI 0.57-0.72) units. Within-unit teamwork was associated with reduced odds of burnout across almost all work areas and staff positions, with the greatest odds reduction among personnel working in emergency (OR 0.25, 95% CI 0.14-0.43), radiology (OR 0.41, 95% CI 0.20-0.83), and labor and delivery/obstetrics (OR 0.42, 95% CI 0.27-0.65); and physicians/medical staff (OR = 0.44, 95% CI: 0.28-0.69), other staff positions (OR 0.48, 95% CI 0.28-0.81), and assistants/technicians/therapists (OR 0.58, 95% CI 0.46-0.73). CONCLUSION: Effective teamwork may reduce burnout in hospital workers. This association between teamwork (particularly teamwork within units) and burnout was found in all work areas, even in those with the highest levels of self-reported workplace chaos. Greater adoption of workplace interventions focused on improving teamwork, such as TeamSTEPPS, is warranted.

Teachers' dissatisfaction during the COVID-19 pandemic: Factors contributing to a desire to leave the profession.

Introduction: The COVID-19 pandemic required more responsibilities from teachers, including implementing prevention strategies, changes in school policies, and managing their own mental health, which yielded higher dissatisfaction in the field. Methods: A cross-sectional web survey was conducted among educators to collect information on their experiences teaching during the COVID-19 pandemic throughout the 2020-2021 academic year. Qualtrics, an online survey platform, fielded the survey from May 6 to June 8, 2021 to a national, convenience sample of 1,807 respondents. Results: Findings revealed that overall, 43% of K-12 teachers reported a greater intention to leave the profession than previously recalled prior to the COVID-19 pandemic. Intention to leave was multi-level, and associated with socio-demographic factors (e.g., age: AOR = 1.87, p < 0.05), individual factors (e.g., perceived COVID risks: AOR = 1.44, p < 0.05), and teachers' agency (e.g., dissatisfaction with school/district communications and decisions: AOR = 1.34, p < 0.05). We also found demographic disparities with respect to race and gender (e.g., female teachers: AOR: 1.78, p < 0.05) around teachers' ability to provide feedback to schools on opening/closing and overall dissatisfaction with school/district COVID-19 prevention strategies implementation and policies. Conclusion: These findings are consistent with the Job-Demand and Resources Model (JD-R), which posits that lack of organizational support can exacerbate job stressors, leading to burnout. Specifically, dissatisfaction with the way school policies were implemented took a toll on teachers' mental health, leading to a desire to leave the profession. These findings are also consistent with research conducted once in-person teaching resumed in 2020-2021, specifically that the COVID-19 pandemic exacerbated preexisting teacher shortages that led to self-reported issues of stress, burnout, and retention. Implications: Further research is necessary to understand the resources that may be most useful to reduce the demands of teaching in the context of the COVID-19 pandemic. Some teachers are more likely to leave the field, and educational agencies may wish to target their teacher-retention efforts with emphasis on strong employee wellness programs that help educators to manage and reduce their stress. Education agency staff may wish to review policies and practices to provide meaningful opportunities to give input to school/district decisions and enable proactive communication channels.

Loss Aversion Explains Physical Activity Changes in a Behavioral Gamification Trial.

Introduction: Loss aversion when using gamification is incompletely understood. The aim of this study was therefore to examine how participants alter their behavior vis-a-vis meeting a daily step goal based on the prospect of losing or gaining a gamification level. Methods: We enrolled 602 participants across four arms who were given pedometers. In the three experimental arms, participants began at the medium level and were allocated 70 points each week, losing 10 points each day they did not meet their step goal. Having at least 40 points at the end of the week resulted in a level increase, otherwise they lost a level. We fit a generalized estimating equation, clustered on participants, modeling step goal attainment on day 7. Our primary predictor was a categorical variable simultaneously indicating what level the participants began the week in and whether they had more than, less than, or exactly 40 points after 6 days. Results: Participants at risk of losing the highest level were 18.40% (confidence interval [95% CI]: 18.26-19.90) more likely to meet their step goal than those who had secured the highest level. Participants who could potentially move from the low to the medium level were 10.61% (95% CI: 9.98-11.24) more likely to meet their step goal than those in the Control group. Those in the Medium group were similarly more likely to achieve their step goal on day 7 (10.00%, 95% CI: 9.15-10.85) than those who had already secured an increase to the high level. Discussion: We find that participants in this trial generally exhibit loss aversion so long as the loss relates to something that was earned rather than endowed. This knowledge can be incorporated in future interventions using gamification by requiring participants to earn all levels as they progress. ClinicalTrials.gov identifier: NCT03311230.

Optimal allocation of HIV resources among geographical regions.

BACKGROUND: Health resources are limited, which means spending should be focused on the people, places and programs that matter most. Choosing the mix of programs to maximize a health outcome is termed allocative efficiency. Here, we extend the methodology of allocative efficiency to answer the question of how resources should be distributed among different geographic regions. METHODS: We describe a novel geographical optimization algorithm, which has been implemented as an extension to the Optima HIV model. This algorithm identifies an optimal funding of services and programs across regions, such as multiple countries or multiple districts within a country. The algorithm consists of three steps: (1) calibrating the model to each region, (2) determining the optimal allocation for each region across a range of different budget levels, and (3) finding the budget level in each region that minimizes the outcome (such as reducing new HIV infections and/or HIV-related deaths), subject to the constraint of fixed total budget across all regions. As a case study, we applied this method to determine an illustrative allocation of HIV program funding across three representative oblasts (regions) in Ukraine (Mykolayiv, Poltava, and Zhytomyr) to minimize the number of new HIV infections. RESULTS: Geographical optimization was found to identify solutions with better outcomes than would be possible by considering region-specific allocations alone. In the case of Ukraine, prior to optimization (i.e. with status quo spending), a total of 244,000 HIV-related disability-adjusted life years (DALYs) were estimated to occur from 2016 to 2030 across the three oblasts. With optimization within (but not between) oblasts, this was estimated to be reduced to 181,000. With geographical optimization (i.e., allowing reallocation of funds between oblasts), this was estimated to be further reduced to 173,000. CONCLUSIONS: With the increasing availability of region- and even facility-level data, geographical optimization is likely to play an increasingly important role in health economic decision making. Although the largest gains are typically due to reallocating resources to the most effective interventions, especially treatment, further gains can be achieved by optimally reallocating resources between regions. Finally, the methods described here are not restricted to geographical optimization, and can be applied to other problems where competing resources need to be allocated with constraints, such as between diseases.

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.

Plasma Tenofovir Levels to Support Adherence to TDF/FTC Preexposure Prophylaxis for HIV Prevention in MSM in Los Angeles, California.

BACKGROUND: Tenofovir disoproxil fumarate/emtricitabine preexposure prophylaxis (PrEP) is effective against HIV acquisition when taken as prescribed. Strategies that identify and intervene with those challenged by adherence to daily medication are needed. SETTING: PATH-PrEP was an open-label single-arm interventional cohort study conducted at 2 community-based clinical sites in Los Angeles, CA. METHODS: We enrolled self-identified men who have sex with men and transgender women ≥18 years of age at an elevated risk of HIV acquisition. Participants received a postexposure prophylaxis (PEP)-based or PrEP-based HIV prevention package for at least 48 weeks. Plasma tenofovir levels from each PrEP visit assessed as below the limit of quantitation (<10 ng/mL) triggered increased adherence support. RESULTS: Three hundred one participants enrolled. Forty-eight-week retention in the PrEP cohort was 75.1%. Biomarker evidence of PrEP adherence consistent with ≥4 doses per week at weeks 4, 12, 24, 36, and 48 was found in 83.1%, 83.4%, 75.7%, 71.6%, and 65.5% of participants, respectively; younger and African American participants were less likely to have protective drug levels. Most of those with suboptimal adherence had adherence improvement after brief intervention. One seroconversion occurred in a participant who discontinued PrEP. Nearly half (46.4%) of participants were diagnosed with at least 1 incident sexually transmitted infection during 48 weeks of study follow-up. CONCLUSIONS AND RELEVANCE: PrEP was acceptable and well tolerated in a diverse population of men who have sex with men in Los Angeles. A brief intervention triggered from biomarkers of poor adherence was associated with improved adherence. Drug level monitoring has the potential to allow targeting of additional adherence support to those struggling with daily tablet adherence.

Evaluation of a Client-Centered Linkage Intervention for Patients Newly Diagnosed with HIV at an Urban United States LGBT Center: The Linkage to Care Specialist Project.

Linkage to care (LTC) is a key element of the HIV care continuum, and a crucial bridge from testing and diagnosis to receipt of antiretroviral therapies and viral suppression. In 2012, the Los Angeles LGBT Center hired a full-time LTC specialist (LTC-S), who developed a unique client-centered approach to LTC. This single-arm demonstration project was designed to systematically evaluate the LTC-S intervention. Individuals who were newly diagnosed with HIV between March 2014 and September 2015 were eligible for enrollment. The LTC-S draws heavily from principles of motivational interviewing and strengths-based case management, helping to normalize fears while guiding clients at a pace that reflects individual needs and resources. These tailored, targeted methods facilitate the rapid development of rapport, enabling the LTC-S to help clients address particular reactions and barriers to care more effectively. Of the 118 newly HIV-diagnosed individuals who enrolled, 111 (94.1%) saw an HIV primary care provider within 3 months of diagnosis; the LTC-S spent an average of 2.1 h working with each participant. Enrolled clients were a racially diverse, urban group composed primarily of young men who have sex with men. The LTC-S intervention was effective in promoting LTC among this sample. Our results demonstrate that client-centered, resiliency-based LTC services can be seamlessly integrated into an existing HIV testing program, thereby increasing the chances that newly diagnosed individuals will link to care.

Project Engage: Snowball Sampling and Direct Recruitment to Identify and Link Hard-to-Reach HIV-Infected Persons Who Are Out of Care.

INTRODUCTION: Innovative strategies are needed to identify and link hard-to-find persons living with HIV (PLWH) who are out of care (OOC). Project Engage, a health department-based project in Los Angeles County, used a mixed-methods approach to locate and provide linkage for PLWH who have limited contact with HIV medical and nonmedical services. METHODS: Incentivized social network recruitment (SNR) and direct recruitment (DR) was used to identify eligible OOC alters for a linkage intervention that included HIV clinic selection, appointment and transportation support, reminder calls/texts, and clinic navigation. RESULTS: Between 2012 and 2015, 112 alters were identified using SNR (n = 74) and DR (n = 38). Most alters were male (80%), African American (38%), and gay (60%). Sizable percentages were homeless (78%), had engaged in sex work (32%) in the previous 6 months, had injected drugs (47%), were incarcerated in the previous 12 months (50%), and had only received HIV care during the previous 5 years while incarcerated (24%). SNR alters were more likely than DR alters to be African American, uninsured, unemployed, homeless, sex workers, injection drug users, recently incarcerated, and have unmet service needs. Alters linked to care within 3 (69%), 4-6 (5%), and 7-12 months (8%), and 72% were retained at 6-12 months. The percent virally suppressed increased (27% vs. 41%) and the median viral load decreased (P = 0.003) between linkage and follow-up at 6-12 months. DISCUSSION: The alternative approaches presented were effective at locating marginalized HIV-positive persons who are OOC for linkage and retention. The SNR approach was most successful at identifying alters with serious social challenges and gaps in needed medical/ancillary services.

Methods to Obtain a Representative Sample of Ryan White-Funded Patients for a Needs Assessment in Los Angeles County: Results from a Replicable Approach.

The Health Resources and Services Administration requires that jurisdictions receiving Ryan White (RW) funding justify need, set priorities, and provide allocations using evidence-based methods. Methods and results from the 2011 Los Angeles Coordinated HIV/AIDS Needs Assessment-Care (LACHNA-Care) study are presented. Individual-level weights were applied to expand the sample from 400 to 18 912 persons, consistent with the 19 915 clients in the system. Awareness, need, and utilization for medical outpatient care were high (>90%). Other services (eg, child care) had limited awareness (21%). Majority of participants reported at least 1 service gap (81%). Lack of insurance (risk ratio [RR] = 3.0, 95% confidence interval [CI]: 1.5-6.2), substance use (RR = 2.9, 95% CI: 1.3-6.4), and past lapses in medical care (RR = 2.8, 95% CI: 1.3-5.9) were associated with gaps. Within clusters, past incarceration was associated with gaps for housing (RR = 13.5, 95% CI: 3.5-52.1), transportation (RR = 3.2, 95% CI: 1.2-8.4), and case management (RR = 4.0, 95% CI: 1.3-12.2). Applied methods resulted in representative data instrumental to RW program planning efforts.

Implementation and Operational Research: The Navigation Program: An Intervention to Reengage Lost Patients at 7 HIV Clinics in Los Angeles County, 2012-2014.

The Navigation Program is a health department-community agency collaboration to reengage lost HIV clinic patients in Los Angeles County using best practices from disease investigator services locator activities and the Antiretroviral Treatment Access Study (ARTAS), a CDC-recommended intervention. Clinic databases were reviewed to identify HIV patients who: (1) had no HIV care visits in 6-12 months and last viral load was greater than 200 copies per milliliter; (2) had no HIV care visits in >12 months; (3) were newly diagnosed and never in care; or (4) were recently released from jail/prison/other institution with no regular HIV medical provider. Patients were contacted by trained Navigators using locator information from clinic medical records, HIV/sexually transmitted disease surveillance, and people-finder databases and offered enrollment in a modified ARTAS intervention. Among the 1139 lost clinic patients identified, 36% were in care elsewhere, 29% could not be located, 8% returned to the clinic independently, 4% declined enrollment, and 7% (n = 78) were located and enrolled in the intervention. Participants received an average of 4.5 Navigator sessions over 11.6 hours. Among reengaged patients, 68% linked within 3 months, 85% linked within 6 months, and 94% linked within 12 months, and 82% of linked patients were retained in care 12 months after study enrollment. The percentage of linked patients virally suppressed was compared at time of linkage by the Navigators (52%) with a second viral load measure after linkage to care (63%) (χ(2) = 11.8; P = 0.01). The combined disease investigator services/ARTAS model of reengagement was effective for locating and reengaging lost HIV clinic patients. Access to HIV surveillance data is critical for the efficient identification of persons truly in need of reengagement.

Contingency management voucher redemption as an indicator of delayed gratification.

This prospective analysis tested whether frequency of voucher redemptions during a contingency management (CM) substance use intervention was significantly associated with participants' ongoing substance use. Homeless, substance-dependent men who have sex with men (N=131) were randomized into either a "full" or "lite" voucher-based CM intervention. All participants earned vouchers for attendance and participation; participants in the CM-full condition also received vouchers for substance abstinence and enactment of prosocial and/or health-promoting behaviors. Multivariate longitudinal negative binomial regression analyses (n=118) assessed the association between substance use during the intervention and frequency of voucher redemptions. Participants who used methamphetamine (IRR=0.66; 95% CI=0.44-0.99) and/or opiates (IRR=0.60; 95% CI=0.40-0.99) during the intervention exhibited less time between voucher redemptions than individuals who achieved abstinence from these substances. Voucher redemption logs can be cost-effective and unobtrusive tools for measuring study participants' tendency to delay gratification.

Lifetime substance use and HIV sexual risk behaviors predict treatment response to contingency management among homeless, substance-dependent MSM.

Homeless, substance-dependent men who have sex with men (MSM) continue to suffer health disparities, including high rates of HIV. One-hundred and thirty one homeless, substance-dependent MSM were randomized into a contingency management (CM) intervention to increase substance abstinence and health-promoting behaviors. Participants were recruited from a community-based, health education/risk reduction HIV prevention program and the research activities were also conducted at the community site. Secondary analyses were conducted to identify and characterize treatment responders (defined as participants in a contingency management intervention who scored at or above the median on three primary outcomes). Treatment responders were more likely to be Caucasian/White (p < .05), report fewer years of lifetime methamphetamine, cocaine, and polysubstance use (p < or = .05), and report more recent sexual partners and high-risk sexual behaviors than nonresponders (p < .05). The application of evidence-based interventions continues to be a public health priority, especially in the effort to implement effective interventions for use in community settings. The identification of both treatment responders and nonresponders is important for intervention development tailored to specific populations, both in service programs and research studies, to optimize outcomes among highly impacted populations.

Barriers and unmet need for supportive services for HIV patients in care in Los Angeles County, California.

Abstract HIV-infected patients frequently experience depression, drug use, and unstable housing but are often unable to access supportive services to manage these challenges. Data on barriers to needed supportive services are critical to improving patient access. Data from the Medical Monitoring Project (MMP), a national supplemental surveillance system for HIV-infected persons in care, was used to examine barriers to support service use and factors associated with need and unmet need for services. Interview data for 333 patients in care in 2007 and 2008 in Los Angeles County (LAC) showed that 71% (n=236) reported needing at least one supportive service and of these, 35% (n=83) reported at least one unmet need for services (46% Latino; 25% white; 83% male; 92% 30+; 77% gay/bisexual; 40% response rate). The main reasons that supportive services were not accessed included lack of information (47%; do not know where to go or who to call); an agency barrier (33%; system too confusing, wait list too long); or a financial/practical barrier (18%; too expensive, transportation problems). In a logistic regression that included all participants (n=333), African Americans (OR=3.1, 95% CI: 1.1-8.7) and those with incomes less than $10,000 were more likely to have service needs (odds ratio [OR]=3.5; 95% confidence interval [CI]: 1.3-9.3). Among those with at least one service need (n=236), those who were gay or bisexual were more likely to report at least one unmet service need (OR=2.8; 95% CI: 1.3-6.1). Disparities were found for need and unmet need for supportive services by race/ethnicity; income and sexual orientation. The reported reasons that services were not obtained suggest needed improvements in information dissemination on availability and location of HIV support services and more streamlined delivery of services.

A youth-focused case management intervention to engage and retain young gay men of color in HIV care.

HIV-positive Latino and African-American young men who have sex with men (YMSM) have low rates of engagement and retention in HIV care. An evaluation of a youth-focused case management intervention (YCM) designed to improve retention in HIV care is presented. HIV-positive Latino and African-American YMSM, ages 18-24, who were newly diagnosed with HIV or in intermittent HIV care, were enrolled into a psychosocial case management intervention administered by Bachelor-level peer case managers at two HIV clinics in Los Angeles County, California. Participants met weekly with a case manager for the first two months and monthly for the next 22 months. Retention in HIV primary care at three and six months of follow-up was evaluated as were factors associated with retention in care. From April 2006 to April 2009, 61 HIV-positive participants were enrolled into the intervention (54% African-American, 46% Latino; mean age 21 years). At the time of enrollment into the intervention, 78% of the YMSM had a critical or immediate need for stable housing, nutrition support, substance abuse treatment, or mental health services. Among intervention participants (n=61), 90% were retained in primary HIV care at three months and 70% at six months. Among those who had previously been in intermittent care (n=33), the proportion attending all HIV primary care visits in the previous six months increased from 7% to 73% following participation in the intervention (p<0.0001). Retention in HIV care at six months was associated with increased number of intervention visits (p=0.05), more hours in the intervention (p=0.02), and prescription of HAART. These data highlight the critical needs of HIV-positive African-American and Latino YMSM and demonstrate that a clinic-based YCM can be effective in stabilizing hard-to-reach clients and retaining them in consistent HIV care.

Delay-discounting among homeless, out-of-treatment, substance-dependent men who have sex with men.

BACKGROUND: Impulsivity is associated with substance use; however, to date, impulsivity has not been characterized among a sample of homeless, non-treatment seeking, substance-dependent men who have sex with men (MSM). OBJECTIVES: The aim of this study was to utilize the delay-discounting instrument to assess impulsive behaviors among a subsample of homeless, non-treatment seeking, substance-dependent men who have sex with men (S-D MSM) enrolled in a randomized, controlled, contingency management (CM) trial. METHODS: Twenty S-D MSM participants from the CM parent study were matched on age and ethnicity to 20 non-substance-dependent, non-homeless control participants using propensity scores (N=40) and were administered the delay-discounting procedure. RESULTS: Although discounting values decreased rapidly with time in both groups, the S-D MSM participants consistently discounted rewards more steeply than controls (p=.05), particularly at all intermediate measured timeframes. The S-D MSM participants also presented greater median discounting rates (k values) compared with the control group (m(S-D MSM)=2.39 (SD=3.72) vs. m(ctrl)=1.27 (SD=3.71), p≤.01). CONCLUSION: This work extends existing findings of increased delay-discounting among substance-dependent individuals to homeless, substance-dependent, non-treatment seeking MSM. SCIENTIFIC SIGNIFICANCE: A better understanding of the prevalence of delay-discounting type behaviors among homeless, substance-dependent MSM can be used to inform the development of tailored substance abuse interventions for this high-risk population.

Contingency management among homeless, out-of-treatment men who have sex with men.

Homeless men who have sex with men are a particularly vulnerable population with high rates of substance dependence, psychiatric disorders, and HIV prevalence. Most need strong incentives to engage with community-based prevention and treatment programs. Contingency management (CM) was implemented in a community HIV prevention setting and targeted reduced substance use and increased health-promoting behaviors over a 24-week intervention period. Participants in the CM condition achieved greater reductions in stimulant and alcohol use (χ(2) = 27.36, p < .01) and, in particular, methamphetamine use (χ(2) = 21.78, p < .01) and greater increases in health-promoting behaviors (χ(2) = 37.83, p < .01) during the intervention period than those in the control group. Reductions in substance use were maintained to 9- and 12-month follow-up evaluations. Findings indicate the utility of CM for this high-risk population and the feasibility of implementing the intervention in a community-based HIV prevention program.

Predictors of condom use among men enrolled in drug treatment programs.

This study identified predictors of condom use and developed a model of condom use in a sample of men (n = 324) enrolled in drug treatment. Utilizing a series of logistic regression analyses reported condom use was predicted by possession of condoms, future intention to use condoms, future intention to increase condom use, having a high-risk partner, low Condom Barriers Scale scores, being unmarried and ethnic minority status. A probit path analysis revealed the following model of condom use among men in drug treatment: Taking condoms from clinic stocks was the best predictor of condom possession, which in turn was the best predictor of condom use. These study findings identify condom availability in treatment programs as an important risk reduction intervention. Treatment programs can apply these predictors of condom use to better identify individuals at risk for HIV and sexually transmitted infections to better target prevention interventions.