Associations between Rat Infestations and Mental Health Vary by Gender, Race, and Income in Chicago.

Rats are an understudied stressor for people in urban environments around the world but the effects may not be distributed equally among residents. In this study, we examined associations between residential rat sightings and mental health in Chicago, where rat complaints are the highest of any American city. We examined how this relationship varied by frequency of rat sightings, race, ethnicity, income, home ownership, and gender and explored potential psychosocial pathways (e.g., feelings about the home) between rat sightings and mental distress. We conducted a randomized household survey along an income gradient in 2021 and asked about depressive symptoms in the past week (i.e., Center for Epidemiologic Studies Depression scale), frequency of rat sightings in/around the home, perceptions of rats, neighborhood conditions, and socio-demographic characteristics. We used logistic regression to assess relationships among these variables for our entire sample and for specific demographics using stratified models. Respondents (n = 589; 409 complete cases) who saw rats in/around the home daily/almost daily had 5.5 times higher odds of reporting high depressive symptoms relative to respondents who saw rats less frequently after accounting for socio-demographics and neighborhood conditions. This relationship was significant for men and respondents with lower incomes or race or ethnicity other than white. Our results show that rat infestations should be considered a threat to mental health among urban residents. Increased mental health support for residents living in rat-infested housing may improve public health in cities.

Reported xylazine exposure highly associated with overdose outcomes in a rapid community assessment among people who inject drugs in Baltimore.

BACKGROUND: Addressing xylazine harms are now a critical harm reduction priority, but relatively little epidemiological information exists to determine prevalence, magnitude, and correlates of xylazine use or related outcomes. METHODS: We conducted a rapid behavioral survey among people who inject drugs (n = 96) in Baltimore November-December 2022. Using a novel indicator of self-reported presumed xylazine effects, we examined prevalence and sociodemographic correlates of past year presumed xylazine effects and association with overdose and wound-related outcomes. Chi-square and descriptive statistics were used to examine bivariate associations overall and separately for those who reported xylazine by name and by reported fentanyl use frequency. RESULTS: Almost two-thirds (61.5%) reported experiencing xylazine effects. There were no differences by socio-demographics, but xylazine effects were more commonly reported among those who reported injecting alone (66% vs 38%%, p < 0.007) and daily fentanyl use (47% vs 24% p < 0.003). Those reporting xylazine exposure was three times as likely to report overdose (32% vs 11%, p < 0.03) and twice as likely to have used naloxone (78% vs 46%, p < 0.003). They also more commonly reported knowing someone who died of an overdose (92% vs 76%, p < 0.09) and to report an abscess requiring medical attention (36% vs 19%, p < 0.80). These associations were higher among respondents who specifically named xylazine and those who used fentanyl more frequently, but fentanyl frequency did not fully explain the heightened associations with xylazine effects. CONCLUSIONS: This study provides insight into the scope of xylazine exposure and associated health concerns among community-based PWID and suggests measures that may be instrumental for urgently needed research.

Injection Behaviors and Use of Syringe Service Programs over Time among People Who Inject Drugs in Baltimore, Maryland.

Introduction: People who inject drugs (PWID) are at increased risk for infectious disease transmission, including hepatitis C and HIV. Understanding trends in injection risk behaviors and syringe service program (SSP) use over time can help improve infectious disease prevention and other harm reduction services. Methods: Using National HIV Behavioral Surveillance System data from Baltimore, Maryland, we examined changes in receptive sharing of (1) syringes, (2) injection equipment, (3) syringes to divide drugs; and (4) receipt of syringes from SSPs among PWID from 2009 to 2018 (n = 518 in 2009, n = 638 in 2012, n = 586 in 2015, and n = 575 in 2018) using unadjusted and adjusted logistic models calculated across time for the total sample. Results: The conditional probability of receptive sharing of syringes and receipt of syringes from SSPs remained relatively stable, while receptive sharing of injection equipment and receptive sharing of syringes to divide drugs dropped substantially after 2009. White race and daily injection frequency were positively associated with sharing syringes and injection equipment and negatively associated with SSP use over time. In 2015, there was a notable shift such that women were twice as likely as men to receive syringes from SSPs and less likely than men to report the use of shared syringes or equipment. Conclusion: Findings indicate overall steady or decreasing trends in injection risk and steady trends in SSP usage over time, with some notable improvements among women and indications of shifting drug market patterns. Injection-related risk behaviors remain high among White PWID and may require targeted outreach and interventions.

Drug Use-Related Discrimination in Healthcare Settings and Subsequent Emergency Department Utilization in a Prospective Cohort Study of People With a History of Injection Drug Use.

BACKGROUND:  People with a history of injection drug use face discrimination in healthcare settings that may impede their use of routine care, leading to greater reliance on the emergency department (ED) for addressing health concerns. The relationship between discrimination in healthcare settings and subsequent ED utilization has not been established in this population. METHODS:  This analysis used longitudinal data collected between January 2014 and March 2020 from participants of the ALIVE (AIDS Linked to the IntraVenous Experience) study, a community-based observational cohort study of people with a history of injection drug use in Baltimore, Maryland. Logistic regressions with generalized estimating equations were used to estimate associations between drug use-related discrimination in healthcare settings and subsequent ED utilization for the sample overall and six subgroups based on race, sex, and HIV status. RESULTS:  1,342 participants contributed data from 7,289 semiannual study visits. Participants were predominately Black (82%), mostly male (66%), and 33% were living with HIV. Drug use-related discrimination in healthcare settings (reported at 6% of study visits) was positively associated with any subsequent ED use (OR = 1.40, 95% CI: 1.15-1.72). Positive associations persisted after adjusting for covariates, including past sixth-month ED use and drug use, among the overall sample (aOR = 1.28, 95% CI: 1.04-1.59) and among some subgroups. CONCLUSIONS:  Drug use-related discrimination in healthcare settings was associated with greater subsequent ED utilization in this sample. Further exploration of mechanisms driving this relationship may help improve care and optimize healthcare engagement for people with a history of injection drug use.

Type of Exchange Sex and Associated Behaviors and Outcomes Among Cisgender Men and Women at Increased Risk for HIV via Heterosexual Transmission in Six U.S. Metropolitan Areas.

Exchange sex is associated with sexual risk behaviors and poor outcomes and different types may incur different levels of risk. We assessed risk profiles of different types of exchange sex among non-injecting cisgender men and women who participated in the 2019 National HIV Behavioral Surveillance project at six sites. Six percent of men and 19% of women reported exchange sex in the past year; most engaged in non-commercial exchange sex for drugs/money with smaller percentages reporting formal sex work or non-commercial exchange sex for goods or services other than drugs/money. Exchange sex was associated with sexual risk and prevention behaviors and psychosocial and sexual health outcomes and associations varied by type of exchange sex. Efforts to improve access to STI/HIV testing and PrEP may benefit from tailoring based on type of exchange sex. Findings indicate value in a broader definition of exchange sex with follow-up assessment of exchange sex typology.

Feasibility, acceptability and effectiveness of a culturally informed intervention to decrease stress and promote well-being in reservation-based Native American Head Start teachers.

BACKGROUND: While benefiting from strong cultural ties to family, land and culture Native Americans residing on reservations experience psychological distress at rates 2.5 times that of the general population. Treatment utilization for psychological health in reservation-based communities is low with access to culturally appropriate care lacking. Evidence suggests that for mental health treatment, Native Americans prefer culturally informed care that respects Native perspectives on health and well-being. METHODS: To decrease stress and promote well-being in tribal Head Start teachers we adapted and implemented a culturally focused intervention within a community-based participatory research framework using mixed methods. Feasibility and acceptability of the adapted 5-session curriculum was tested in a single arm intervention study with a sample of 18 teachers on the Fort Peck Reservation. Participants completed surveys at baseline and upon completion of the intervention. Within session observations and two post-intervention focus groups (n = 8, n = 10) were conducted to elaborate and explain the quantitative results eliciting participant experience of intervention effectiveness and feasibility, acceptably and appropriateness. Implementation outcomes were assessed quantitatively using the Acceptability of Intervention, Intervention Appropriateness, and Feasibility of Intervention measures. RESULTS: Quantitively, attendance rate overall was 93% with no dropouts. Pretest/posttest surveys were analyzed using t-tests and Hedges g to measure effect size. Contrary to our hypothesis, self-perceived stress showed a small positive effect size, indicating that participants were more stressed post intervention. However, depression decreased, with tribal identity and resilience showing positive effect sizes. Content analysis for the qualitative data collected within session observations and post intervention focus groups revealed how lifetime traumas were affecting participants, providing some explanation for the increase in stress. Teachers reported that the sessions helped their psychological health and well-being, supporting feasibility of future interventions. Acceptability scored highest with a mean (SD) of 4.25 (.84) out of 5, appropriateness 4.18 (.86) and feasibility 4.06 (.96) supporting intervention to be acceptable, appropriate, and feasible. CONCLUSION: Utilizing a culturally based intervention to buffer stress and support the well-being of reservation-based teachers showed promise in helping them recognize their cultural strengths, stress, and need for ongoing support. Implementation outcomes show that intervention scale-out is feasible.

Public perception of urban wildlife during a COVID-19 stay-at-home quarantine order in Chicago.

Reduced human activity to mitigate the spread of the COVID-19 pandemic was accompanied by reports of unusual wildlife sightings in highly developed areas. Such experiences with urban nature may have helped residents cope with the stress of the pandemic and increased public interest in urban wildlife; however, this may depend on the species residents encountered. In this study, we surveyed Chicago, Illinois, USA residents during a stay-at-home order to understand if residents in more affluent or greener neighborhoods saw more wildlife species. We also evaluated whether encounters with pest and non-pest species were associated with residents' values about wildlife. Of 593 responses included in our analyses, respondents in higher-income and greener neighborhoods were more likely to perceive increased wildlife sightings and respondents in higher-income areas reported observing a higher number common birds and mammals. Support for seeing wildlife in residential areas was associated with seeing passerine birds and not seeing rats during the stay-at-home order. Our results suggest that perceived increases in wildlife sightings were common during a stay-at-home order, especially for affluent residents, and that residents' perceptions depended on the species encountered. Understanding how changes in human behavior modifies human-wildlife interactions can help mitigate human-wildlife conflict and foster positive engagement with local wildlife. Supplementary Information: The online version contains supplementary material available at 10.1007/s11252-022-01284-x.

Metrics of Sexual Behavior Stigma Among Cisgender Men Who Have Sex With Men in 9 Cities Across the United States.

Men who have sex with men (MSM) in the United States are stigmatized for their same-sex practices, which can lead to risky sexual behavior, potentiating risk for human immunodeficiency virus (HIV) infection. Improved measurement is necessary for accurately reporting and mitigating sexual behavior stigma. We added 13 sexual behavior stigma items to local surveys administered in 2017 at 9 sites in the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance system, which uses venue-based, time-sampling procedures to survey cisgender MSM in US Census Metropolitan Statistical Areas. We performed exploratory factor analytical procedures on site-specific (Baltimore, Maryland; Denver, Colorado; Detroit, Michigan; Houston, Texas; Nassau-Suffolk, New York; Portland, Oregon; Los Angeles, California; San Diego, California; and Virginia Beach-Norfolk, Virginia) and pooled responses to the survey items. A 3-factor solution-"stigma from family" (α = 0.70), "anticipated health-care stigma" (α = 0.75), and "general social stigma" (α = 0.66)-best fitted the pooled data and was the best-fitting solution across sites. Findings demonstrate that MSM across the United States experience sexual behavior stigma similarly. The results reflect the programmatic utility of enhanced stigma measurement, including tracking trends in stigma over time, making regional comparisons of stigma burden, and supporting evaluation of stigma-mitigation interventions among MSM across the United States.

Associations between HIV testing and multilevel stigmas among gay men and other men who have sex with men in nine urban centers across the United States.

BACKGROUND: Complex manifestation of stigma across personal, community, and structural levels and their effect on HIV outcomes are less understood than effects in isolation. Yet, multilevel approaches that jointly assesses HIV criminalization and personal sexual behavior stigma in relation to HIV testing have not been widely employed or have only focused on specific subpopulations. The current study assesses the association of three types of MSM-related sexual behavior-related stigma (family, healthcare, general social stigma) measured at both individual and site levels and the presence/absence of laws criminalizing HIV transmission with HIV testing behaviors to inform HIV surveillance and prevention efforts among HIV-negative MSM in a holistic and integrated way. METHODS: We included nine National HIV Behavioral Surveillance (NHBS) 2017 sites: Baltimore, MD; Denver, CO; Detroit, MI; Houston, TX; Long Island/Nassau-Suffolk, NY; Los Angeles, CA; Portland, OR; San Diego, CA; and Virginia Beach and Norfolk, VA. Multivariable generalized hierarchical linear modeling was used to examine how sexual behavior stigmas (stigma from family, anticipated healthcare stigma, general social stigma) measured at the individual and site levels and state HIV criminalization legislation (no, HIV-specific, or sentence-enhancement laws) were associated with past-year HIV testing behaviors across sites (n = 3,278). RESULTS: The majority of MSM across sites were tested for HIV in the past two years (n = 2,909, 95.4%) with the average number of times tested ranging from 1.79 (SD = 3.11) in Portland, OR to 4.95 (SD = 4.35) in Los Angeles, CA. In unadjusted models, there was a significant positive relationship between stigma from family and being tested for HIV in the past two years. Site-level HIV-specific criminalization laws were associated with an approximate 5% reduction in the prevalence of receiving any HIV test in the past two years after individual level stigma and sociodemographic covariate adjustments (PR = 0.94, 95% CI, 0.90-0.99). CONCLUSIONS: Structural barriers faced by MSM persist and ending the HIV epidemic in the US requires a supportive legal environment to ensure effective engagement in HIV services among MSM. Home-based solutions, such as self-testing, used to deliver HIV testing may be particularly important in punitive settings while legal change is advocated for on the community and state levels.

"I don't feel safe sitting in my own yard": Chicago resident experiences with urban rats during a COVID-19 stay-at-home order.

BACKGROUND: Encounters with rats in urban areas increase risk of human exposure to rat-associated zoonotic pathogens and act as a stressor associated with psychological distress. The frequency and nature of human-rat encounters may be altered by social distancing policies to mitigate the COVID-19 pandemic. For example, restaurant closures may reduce food availability for rats and promote rat activity in nearby residential areas, thus increasing public health risks during a period of public health crisis. In this study, we aimed to identify factors associated with increased perceived exposure to rats during a stay-at-home order, describe residents' encounters with rats relevant to their health and well-being, and identify factors associated with increased use of rodent control. METHODS: Urban residents in Chicago, a large city with growing concerns about rats and health disparities, completed an online questionnaire including fixed response and open-ended questions during the spring 2020 stay-at-home order. Analyses included ordinal multivariate regression, spatial analysis, and thematic analysis for open-ended responses. RESULTS: Overall, 21% of respondents (n = 835) reported an increase in rat sightings around their homes during the stay-at-home order and increased rat sightings was positively associated with proximity to restaurants, low-rise apartment buildings, and rat feces in the home (p ≤ 0.01). Many respondents described feeling unsafe using their patio or yard, and afraid of rats entering their home or spreading disease. Greater engagement with rodent control was associated with property ownership, information about rat control, and areas with lower incomes (p ≤ 0.01). CONCLUSIONS: More frequent rat encounters may be an unanticipated public health concern during periods of social distancing, especially in restaurant-dense areas or in low-rise apartment buildings. Rat presence may also limit residents' ability to enjoy nearby outdoor spaces, which otherwise might buffer stress experienced during a stay-at-home order. Proactive rat control may be needed to mitigate rat-associated health risks during future stay-at-home orders.

HIV and employment among Black men who have sex with men in Baltimore.

Employment status is a key social determinant of health, and many populations in the United States that are impacted by HIV have unequal access to education and employment opportunities which contributes to HIV-related disparities. Black men who have sex with men (BMSM) are one of the groups most heavily burdened by HIV. With improved health outcomes associated with advancements in HIV treatment, research suggests that more people living with HIV want to work. This study describes employment among BMSM living in Baltimore, assesses differences in employment by HIV status and assesses predictors of full-time employment among BMSM. The study found that BMSM have limited access to full-time employment and that this disparity is even more pronounced among BMSM living with HIV. Men living with HIV were less likely to be employed full-time compared to men not living with HIV controlling for education and social contextual factors (OR 0.40 95% CI (0.22-0.73)). HIV will most likely have important implications for employment patterns and trajectories of BMSM over the life course. Additional research is needed among BMSM living with HIV to understand work histories and experiences, facilitating factors, and the impact of various work experiences on the health and wellbeing.

Social Stability Relates Social Conditions to the Syndemic of Sex, Drugs, and Violence.

The distribution of violence, sexually transmitted infections, and substance use disorders is not random, but rather the product of disease, behavior, and social conditions that co-occur in synergistic ways (syndemics). Syndemics often disproportionately affect urban communities. Studies of syndemics, however, rarely apply consistent measures of social conditions. Here, the construct of social stability (SS) (housing, legal, residential, income, employment, and relationship stability) was evaluated as a consistent measure of social conditions related to sex, drug, and violence exposures in a new population in a Mid-Atlantic urban center. Lower SS predicted greater likelihood of any and combinations of risk. The magnitude varied based on specification: odds of sex-drug-violence exposure were greater for low vs. high latent SS class (OR = 6.25; 95%CI = 2.46, 15.96) compared with low vs. high SS category (OR = 2.64; 95%CI = 1.29, 5.39). A latent class characterized by residential instability was associated with greater likelihood of risk-a relationship that would have been missed with SS characterized only as an ordinal category. SS reliably captured social conditions associated with sexual, drug, and violence risks, and both quantity and quality of SS matter.

Collecting sexual orientation and gender identity information in the emergency department : the divide between patient and provider perspectives.

BACKGROUND: In the USA, The Joint Commission and Institute of Medicine have called for collection of patient sexual orientation (SO) and gender identity (GI) information in healthcare. In a recent study, we reported that ED clinicians believe patients will refuse to provide this information; however, very few patients say they would refuse to provide SO/GI. As part of this study, we interviewed patients and providers regarding the importance of collecting this information. While these interviews were briefly summarised in our prior report, the qualitative data warranted a more thorough analysis and exposition to explore provider and patient views as well as risks and benefits of collecting SO/GI. METHODS: A purposive sample of 79 participants was recruited for semi-structured interviews between August 2014 and January 2015. Participants included community members who had a previous ED encounter and ED providers from 3 community and 2 academic centres in a major US metropolitan area. Interviews were conducted one-on-one in person, audio-recorded and transcribed verbatim. Data were analysed using the constant comparative method. RESULTS: Fifty-three patients and 26 ED providers participated. Patients perceived collection of SO/GI to be important in most clinical circumstances because SO/GI is relevant to their identity and allows providers to treat the whole person. However, many providers felt SO/GI was not relevant in most clinical circumstances because similar care is provided to all patients regardless of SO/GI. Patients and providers agreed there are risks associated with collecting SO/GI in the ED. CONCLUSIONS: ED clinicians do not perceive routine collection of SO/GI to be medically relevant in most circumstances. However, patients feel routine SO/GI collection allows for recognition of individual identity and improved therapeutic relationships in the ED. These discordant perspectives may be hindering patient-centred care, especially for sexual and gender minority patients.

Impact of Providing Preexposure Prophylaxis for Human Immunodeficiency Virus at Clinics for Sexually Transmitted Infections in Baltimore City: An Agent-based Model.

BACKGROUND: Preexposure prophylaxis (PrEP) greatly reduces the risk of human immunodeficiency virus (HIV) acquisition, but its optimal delivery strategy remains uncertain. Clinics for sexually transmitted infections (STIs) can provide an efficient venue for PrEP delivery. METHODS: To quantify the added value of STI clinic-based PrEP delivery, we used an agent-based simulation of HIV transmission among men who have sex with men (MSM). We simulated the impact of PrEP delivery through STI clinics compared with PrEP delivery in other community-based settings. Our primary outcome was the projected 20-year reduction in HIV incidence among MSM. RESULTS: Assuming PrEP uptake and adherence of 60% each, evaluating STI clinic attendees and delivering PrEP to eligible MSM reduced HIV incidence by 16% [95% uncertainty range, 14%-18%] over 20 years, an impact that was 1.8 (1.7-2.0) times as great as that achieved by evaluating an equal number of MSM recruited from the community. Comparing strategies where an equal number of MSM received PrEP in each strategy (ie, evaluating more individuals for PrEP in the community-based strategy, because MSM attending STI clinics are more likely to be PrEP eligible), the reduction in HIV incidence under the STI clinic-based strategy was 1.3 (1.3-1.4) times as great as that of community-based delivery. CONCLUSIONS: Delivering PrEP to MSM who attend STI clinics can improve efficiency and effectiveness. If high levels of adherence can be achieved in this population, STI clinics may be an important venue for PrEP implementation.

Network Research Experiences in New York and Eastern Europe: Lessons for the Southern US in Understanding HIV Transmission Dynamics.

PURPOSE: This paper presents an overview of different kinds of risk and social network methods and the kinds of research questions each can address. RECENT FINDINGS: It also reviews what network research has discovered about how network characteristics are associated with HIV and other infections, risk behaviors, preventive behaviors, and care, and discusses some ways in which network-based public health interventions have been conducted. Based on this, risk and social network research and interventions seem both feasible and valuable for addressing the many public health and social problems raised by the widespread use of opioids in the US South.

Sexual Stigma Patterns Among Nigerian Men Who Have Sex with Men and Their Link to HIV and Sexually Transmitted Infection Prevalence.

Sexual stigma facilitates the spread of HIV and sexually transmitted infections (STIs) but little is known about stigma affecting Nigerian men who have sex with men (MSM). We assessed patterns of sexual stigma across Nigerian MSM and their relationship to HIV and STIs. Data were collected from the TRUST/RV368 Study, a prospective cohort of 1480 Nigerian MSM enrolled from March 2013 to February 2016 using respondent driven sampling. Structural equation modeling was utilized to assess the association between stigma classes and HIV and STI prevalence, adjusting for participants' characteristics. A dose-response association was found between stigma class and HIV prevalence (27, 40, 55%, overall χ2 p < 0.001) and STI prevalence (15, 21, 24%, overall χ2 p = 0.011). These data suggest that stigma mitigation strategies, combined with increased engagement of MSM and retention in the HIV care continuum, need to be a component of interventions focused on reducing HIV transmission risks among MSM in Nigeria.

Comparison of Self-report to Biomarkers of Recent HIV Infection: Findings from the START Trial.

Identifying individuals with recent HIV infection is critical to research related to viral reservoirs, outbreak investigations and intervention applications. A multi-assay algorithm (MAA) for recency of infection was used in conjunction with self-reported date of infection and documented date of diagnosis to estimate the number of participants recently infected in the Strategic Timing of AntiRetroviral Treatment (START) trial. We tested samples for three groups of participants from START using a MAA: (1) 167 individuals who reported being infected ≤ 6 months before randomization; (2) 771 individuals who did not know their date of infection but were diagnosed within 6 months before randomization; and (3) as controls for the MAA, 199 individuals diagnosed with HIV ≥ 2 years before randomization. Participants with low titer and avidity and a baseline viral load > 400 copies/mL were classified as recently infected. A significantly higher percentage of participants who self-reported being infected ≤ 6 months were classified as recently infected compared to participants diagnosed ≥ 2 years (65% [109/167] vs. 2.5% [5/199], p < 0.001). Among the 771 individuals who did not know their duration of infection at randomization, 206 (26.7%) were classified as recently infected. Among those diagnosed with HIV in the 6 months prior to enrollment, the 373 participants who reported recent infection (n = 167) or who had confirmed recent infection by the MAA (n = 206) differed significantly on a number of baseline characteristics from those who had an unknown date of infection and were not confirmed by the MAA (n = 565). Participants recently infected by self-report and/or MAA were younger, more likely to be Asian, less likely to be black, less likely to be heterosexual, more likely to be enrolled at sites in the U.S., Europe or Australia, and have higher HIV RNA levels. There was good agreement between self-report of recency of infection and the MAA. We estimate that 373 participants enrolled in START were infected within 6 months of randomization. Compared to those not recently infected, these participants were younger, had higher HIV RNA levels and were more likely to come from high income countries and from populations such as MSM with more regular HIV testing.

The Synergistic Impact of Sexual Stigma and Psychosocial Well-Being on HIV Testing: A Mixed-Methods Study Among Nigerian Men who have Sex with Men.

Although sexual stigma has been linked to decreased HIV testing among men who have sex with men (MSM), mechanisms for this association are unclear. We evaluated the role of psychosocial well-being in connecting sexual stigma and HIV testing using an explanatory sequential mixed methods analysis of 25 qualitative and 1480 quantitative interviews with MSM enrolled in a prospective cohort study in Nigeria from March/2013-February/2016. Utilizing structural equation modeling, we found a synergistic negative association between sexual stigma and suicidal ideation on HIV testing. Qualitatively, prior stigma experiences often generated psychological distress and perceptions of feeling unsafe, which decreased willingness to seek services at general health facilities. MSM reported feeling safe at the MSM-friendly study clinic but still described a need for psychosocial support services. Addressing stigma and unmet mental health needs among Nigerian MSM has the potential to improve HIV testing uptake.

Correlates of exchange sex among a population-based sample of low-income women who have heterosexual sex in Baltimore.

Sex exchange is associated with HIV and other morbidities yet has received little research, surveillance, and programmatic attention in the U.S. This study identified correlates of exchange sex and among low-income women in Baltimore, Maryland. Participants were recruited into the National HIV Behavioral Surveillance (NHBS) system in 2013 using respondent driven sampling (RDS) and completed a survey and HIV testing. The analytic sample (n = 253) consisted of women aged ≥18 years who had recent (past year) heterosexual sex. Multivariable logistic regression identified correlates of recent exchange sex. Independently associated with recent exchange sex were history of injection drug use (adjusted odds ratio (AOR) = 3.4, 95% CI: 1.1-10.3), recent prescription painkiller use (AOR = 3.7, 95% CI: 1.4-9.9), recent crack/cocaine use (AOR = 6.6, 95% CI: 2.1-20.9), recent arrest (AOR = 4.1, 95% CI: 1.2-14.8), and recent consistent condom use (AOR 1.1; 95% CI: 1.0-1.3). Women who exchanged sex exhibited heightened social and structural vulnerability and substance use. These data demonstrate the need for further research examining the context of exchange sex among low-income women and synergies between substance use and HIV risk.