Transgender Women Experiencing Homelessness - National HIV Behavioral Surveillance Among Transgender Women, Seven Urban Areas, United States, 2019-2020.

Transgender women experience high prevalence of homelessness, which can affect their likelihood of acquiring HIV infection and can lead to poor medical outcomes. CDC analyzed data from the National HIV Behavioral Surveillance Among Transgender Women to identify whether personal characteristics and social factors affecting transgender women were associated with duration of homelessness during the past 12 months. Longer duration and chronic homelessness might indicate greater unmet needs, which increases their likelihood for acquiring HIV infection. Ordinal logistic regression was conducted to calculate adjusted prevalence odds ratios and 95% CIs for transgender women from seven urban areas in the United States experiencing homelessness 30-365 nights, 1-29 nights, and zero nights during the past 12 months. Among 1,566 transgender women, 9% reported 1-29 nights homeless and 31% reported 30-365 nights homeless during the past 12 months. Among participants who reported physical intimate partner violence or forced sex, 50% and 47%, respectively, reported experiencing 30-365 nights homeless. Furthermore, 55% who had been evicted or denied housing because of their gender identity and 58% who had been incarcerated during the past year experienced 30-365 nights homeless. The odds of transgender women experiencing longer duration of homelessness was associated with being younger and having a disability; higher psychological distress scores were associated with longer duration of homelessness. Analysis of social determinants of health found transgender women experiencing longer homelessness to be less educated, living below the Federal poverty level, and having lower social support. Therefore, focusing on HIV prevention and interventions addressing housing instability to reduce the duration of homelessness among transgender women is important. Further, integrating housing services with behavioral health services and clinical care, specifically designed for transgender women, could reduce HIV acquisition risk and improve HIV infection outcomes.

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.

Socioeconomic and racial/ethnic spatial polarization and incarceration among people who inject drugs in 19 US metropolitan areas, 2015.

The purpose of this study is to test, for the first time, the association between spatial social polarization and incarceration among people who inject drugs (PWID) in 19 large U.S. metropolitan statistical areas (MSAs) in 2015. PWID were recruited from MSAs for the Centers for Disease Control and Prevention's 2015 National HIV Behavioral Surveillance. Administrative data were used to describe the ZIP-code areas, counties, and MSAs where PWID lived. We operationalized spatial polarization using the Index of Concentration at the Extremes (ICE), a measure that reflects polarization in race and household income at the ZIP-code level. We tested the association between spatial polarization and odds of past-year arrest and detainment using multilevel multivariable models. We found 37% of the sample reported being incarcerated in the past year. Report of past-year incarceration varied by race/ethnicity: 45% of non-Hispanic white PWID reported past-year incarceration, as did 25% of non-Hispanic Black PWID, and 43% of Hispanic/Latino PWID (N = 9047). Adjusted odds ratios suggest that Black PWID living in ZIP-code areas with a higher ICE score, meaning more white and affluent, had higher odds of past-year incarceration, compared to white PWID. In previous research, incarceration has been found to be associated with HIV acquisition and can deter PWID from engaging in harm reduction activities.

HIV Pre-exposure Prophylaxis Persistence and Adherence Among Men Who Have Sex With Men in Four US Cities.

BACKGROUND: HIV pre-exposure prophylaxis (PrEP) persistence and adherence are critical to ending the HIV epidemic in the United States. SETTING: In 2017 National HIV Behavioral Surveillance, HIV-negative men who have sex with men (MSM) in 4 US cities completed a survey, HIV testing, and dried blood spots at recruitment. METHODS: We assessed 3 PrEP outcomes: persistence (self-reported PrEP use at any time in the past 12 months and had tenofovir, emtricitabine, or tenofovir diphosphate detected in dried blood spots), adherence at ≥4 doses/week (self-reported past-month PrEP use and tenofovir diphosphate concentration ≥700 fmol/punch), and adherence at 7 doses/week (self-reported past-month PrEP use and tenofovir diphosphate concentration ≥1250 fmol/punch). Associations with key characteristics were examined using log-linked Poisson regression models with generalized estimating equations. RESULTS: Among 391 MSM who took PrEP in the past year, persistence was 80% and was lower among MSM who were younger, had lower education, and had fewer sex partners. Of 302 MSM who took PrEP in the past month, adherence at ≥4 doses/week was 80% and adherence at 7 doses/week was 66%. Adherence was lower among MSM who were younger, were Black, and had fewer sex partners. CONCLUSIONS: Although persistence and adherence among MSM were high, 1 in 5 past-year PrEP users were not persistent and 1 in 5 past-month PrEP users were not adherent at levels that would effectively protect them from acquiring HIV (ie, ≥4 doses/week). Efforts to support PrEP persistence and adherence should include MSM who are young, are Black, and have less education.

A Key Comprehensive System for Biobehavioral Surveillance of Populations Disproportionately Affected by HIV (National HIV Behavioral Surveillance): Cross-sectional Survey Study.

BACKGROUND: The National HIV Behavioral Surveillance (NHBS) is a comprehensive system for biobehavioral surveillance conducted since 2003 in 3 populations disproportionately affected by HIV: gay, bisexual, and other men who have sex with men (MSM); people who inject drugs; and heterosexually active persons at increased risk for HIV infection (HET). This ongoing and systematic collection and analysis of data is needed to identify baseline prevalence of behavioral risk factors and prevention service use, as well as to measure progress toward meeting HIV prevention goals among key populations disproportionately affected by HIV. OBJECTIVE: This manuscript provides an overview of NHBS from 2003 to 2019. METHODS: NHBS is conducted in rotating, annual cycles; these 3 annual cycles are considered a round. Venue-based, time-space sampling is used for the MSM population. Respondent-driven sampling is used for people who inject drugs and HET populations. A standardized, anonymous questionnaire collects information on HIV-related behavioral risk factors, HIV testing, and use of prevention services. In each cycle, approximately 500 eligible persons from each participating area are interviewed and offered anonymous HIV testing. RESULTS: From 2003 to 2019, 168,600 persons were interviewed and 143,570 agreed to HIV testing across 17 to 25 cities in the United States. In the fifth round (2017 to 2019), over 10,000 (10,760-12,284) persons were interviewed each of the 3 population cycles in 23 cities. Of those, most (92%-99%) agreed to HIV testing. Several cities also conducted sexually transmitted infection or hepatitis C testing. CONCLUSIONS: NHBS is critical for monitoring the impact of the Ending the HIV Epidemic in the United States initiative. Data collected from NHBS are key to describe trends in key populations and tailor new prevention activities to ensure high prevention impact. NHBS data provide valuable information for monitoring and evaluating national HIV prevention goals and guiding national and local HIV prevention efforts. Furthermore, NHBS data can be used by public health officials and researchers to identify HIV prevention needs, allocate prevention resources, and develop and improve prevention programs directed to the populations of interest and their communities.

Material Hardship and Association With Sexual Risk Behavior Among Adolescent Sexual Minority Males in 3 US Cities-National HIV Behavioral Surveillance-Young Men Who Have Sex With Men, 2015.

INTRODUCTION: Adolescent sexual minority males (ASMMs) are disproportionately affected by HIV relative to other youth within the United States. Social determinants of health have been explored among this population; however, economic determinants, such as material hardship, remain understudied. We examined the relationship between material hardship and sexual behavior among ASMMs aged 13-18 years residing in 3 US cities using 2015 data from CDC's National HIV Behavioral Surveillance among Young Men Who Have Sex with Men. METHODS: Young men ages 13-18 years residing in 3 US cities were recruited through venue-based, respondent-driven, or Facebook sampling. We estimated adjusted prevalence ratios (aPRs) with 95% confidence intervals (CIs) for condomless anal intercourse (CAI) with a male sex partner in the past 12 months and with having 4 or more male sex partners in the past 12 months. RESULTS: Of 547 ASMMs, 27% reported experiencing material hardship in the past 12 months. After adjusting for demographics, household characteristics, and city, ASMMs who experienced material hardship were more likely to report CAI with a male partner in the past 12 months (aPR: 1.55, 95% CI: 1.25 to 1.93) and to have had 4 or more male sex partners in the past 12 months (aPR: 1.44, 95% CI: 1.08 to 1.91). DISCUSSION: More than a quarter of ASMMs experienced material hardship that was associated with increased sexual risk behavior among ASMMs. Incorporating services that address all unmet needs is important to consider for HIV prevention efforts for ASMMs.

Racial, Ethnic, and Gender Disparities in Awareness of Preexposure Prophylaxis Among HIV-Negative Heterosexually Active Adults at Increased Risk for HIV Infection - 23 Urban Areas, United States, 2019.

In 2019, heterosexual sex accounted for 23% of new HIV diagnoses in the United States and six dependent areas (1). Although preexposure prophylaxis (PrEP) can safely reduce the risk for HIV infection among heterosexual persons, this group is underrepresented in PrEP research (2). CDC analyzed National HIV Behavioral Surveillance (NHBS) data to describe PrEP awareness among heterosexually active adults in cities with high HIV prevalence. Overall, although 32.3% of heterosexually active adults who were eligible were aware of PrEP, <1% used PrEP. Racial, ethnic, and gender disparities were identified, with the lowest awareness of PrEP among residents of Puerto Rico (5.8%) and Hispanic or Latino (Hispanic) men (19.5%) and women (17.6%). Previous studies have found that heterosexual adults are interested in taking PrEP when they are aware of it (3); tailoring PrEP messaging, including Spanish-language messaging, to heterosexual adults, might increase PrEP awareness and mitigate disparities in use.

Health Care Coverage and Preexposure Prophylaxis (PrEP) Use Among Men Who Have Sex With Men Living in 22 US Cities With vs Without Medicaid Expansion, 2017.

Objectives. To compare health care coverage and utilization between men who have sex with men (MSM) in Medicaid expansion versus nonexpansion states.Methods. We used cross-sectional weighted data from the National HIV Behavioral Surveillance system, which used venue-based methods to interview and test MSM in 22 US cities from June through December, 2017 (n = 8857). We compared MSM in Medicaid expansion versus nonexpansion states by using the Rao-Scott χ2 test stratified by HIV status. We used multivariable logistic regression to model the relationship between Medicaid expansion, coverage, and preexposure prophylaxis (PrEP) use.Results. MSM in expansion states were more likely to have insurance (87.9% vs 71.6%), have Medicaid (21.3% vs 3.8%), discuss PrEP with a provider (58.8% vs 44.3%), or use PrEP (31.1% vs 17.5%).Conclusions. Medicaid expansion is associated with higher coverage and care, including PrEP.Public Health Implications. States may consider expanding Medicaid to help end the HIV epidemic.

Assessing self-reported discrimination among men who have sex with men (MSM).

OBJECTIVES: To determine the prevalence of four forms of sexual identity discrimination among MSM in 23 US metropolitan statistical areas, examine racial/ethnic and socioeconomic disparities in each form of discrimination. METHODS: We examined interview data collected during 2017 for National HIV Behavioral Surveillance (n = 10 029 respondents) and used generalized linear models to assess the association between the prevalence of reported discrimination during the previous 12 months and selected sociodemographic groups. RESULTS: Overall, 34% of participants reported experiencing verbal discrimination; 16%, discrimination in a workplace, school, or a healthcare setting; and 8%, physical assault. MSM who had reported experiencing discrimination were most likely to be young, had achieved lower education, and had lower incomes. High prevalence of reported discrimination was associated with young age, lower education, lower household income, sexual identity disclosure, and lower perceived community tolerance of gay or bisexual persons. CONCLUSION: MSM discrimination affects different groups and occurs in multiple settings. Addressing discrimination should be an integral aspect of multifaceted efforts to improve MSM health.

Healthcare Access and Utilization Among Persons Who Inject Drugs in Medicaid Expansion and Nonexpansion States: 22 United States Cities, 2018.

BACKGROUND: Medicaid expansion under the Affordable Care Act increased insurance coverage, access to healthcare, and substance use disorder treatment, for many Americans. We assessed differences in healthcare access and utilization among persons who inject drugs (PWID) by state Medicaid expansion status. METHODS: In 2018, PWID were interviewed in 22 US cities for National HIV Behavioral Surveillance. We analyzed data from PWID aged 18-64 years who reported illicit use of opioids (n = 9957) in the past 12 months. Poisson regression models with robust standard errors were used to estimate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) were used to examine differences by Medicaid expansion status in indicators of healthcare access and utilization. RESULTS: Persons who inject drugs in Medicaid expansion states were more likely to have insurance (87% vs 36%; aPR, 2.3; 95% CI, 2.0-2.6), a usual source of healthcare (53% vs 34%; aPR, 1.5; 95% CI, 1.3-1.9), and have used medication-assisted treatment (61% vs 36%; aPR, 1.4; 95% CI, 1.1-1.7), and they were less likely to have an unmet need for care (21% vs 39%; aPR, 0.6; 95% CI, 0.4-0.7) than those in nonexpansion states. CONCLUSIONS: Low insurance coverage, healthcare access, and medication-assisted treatment utilization among PWID in some areas could hinder efforts to end the intertwined human immunodeficiency virus and opioid overdose epidemics.

Serious Mental Illness Among Young People Who Inject Drugs: An Assessment of Injection Risks and Healthcare Use.

BACKGROUND: Data on behavioral correlates of mental illness among young people who inject drugs (PWID) are limited. We examine injection risks and healthcare use among young PWID with probable serious mental illness (PSMI). METHODS: People who inject drugs were recruited and interviewed in 20 US cities for 2015 National HIV Behavioral Surveillance. Probable serious mental illness was assessed using the Kessler-6 screening scale. Bivariate analyses using log-linked Poisson regression with generalized estimating equations adjusted for design covariates were conducted to examine associations between PSMI and behaviors among PWID ages 18-29 years. RESULTS: Of 1769 young PWID, 45% had PSMI. Compared to those without PSMI, PWID with PSMI were more likely to report injecting more than once a day, receptive syringe sharing, sharing of other injection equipment, and unmet needs for medical care and substance use disorder (SUD) treatment. Those with PSMI were less likely to use syringe services programs than those without PSMI. CONCLUSIONS: Approximately half of young PWID had PSMI. People who inject drugs with PSMI engaged in high-risk injection behaviors and encountered barriers to healthcare. Human immunodeficiency virus prevention programs such as Syringe Services Programs (SSPs) could benefit from screening for mental illness among young PWID and strong linkage to healthcare, including mental health and SUD treatment.

HIV Injection Risk Behaviors among HIV-Negative People Who Inject Drugs Experiencing Homelessness, 23 U.S. Cities.

Despite recent declines in numbers of people who inject drugs (PWID) diagnosed with HIV, clusters of HIV among PWID are ongoing, especially among PWID experiencing homelessness. Using data from the National HIV Behavioral Surveillance in 2018, we evaluated the association between homelessness and injection risk and prevention behaviors among HIV-negative PWID who were recruited by respondent-driven sampling in 23 U.S. cities. Interviewers assessed sociodemographic characteristics, history of overdose, and behavioral risk and prevention factors for HIV. Adjusted prevalence ratios (aPR) and 95% CI were obtained using Poisson regression models. Of 10,614 HIV-negative PWID participants, 7275 (68.5%) reported experiencing homelessness. Homeless PWID were more likely than those who were not to be younger age, white, unemployed, without health insurance, in poverty, experiencing psychological distress, and incarcerated in the past 12 months. PWID experiencing homelessness were significantly more likely to report injection risk behaviors [share syringes/equipment (aPR = 1.26; 95% CI = 1.20-1.33), non-fatal opioid overdose (aPR = 1.64; 95% CI = 1.49-1.79)] and prevention behaviors [testing for HIV in past 12 months (aPR = 1.18; 95% CI = 1.12-1.24) and using syringe services programs (aPR = 1.09; 95% CI = 1.03-1.16)] than PWID not experiencing homelessness. Homelessness among PWID is associated with injection risk behaviors and non-fatal overdose.

High prevalence of disability and HIV risk among low socioeconomic status urban adults, 17 U.S. cities.

BACKGROUND: In the United States, approximately 10% of adults 18-64 years are disabled. However, there is scarce literature on the associations between disability and HIV risk. OBJECTIVE: To assess disability prevalence and its associations to health and HIV risk factors among low socioeconomic status (SES) (≤high school education or ≤ poverty guidelines) urban adults. METHODS: We assessed disability prevalence from a cross-sectional sample of low SES urban heterosexually active adults at risk for HIV participating in the 2016 National HIV Behavioral Surveillance (NHBS) and calculated crude and adjusted prevalence ratios and 95% confidence intervals of disability for health and HIV risk behaviors. RESULTS: In the NHBS sample, 39.6% of participants reported any disability. Disability was associated with health care utilization and risk behaviors, even when adjusting for demographics. Participants with disabilities were more likely to have condomless sex with a casual partner and engage in exchange sex. CONCLUSIONS: Low SES urban heterosexually active adults reported high prevalence of disabilities and differences in health, health care utilization, and risk factors. Disability might contribute to sexual risk behaviors that increase the likelihood of HIV infection. Further investigations into the intersection of disability and HIV risk are needed, especially in poor communities often excluded from national assessments.

Incarceration, HIV Risk-Related Behaviors, and Partner Characteristics Among Heterosexual Men at Increased Risk of HIV Infection, 20 US Cities.

OBJECTIVES: The effect of incarceration on HIV risk-related behaviors among at-risk heterosexual men is understudied. The objective of our study was to examine the association between incarceration and HIV risk-related behaviors among a sample of predominantly non-Hispanic black and Hispanic heterosexual men residing in urban areas in the United States with a high prevalence of AIDS. METHODS: We analyzed data from the 2013 National HIV Behavioral Surveillance system on 5321 at-risk heterosexual men using log-linked Poisson regression models, adjusted for demographic characteristics and clustered on city. RESULTS: Of 5321 men, 1417 (26.6%) had recently been incarcerated (in the past 12 months), 2781 (52.3%) had ever been incarcerated but not in the past 12 months, and 1123 (21.1%) had never been incarcerated. Recent incarceration was associated with multiple casual female sexual partners (adjusted prevalence ratio [aPR] = 1.23; 95% confidence interval [CI], 1.05-1.44), condomless sex with multiple female sexual partners (aPR = 1.32; 95% CI, 1.06-1.66), injection drug use (aPR = 3.75; 95% CI, 2.64-5.32), and having sexual partners who were more likely to have ever injected drugs (aPR = 1.84; 95% CI, 1.48-2.28), been incarcerated (aPR = 2.28; 95% CI, 2.01-2.59), or had a concurrent sexual partner (aPR = 1.08; 95% CI, 1.05-1.11), as compared with never-incarcerated men. CONCLUSIONS: Incarceration history was associated with HIV risk-related behaviors among heterosexual men from urban areas in the United States. Correctional rehabilitation initiatives are needed to promote strategies that mitigate HIV risk-related behaviors and promote healthy reentry into communities among heterosexual men at high risk for HIV.

Recent US Centers for Disease Control and Prevention Activities to Reduce HIV Stigma.

HIV stigma affects many persons living with HIV in the United States, and reducing stigma is central to the US Centers for Disease Control and Prevention's (CDC) mission to promote health and prevent HIV transmission. To this end, CDC funds and implements programmatic activities, research, communication campaigns, and monitoring through data collection and public health surveillance. Centers for Disease Control and Prevention-funded programs have developed promising interventions and educational materials for reducing HIV stigma. Research conducted by CDC staff and their collaborators have made important contributions to the scientific literature on stigma, which have informed current CDC programmatic efforts, including public education activities and social marketing campaigns. By monitoring HIV stigma in multiple populations, CDC can evaluate the population-level effectiveness of stigma-reduction efforts and identify key populations in need of support and intervention. This article describes these and other recent CDC efforts to address HIV stigma, and discusses new strategies with the potential to further reduce stigma.

Undisclosed HIV infection among MSM in a behavioral surveillance study.

OBJECTIVE: As a proxy for undiagnosed HIV, the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance (NHBS) monitors participants who report being unaware of their infection, defined as self-reporting an HIV-negative or unknown status during the interview but testing positive for HIV infection. We validated the NHBS measure of awareness among MSM in 2014. DESIGN: We tested dried blood spots from MSM who reported being unaware of their infection for seven antiretrovirals (ARVs). MSM unaware with at least one ARV detected were defined as misreporters. METHODS: Weighted percentages and 95% confidence intervals were calculated to compare characteristics among misreporters, nonmisreporters, and those who self-reported as HIV-positive. Viral load was quantified with a validated assay using dried blood spots. RESULTS: Of 1818 HIV-positive MSM, 299 (16%) self-reported as HIV-negative or unknown infection status. Of these 299, 145 (49%) were considered misreporters based on ARV detection. Among the unaware, misreporters were more likely than nonmisreporters to be older and have health insurance. Compared with self-reported HIV-positive MSM, misreporters were more likely to be black, be bisexual, and have perceived discrimination. Of 138 misreporters with viral load data, 116 (84%) had an undetectable viral load. CONCLUSION: ARV testing revealed that half of MSM classified as unaware of their infection misreported their status. Although off-label preexposure prophylaxis use might explain the presence of ARVs, it is unlikely as many misreporters were virally suppressed, suggesting they were on HIV therapy. Biomarker validation of behavioral data can improve data quality and usefulness in NHBS and other studies.

An Innovative Approach to Assess Similarity Between Sex Partners.

We present a simple, comprehensive method for assessing similarity between sex partners of a participant and demonstrate its application using data collected in 2015 as part of CDC's National HIV behavioral surveillance (NHBS) among persons who inject drugs (PWID). We found that the pairwise similarity between sex partners of a survey participant was high. The similarity between second-to-last and third-to-last partners in the past 3 months was significantly higher than that between last and second-to-last partner in partner type, frequency of sex acts, and the contextual characteristics of sex behavior at last sexual encounter. The proposed approach provides an innovative measure of the added value of multi-partner series. The empirical analysis suggests that querying additional sex partners contributes limited data to characterize a participant's sexual behaviors among NHBS PWID. Future studies should apply the proposed method to evaluate the added value of data on multiple sex partners among other populations.

Assessing the Theory of Gender and Power: HIV Risk Among Heterosexual Minority Dyads.

This study drew on the Theory of Gender and Power (TGP) as a framework to assess power inequalities within heterosexual dyads and their effects on women. Structural equation modeling was used to better understand the relationship between structural and interpersonal power and HIV sexual risk within African American and Latina women's heterosexual dyads. The main outcome variable was women's sexual HIV risk in the dyad and was created using women's reports of condomless sex with their main male partners and partners' reports of their HIV risk behaviors. Theoretical associations developed a priori yielded a well-fitting model that explained almost a quarter of the variance in women's sexual HIV risk in main partner dyads. Women's and partner structural power were indirectly associated with women's sexual HIV risk through substance use and interpersonal power. Interpersonal power was directly associated with risk. In addition, this study found that not identifying as heterosexual was directly and indirectly associated with women's heterosexual sex risk. This study provides further support for the utility of the TGP and the relevance of gender-related power dynamics for HIV prevention among heterosexually-active women.

Cross-sectional association between ZIP code-level gentrification and homelessness among a large community-based sample of people who inject drugs in 19 US cities.

BACKGROUND: Housing instability has been associated with poor health outcomes among people who inject drugs (PWID). This study investigates the associations of local-level housing and economic conditions with homelessness among a large sample of PWID, which is an underexplored topic to date. METHODS: PWID in this cross-sectional study were recruited from 19 large cities in the USA as part of National HIV Behavioral Surveillance. PWID provided self-reported information on demographics, behaviours and life events. Homelessness was defined as residing on the street, in a shelter, in a single room occupancy hotel, or in a car or temporarily residing with friends or relatives any time in the past year. Data on county-level rental housing unaffordability and demand for assisted housing units, and ZIP code-level gentrification (eg, index of percent increases in non-Hispanic white residents, household income, gross rent from 1990 to 2009) and economic deprivation were collected from the US Census Bureau and Department of Housing and Urban Development. Multilevel models evaluated the associations of local economic and housing characteristics with homelessness. RESULTS: Sixty percent (5394/8992) of the participants reported homelessness in the past year. The multivariable model demonstrated that PWID living in ZIP codes with higher levels of gentrification had higher odds of homelessness in the past year (gentrification: adjusted OR=1.11, 95% CI=1.04 to 1.17). CONCLUSIONS: Additional research is needed to determine the mechanisms through which gentrification increases homelessness among PWID to develop appropriate community-level interventions.