Injection network drivers of HIV prevention service utilization among people who inject drugs: results of a community-based sociometric network cohort in New Delhi, India.

INTRODUCTION: Injection drug networks may influence their network members' health-seeking behaviours. Using data from a sociometric injecting partner network of people who inject drugs (PWID) in New Delhi, India, we assessed the role of injecting partner (alter) behaviours on individual engagement in HIV prevention services. METHODS: We enumerated injecting partner linkages among 2512 PWID using coupon referrals and biometric data from November 2017 to March 2020. Participants completed interviewer-administered questionnaires and provided information on injection behaviours, injecting partners, HIV/hepatitis C (HCV) testing and service engagement. Multilevel multiple-membership models (MMMM) evaluated individual PWID HIV testing, medication for opioid use disorder (MOUD) and syringe service engagement as a function of alter attributes, accounting for membership across multiple ego-networks. Logistic regression models assessed parallel associations among socially proximal injecting peers, defined as PWID ≤3 path length from ego. RESULTS: Median age was 26 years; 99% were male. PWID had median 2 injecting partners and 8 socially proximal peers; 14% reported HIV testing, 33% accessed MOUD and 13% used syringe services 6 months prior. In MMMM analyses, PWID with ≥1 versus 0 injecting partners who received HIV testing were significantly more likely to report HIV testing (adjusted odds ratio [aOR]: 2.27, 95% confidence interval [CI]: 1.68-3.16), MOUD (aOR: 1.99, 95% CI: 1.60-2.53) and syringe service use (aOR: 1.66, 95% CI: 1.21-2.39). We observed similar findings for individual MOUD and syringe service use. Having ≥1 versus 0 HIV-positive partners was associated with decreased HIV testing and MOUD but increased syringe service use (aOR: 1.54, 95% CI: 1.09-2.17). PWID with ≥1 versus 0 socially proximal peers who used non-sterile injection equipment reported increased HIV testing (aOR: 1.39, 95% CI: 1.01-1.92), MOUD (aOR: 1.40, 95% CI: 1.10-1.77) and syringe service use (aOR: 1.82, 95% CI: 1.23-2.68). CONCLUSIONS: We found differential associative relationships between individual HIV prevention service engagement and the health or risk behaviours of direct and indirect alters. Characterizing network exposure beyond direct injecting partnerships provided important context on possible mechanisms of behavioural influence. Findings could be leveraged to design peer-based interventions that promote network diffusion of health-seeking behaviours.

Network centrality and HIV prevention service use among people who inject drugs: Findings from a sociometric network cohort in New Delhi, India.

BACKGROUND AND AIMS: Network centrality, an indicator of an individual's importance and potential to drive behavioral change, is rarely used to select peer educators. Individual-level predictors of network centrality might be useful to identify people who inject drugs (PWID) for potential roles as peer navigators or change agents in network-based interventions in settings where sociometric data are unavailable. We assessed the relationship between network centrality and HIV prevention service engagement to determine whether centrally-positioned PWID share measurable commonalities. DESIGN: Observational study and survey using baseline data from a sociometric network cohort of PWID, enumerated using network software and biometric data (2017-2020). Network ties corresponded to direct injection partnerships in the prior month. SETTING: New Delhi, India. PARTICIPANTS: A total of 2512 PWID who were ≥18 years, provided written informed consent, and reported illicit injection drug use within the 24 months before study enrollment. MEASUREMENTS: Interviewer-administered questionnaires measured demographics and substance use behaviors. Central versus peripheral network position was categorized using betweenness centrality 75th%ile . Logistic regression was used to estimate adjusted odds ratios (aOR) with 95% confidence intervals (95%CI) between network position and HIV testing, medication for opioid use disorder (MOUD), or syringe service use. Lasso models selected predictors of central network position among 20 covariates detailing demographic, biologic, and substance use information. Predictive accuracy was evaluated using model performance metrics. FINDINGS: Overall, median age was 26 years (interquartile range 22-34); 99% were male; 628 were classified as central. Compared with PWID at the periphery, central PWID were more likely to use MOUD (aOR: 1.59, 95%CI: 1.30-1.94) and syringe services (aOR: 2.91, 95%CI: 2.25, 3.76) in the prior six months. Findings for HIV testing were inconclusive (aOR: 1.30, 95%CI: 1.00-1.69). The lasso variable selector identified several predictors of network centrality: HIV and hepatitis C infection, number of PWID seen in the prior month, injecting heroin and buprenorphine (vs. heroin only) six months prior, sharing injection equipment six months prior, experiencing drug overdose in the past year, and moderate/severe depression (vs. none/mild). Average agreement between model-predicted vs. observed values was 0.75; area under the receiver operator curve was 0.69. CONCLUSIONS: In a socioeconomic network of people who inject drugs (PWID) in New Delhi, India, there are common characteristics among individuals based on their network position (central vs. peripheral) but individual-level predictors have only moderate predictive accuracy. Although central network members appear to be more likely to use HIV prevention services than peripheral network members, their potential as change agents may be limited by other factors that impede their ability to adopt or promote HIV prevention service use.

Demographic dividend-favorable policy environment in two pre-dividend African nations: review of national policies and prospects for policy amendments in Nigeria and Tanzania.

BACKGROUND: In collaboration with local partners, we reviewed 18 national policy documents across two sub-Saharan African countries identified as pre-dividend nations by the World Bank in 2017: Nigeria and Tanzania. Our aim was to assess national policies in pre-dividend countries and to determine whether national strategies were primed to capitalize on changing demographic structures, maximally attain the demographic dividend, and augment socio-economic growth. METHODS: We conducted policy reviews by focusing on five key sectors of the Gates Institute Demographic Dividend Framework: Family Planning, Maternal and Child Health, Education, Women's Empowerment, and Labor Market. This framework was developed as a tool for countries to apply targeted policies for accelerating the demographic dividend based on their demographic structure. For each component we used a comprehensive list of indicators, defined via a systematic literature review, through which we assessed national policies aimed at maximizing the demographic dividend. RESULTS: Between the two countries, we observed persistent gaps in policies targeting family planning. Although more comprehensive, policies addressing maternal and child health, education, women's empowerment, and labor market still lagged in their specificity and measurability. We identified specific policy amendments and alternatives that Nigeria and Tanzania could consider to mitigate these gaps. We also stress the importance of designing measurable policy initiatives across sectors. CONCLUSIONS: Based on these recommendations, as Nigeria, Tanzania, and other pre-dividend nations start experiencing rapid demographic changes, they may consider implementing routine policy reviews to strengthen policies across the five key sectors and harness the benefits of a demographic dividend.

Changes in HIV care continuum indicators among community-based samples of HIV-infected people who inject drugs and men who have sex with men across 21 cities in India.

Monitoring key populations' progress towards UNAIDS 90-90-90 targets is essential to achieving HIV/AIDS epidemic control. Using serial cross-sectional data, we evaluated changes in HIV care continuum among people who inject drugs(PWID) and men who have sex with men(MSM) in India. Cross-sectional baseline (2012/2013) and follow-up (2016/2017) samples were recruited using respondent-driven sampling across 21 cities. All participants were tested for HIV and RNA measured in HIV-positive participants. Linear regression was used to model temporal site-level changes in continuum indicators in MSM versus PWID. At baseline, we recruited 2,544 HIV-infected PWID and 1,086 HIV-infected MSM. At follow-up, we recruited 2,517 HIV-infected PWID and 1,763 HIV-infected MSM. At baseline, there were no significant differences in continuum indicators between MSM and PWID. At follow-up, compared to PWID, the proportion of MSM reaching each care continuum indicator-awareness of status, receipt of care, ART use, viral suppression-increased by 15-33 percentage points: 78% of MSM versus 49% of PWID were aware of their status (p < 0.01); 56% of MSM versus 32% of PWID were virologically suppressed (p = 0.05). MSM showed marked improvements across the care continuum, whereas PWID lagged and may require additional intervention. Differential improvement in HIV engagement may necessitate population-specific interventions and routine surveillance to facilitate HIV elimination.

Drug use stigma, antiretroviral therapy use, and HIV viral suppression in a community-based sample of people with HIV who inject drugs.

OBJECTIVE: To examine the association of drug use stigma with antiretroviral therapy (ART) use and HIV viral suppression among people with HIV who inject drugs in India. DESIGN: Cross-sectional biobehavioral survey. METHODS: Between August 2016 and May 2017, persons aged at least 18 years who reported injection drug use in the past 2 years were recruited via respondent-driven sampling (RDS) in 12 Indian cities (approximately 1000 per city). The analysis was restricted to participants with laboratory-confirmed HIV infection who self-reported a prior HIV diagnosis and were eligible for ART per concurrent national HIV treatment guidelines. Enacted and internalized drug use stigma were each measured by five to six-item subscales. The study outcomes were HIV viral suppression (<150 copies/ml) and self-reported past 30-day ART use. RDS-II weighted multivariable logistic regression with a city-level random-intercept was used to estimate adjusted odds ratios (aOR) and corresponding 95% confidence intervals (CIs). RESULTS: Among 971 ART-eligible participants previously diagnosed with HIV, 65.1% reported ART use and 56.1% were virally suppressed. Reporting any enacted stigma (vs. none) was associated with lower odds of ART use [aOR = 0.26 (95% CI = 0.15-0.44)] and viral suppression [aOR = 0.49 (95% CI = 0.31-0.78)]. High internalized stigma scores (>median vs. ≤median) were associated with lower odds of viral suppression among participants aged at least 35 years [aOR = 0.51 (95% CI = 0.27-0.97)] but not among participants aged less than 35 years [aOR = 1.22 (95% CI = 0.57-2.60)]. Similar associations were observed in analyses restricted to participants ever linked to HIV care. CONCLUSION: Drug use stigma may be a barrier to HIV viral suppression among people with HIV who inject drugs, thereby hindering efforts to achieve HIV control.

Racial and ethnic disparities in viral acute respiratory infections in the United States: protocol of a systematic review.

BACKGROUND: The COVID-19 pandemic caused by SARS-CoV-2 has highlighted consistent inequities in incidence, disease severity, and mortality across racial and ethnic minority populations in the United States (US) and beyond. While similar patterns have been observed with previous viral respiratory pathogens, to date, no systematic review has comprehensively documented these disparities or potential contributing factors. In response, this review aims to synthesize data on racial and ethnic disparities in morbidity and mortality due to viral acute respiratory infections (ARI) other than SARS-CoV-2. This review will focus on understanding structural health and social factors to contextualize race and ethnicity driving these disparities in the US. METHODS: We will conduct a systematic review of studies published from January 1, 2002, onward. Our search will include PubMed/MEDLINE, EBSCO Host-CINAHL Plus, PsycInfo, EMBASE, and Cochrane Library databases to identify relevant articles. We will include studies of any design that describe racial/ethnic disparities associated with viral ARI conducted in the US. Primary outcomes include incidence, disease severity or complication, hospitalization, or death attributed to ARI. Secondary outcomes include uptake of preventive interventions including vaccination, handwashing, social distancing, and wearing masks. Two reviewers will independently screen all citations, full-text articles, and abstract relevant data. Data characterizing individual-, community-, and structural-level factors associated with these disparities will be abstracted to better understand the underlying structural inequities contributing to racial disparities in ARI. We will assess the methodological quality of all studies and will conduct meta-analyses using random effects models if appropriate. DISCUSSION: Findings from this systematic review will shed light on patterns of racial and ethnic disparities in viral ARI in the United States to support mathematical modeling of epidemic trajectories, intervention impact, and structural drivers of transmission, including structural racism. Moreover, data emerging from this review may reignite pandemic preparedness focused on communities with specific vulnerabilities related to living and working conditions given prevailing structural inequities, thus facilitating improved future pandemic responses to novel or endemic viral respiratory pathogens. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020219771.

The Relationship Between the Global Burden of Influenza From 2017 to 2019 and COVID-19: Descriptive Epidemiological Assessment.

BACKGROUND: SARS-CoV-2 and influenza are lipid-enveloped viruses with differential morbidity and mortality but shared modes of transmission. OBJECTIVE: With a descriptive epidemiological framing, we assessed whether recent historical patterns of regional influenza burden are reflected in the observed heterogeneity in COVID-19 cases across regions of the world. METHODS: Weekly surveillance data reported by the World Health Organization from January 2017 to December 2019 for influenza and from January 1, 2020 through October 31, 2020, for COVID-19 were used to assess seasonal and temporal trends for influenza and COVID-19 cases across the seven World Bank regions. RESULTS: In regions with more pronounced influenza seasonality, COVID-19 epidemics have largely followed trends similar to those seen for influenza from 2017 to 2019. COVID-19 epidemics in countries across Europe, Central Asia, and North America have been marked by a first peak during the spring, followed by significant reductions in COVID-19 cases in the summer months and a second wave in the fall. In Latin America and the Caribbean, COVID-19 epidemics in several countries peaked in the summer, corresponding to months with the highest influenza activity in the region. Countries from regions with less pronounced influenza activity, including South Asia and sub-Saharan Africa, showed more heterogeneity in COVID-19 epidemics seen to date. However, similarities in COVID-19 and influenza trends were evident within select countries irrespective of region. CONCLUSIONS: Ecological consistency in COVID-19 trends seen to date with influenza trends suggests the potential for shared individual, structural, and environmental determinants of transmission. Using a descriptive epidemiological framework to assess shared regional trends for rapidly emerging respiratory pathogens with better studied respiratory infections may provide further insights into the differential impacts of nonpharmacologic interventions and intersections with environmental conditions. Ultimately, forecasting trends and informing interventions for novel respiratory pathogens like COVID-19 should leverage epidemiologic patterns in the relative burden of past respiratory pathogens as prior information.

Recommendations to the Society for Epidemiologic Research for Further Promoting Diversity and Inclusion at the Annual Meeting and Beyond.

Increasing diverse engagement in the Society for Epidemiologic Research (SER) will positively impact the field of epidemiology. As the largest and longest-running epidemiologic society in North America, SER has long been a pioneer in promoting diversity and inclusion. A recent survey of SER members, however, showed there is still room for improving diversity, inclusion, representation, and participation in the Society. In this commentary, as members of both the SER and the Johns Hopkins Bloomberg School of Public Health Department of Epidemiology's Inclusion, Diversity, Equity, Anti-Racism, and Science (Epi IDEAS) Working Group, we recommend 4 goals for the SER Annual Meeting and beyond: 1) convene epidemiologic researchers with diverse backgrounds and ideas; 2) promote an inclusive environment at the SER Annual Meeting; 3) develop, compile, and disseminate best practices to honor diversity in epidemiologic research; and 4) increase prioritization of health disparities research and methods. We also suggest strategies for achieving these goals so that SER can better include, support, and elevate members from historically disadvantaged groups. While our recommendations are tailored specifically to SER, the greater epidemiologic and academic communities could benefit from adopting these goals and strategies within their professional societies and conferences.