Racial/Ethnic Disparities in Club Drug Use, Situational Club Drug Use during Sex, and Sexual Risk Behaviors among Alcohol-Using Men Who Have Sex with Men (MSM) in San Francisco.

BACKGROUND: Club drug use-including 3,4-Methylenedioxymethamphetamine, ketamine, crack/cocaine, hallucinogens, gamma hydroxybutyrate, volatile nitrites, and methamphetamine-has been linked to sexual risk behaviors among MSM. Few studies examine how the use of club drugs and the association between club drug use during sex and sexual risk may differ by race/ethnicity. METHODS: Using data from a cross-sectional study among alcohol-using MSM in San Francisco (n = 252), we examined the associations between the interaction of race/ethnicity and club drug use during sex, and the following behavioral outcomes: any condomless anal intercourse (CAI), insertive CAI, receptive CAI, and any serodiscordant sex in the past six months. All models controlled for income, HIV status, relationship status, age, and current use of a biomedical HIV prevention tool (i.e., Pre-Exposure Prophylaxis [PrEP] or antiretroviral therapy). RESULTS: There were significant racial differences in club drug use (p < 0.001) and club drug use during sex (p = 0.01). Asian/Pacific Islander (API) and Latino participants reported using club drugs the most at 78.8% and 79%, respectively. Among users of club drugs, club drug use during sex was most common among Black (100%), and Latino MSM (93%). Significant interactions between race/ethnicity and club drug use during sex were observed for CAI (p = 0.02), insertive CAI (p = 0.01), and receptive CAI (p = 0.01). API participants who used club drug during sex had higher odds of reporting CAI (aOR = 15.27, CI = 1.50-155.34), insertive CAI (aOR = 21.11, CI = 2.04-218.10), and receptive CAI (aOR = 21.11, CI = 2.04-218.10). CONCLUSIONS: Given the differing rates of club drug use during sex by race/ethnicity and the role race/ethnicity plays in modifying the relationships between club drug use during sex and sexual risk behaviors, culturally-tailored interventions may be needed to address the needs of ethnically-diverse, club drug-using MSM.

Socio-ecological Barriers to Viral Suppression Among Transgender Women Living with HIV in San Francisco and Los Angeles, California.

Troubling disparities in viral suppression persist among transgender (trans) women living with HIV in the US. We utilized baseline data from a randomized controlled trial of a behavioral intervention among trans women living with HIV in San Francisco and Los Angeles, to identify the socio-ecological correlates of biologically confirmed viral suppression (< 200 HIV-1 RNA copies/mL). Among 253 participants, the mean age was 43 (SD = 11), 46% identified as Black or African American and 35% were virally non-suppressed. In adjusted Poisson regression models, the following barriers to viral suppression were identified: injection drug use [adjusted risk ratio (aRR) 0.78, 95% CI 0.65-0.93, Z = - 2.64, p = 0.008], methamphetamine use (aRR 0.65, 95% CI 0.51-0.83, Z = - 3.45, p = 0.001), amphetamine use (aRR 0.62, 95% CI 0.44-0.87, Z = - 2.75, p = 0.006), homelessness (aRR 0.79, 95% CI 0.63-0.98, Z = - 2.06, p = 0.039), and sex work (aRR 0.60, 95% CI 0.41-0.86, Z = - 2.77, p = 0.009). These findings underscore the importance of interventions that address the socio-ecological barriers to viral suppression among trans women in urban settings.

RESUMEN: Persisten disparidades preocupantes en la supresión viral entre las mujeres transgénero (trans) que viven con el VIH en los EE. UU. Utilizamos datos de referencia de un ensayo controlado aleatorizado de una intervención conductual entre mujeres trans que viven con el VIH en San Francisco y Los Ángeles, para identificar los correlatos socioecológicos de la supresión viral confirmada biológicamente (< 200 copias/ml de ARN del VIH-1). Entre 253 participantes, la edad media fue de 43 años (DE = 11), el 46% se identificó como negro o afroamericano y el 35% no tenía supresión viral. En modelos de regresión de Poisson ajustados, se identificaron las siguientes barreras para la supresión viral: uso de drogas inyectables [razón de riesgo ajustada (aRR) 0,78, IC del 95% 0,65­0,93, Z = − 2,64, p = 0,008], uso de metanfetamina (aRR 0,65, IC 95% 0,51­0,83, Z = − 3,45, p = 0,001), consumo de anfetaminas (aRR 0,62, IC 95% 0,44­0,87, Z = − 2,75, p = 0,006), falta de vivienda (aRR 0,79, IC 95% 0,63­0,98, Z = − 2,06, p = 0,039), y trabajo sexual (aRR 0,60, IC 95% 0,41­0,86, Z = − 2,77, p = 0,009). Estos hallazgos subrayan la importancia de las intervenciones que abordan las barreras socioecológicas para la supresión viral entre las mujeres trans en entornos urbanos.

Influence of depression and interpersonal support on adherence to antiretroviral therapy among people living with HIV.

BACKGROUND: Poor adherence and under-utilization of antiretroviral therapy (ART) services have been major setbacks to achieving 95-95-95 policy goals in Sub-Saharan Africa. Social support and mental health challenges may serve as barriers to accessing and adhering to ART but are under-studied in low-income countries. The purpose of this study was to examine the association of interpersonal support and depression scores with adherence to ART among persons living with HIV (PLWH) in the Volta region of Ghana. METHODS: We conducted a cross-sectional survey among 181 PLWH 18 years or older who receive care at an ART clinic between November 2021 and March 2022. The questionnaire included a 6-item simplified ART adherence scale, the 20-item Center for Epidemiologic Studies Depression Scale (CES-D), and the 12-item Interpersonal Support Evaluation List-12 (ISEL-12). We first used a chi-squared or Fisher's exact test to assess the association between these and additional demographic variables with ART adherence status. We then built a stepwise multivariable logistic regression model to explain ART adherence. RESULTS: ART adherence was 34%. The threshold for depression was met by 23% of participants, but it was not significantly associated with adherence in multivariate analysis(p = 0.25). High social support was reported by 48.1%, and associated with adherence (p = 0.033, aOR = 3.45, 95% CI = 1.09-5.88). Other factors associated with adherence included in the multivariable model included not disclosing HIV status (p = 0.044, aOR = 2.17, 95% CI = 1.03-4.54) and not living in an urban area (p = 0.00037, aOR = 0.24, 95% CI = 0.11-0.52). CONCLUSION: Interpersonal support, rural residence, and not disclosing HIV status were independent predictors of adherence to ART in the study area.

Prevalence and correlates of methamphetamine use in transitional age youth experiencing homelessness or housing instability in San Francisco, CA.

INTRODUCTION: Substance use, including methamphetamine use, is a contributing factor in HIV acquisition and treatment. Stimulant use is linked to mental health yet there is limited data from youth in community-based settings. DESIGN: One hundred marginally housed or homeless transitional age youth (TAY) were recruited at Larkin Street Youth Services and completed a survey on mental health and substance use. METHODS: We conducted secondary data analysis using multivariable logistic regression models to identify the correlates of methamphetamine use among TAY. RESULTS: The participants' mean age was 22. Of those who reported methamphetamine use in the past 3 months, 64% were Gay, Bisexual, or Pansexual. Factors independently associated with methamphetamine use were; living with HIV (adjusted odds ratio [aOR] = 3.18, 95% CI = 1.11-9.15), depressive symptoms (aOR = 6.02, 95% CI = 1.46-24.78), symptoms of PTSD (aOR = 13.38, 95% CI = 1.59-112.73), polysubstance use in the past 3 months (aOR = 50.02, 95% CI = 9.72-257.46) and a history of injection drug use (aOR = 8.38, 95% CI = 1.87-37.53). CONCLUSIONS: Results from this study suggest a need to develop, adapt, and rapidly implement comprehensive interventions that address the combined epidemics of substance use, HIV, and mental health among TAY. CLINICAL RELEVANCE: This article examines factors associated with methamphetamine use among transitional age youth (TAY) experiencing homelessness or housing instability. Several factors were associated with use, including depression, PTSD, HIV status, polysubstance use, and injection drug use. These findings highlight the need for nurses to assess for methamphetamine use among youth as well as associated mental health and physical health problems. Nurses should link TAY who are using methamphetamine to evidence-based treatment programs to address substance use and comorbid conditions.

Correlates of high phosphatidylethanol (PEth) levels and their concordance with self-reported heavy alcohol consumption among men who have sex with men who binge drink alcohol.

BACKGROUND: Heavy alcohol use, including binge drinking, is associated with high morbidity and mortality among men who have sex with men (MSM). Self-reported alcohol measures may lead to inaccurate estimates due to recall and social desirability biases. Objective alcohol biomarkers like phosphatidylethanol (PEth) can be used to corroborate self-report and could help to inform treatment approaches and research strategies for alcohol using MSM. METHODS: From 2015 to 2020, alcohol using MSM ≥18 years were enrolled in a randomized controlled trial evaluating the efficacy of naltrexone in reducing binge drinking. Using this trial's baseline data, we applied multivariable logistic regression to identify the correlates of high PEth levels (i.e., ≥87 ng/ml) and concordance between PEth levels and self-reported heavy drinking. RESULTS: Of 118 MSM, 64% had PEth levels ≥87 ng/ml and 72% had PEth levels that were concordant with self-reported heavy alcohol use. Factors significantly associated in separate models with elevated PEth levels were income ≥$60,000 (adjusted odds ratio [aOR] = 4.09; 95% CI = 1.13 to 14.82), being employed (aOR = 4.04; 95% CI = 1.45 to 11.32), episodic cannabis use (aOR = 4.63; 95% CI = 1.27 to 16.92), and any alcohol/substance use prior to or during anal intercourse (aOR = 2.52; 95% CI = 1.08 to 5.90). Living with HIV was associated with significantly lower odds of elevated PEth levels (aOR = 0.23; 95% CI = 0.09 to 0.61). Factors associated with significantly higher concordance between PEth levels and self-reported heavy alcohol use included at least weekly use of poppers (aOR = 6.41; 95% CI = 1.27 to 32.28) and polysubstance use (aOR = 2.53; 95% CI = 1.02 to 6.27). Living with HIV was associated with lower odds of concordance (aOR = 0.36; 95% CI = 0.14 to 0.97). CONCLUSIONS: PEth may enhance the detection of heavy drinking among MSM, including the identification of subpopulations that may benefit from targeted alcohol reduction interventions. However, PEth values for MSM living with HIV showed modest concordance with self-reported alcohol use and may need to be supplemented with additional biomarkers or evaluated against a different cutoff.

Prevalence and correlates of substance use and associations with HIV-related outcomes among trans women in the San Francisco Bay Area.

BACKGROUND: Trans women face tremendous social inequities as well as disproportionate rates of HIV and substance use, yet disaggregated substance use data specific to trans women remain limited. METHODS: We conducted a secondary analysis of baseline data from the Trans*National Study (2016-2017) surveying trans women in the San Francisco Bay Area (n = 629). Multivariable logistic regression was used to analyze socio-demographic and environmental correlates of substance use, and bivariate associations between substance use and HIV-associated outcomes are presented alongside prevalence data. RESULTS: Over half (52.9%) reported using substances in the prior year, most frequently marijuana, methamphetamine, and crack/cocaine. Those with unmet gender-affirming health care needs, lack of insurance, or a history of experiencing racial violence, transphobic violence, adult housing instability, or extreme poverty had higher odds of substance use. Sex work and condomless anal sex were also independently associated with substance use. CONCLUSIONS: Among this sample of trans women, substance use and substance use concurrent with sex were highly prevalent, and associated with a number of socioeconomic and health care needs. These findings corroborate the need for holistic and intersectional efforts to reduce substance use and HIV risk.

Stimulant use for self-management of pain among safety-net patients with chronic non-cancer pain.

BACKGROUND: Chronic pain affects one-fifth of US adults. Reductions in opioid prescribing have been associated with increased non-prescription opioid use and, chronologically, increased stimulant (methamphetamine and cocaine) use. While non-prescription opioid use is commonly attributed to pain self-management, the role of stimulants in managing pain is unclear. METHODS: We analyzed baseline data from a longitudinal study of patients with chronic non-cancer pain in an urban safety-net healthcare system who had been prescribed an opioid for ≥3 of the last 12 months, and had a history of non-prescription opioid, cocaine, or amphetamine use (N = 300). We estimated the prevalence and identified correlates of stimulant use to treat pain among a subgroup of patients who reported past-year stimulant use (N = 105). Data sources included computer-assisted questionnaire (demographics, substance use, pain), clinical exam and procedures (pain, pain tolerance), and chart abstraction (opioid prescriptions). We conducted bivariate analyses to assess associations between demographics, pain characteristics, non-opioid therapies, substance use, opioid prescriptions, and self-reported symptoms, with reporting using stimulants to treat pain. Demographic variables and those with significant bivariate associations were included in a multivariable logistic regression model. RESULTS: Fifty-two percent of participants with past-year stimulant use reported using stimulants in the past year to treat pain. Participants who used stimulants for pain reported slightly higher average pain in the past 3 months (median of 8 (IQR: 6-8) vs 7 (7-9) out of 10, p = 0.049). In the multivariable analysis, female gender (AOR= 3.20, 95% CI: 1.06-9.63, p = 0.039) and higher score on the Douleur Neuropathique 4 neuropathic pain questionnaire (AOR = 1.34, 95% CI: 1.05-1.70, p = 0.017) were associated with past-year stimulant use to treat pain. CONCLUSION: Stimulants may be used for pain self-management, particularly for neuropathic pain and among women. Our findings suggest an underexplored motivation for stimulant use in an era of reduced access to prescribed opioids.

Economic, Mental Health, HIV Prevention and HIV Treatment Impacts of COVID-19 and the COVID-19 Response on a Global Sample of Cisgender Gay Men and Other Men Who Have Sex with Men.

There is an urgent need to measure the impacts of COVID-19 among gay men and other men who have sex with men (MSM). We conducted a cross-sectional survey with a global sample of gay men and other MSM (n = 2732) from April 16, 2020 to May 4, 2020, through a social networking app. We characterized the economic, mental health, HIV prevention and HIV treatment impacts of COVID-19 and the COVID-19 response, and examined whether sub-groups of our study population are disproportionately impacted by COVID-19. Many gay men and other MSM not only reported economic and mental health consequences, but also interruptions to HIV prevention and testing, and HIV care and treatment services. These consequences were significantly greater among people living with HIV, racial/ethnic minorities, immigrants, sex workers, and socio-economically disadvantaged groups. These findings highlight the urgent need to mitigate the negative impacts of COVID-19 among gay men and other MSM.

RESUMEN: Existe una necesidad urgente para medir los impactos de COVID-19 entre hombres gay y otros hombres que tienen sexo con hombres (HSH). Hemos conducido una encuesta multifuncional con una prueba mundial de hombres gay y otros HSH (n = 2732) desde el 16 de Abril hasta el 4 de Mayo del 2020, a través de una aplicación de red social. Nosotros caracterizamos los impactos económicos, de salud mental, prevención del VIH y tratamiento del VIH e impactos a COVID-19 y la respuesta de COVID-19, y examinamos si subgrupos de nuestra población de estudio fueron impactados desproporcionadamente por COVID-19. Muchos hombres no tan solo reportaron consecuencias económicas y de salud mental, sino también interrupciones de prevención y de pruebas de VIH, y cuidado del VIH y servicios de tratamiento. Encontramos consecuencias más significantes entre personas viviendo con VIH, grupos raciales/etnicos, migrantes, sexo servidores, y groupos socioeconomicamente disfavorecidos. Los resultados subrayan la necesidad crucial de mitigar los impactos multifacéticos de COVID-19 entre los hombres homosexuales y otros HSH, especialmente para aquellos con vulnerabilidades entrelazadas.

Partnership-level correlates of sexual risk taking within the sexual partnerships of young transwomen in San Francisco, California.

OBJECTIVES: Little is known about the sexual networks of young transwomen, leaving a major gap in what we know about transmission dynamics and the elevated rates of HIV in this population. The objective of this study was to understand partnership-level factors associated with condomless anal sex among young transwomen. METHODS: A secondary data analysis of the sexual partnerships of young transwomen was conducted using baseline data from the SHINE study. Generalised estimating equation logistic regressions were used to assess for partnership-level associations between partnership type, age, injection drug use and racial concordance, HIV seroconcordance, sexual role and condomless receptive (CRAI) and insertive anal intercourse (CIAI). RESULTS: Our analysis included 187 young transwomen that reported a total of 464 sexual partnerships where they had at least one episode of anal sex in the past 6 months. We found casual (n=232 or 50%) and commercial partnerships (n=106 or 22.8%) to be significantly associated with a lower odds of CIAI (OR=0.53, 95% CI 0.32 to 0.86 and OR=0.39, 95% CI 0.18 to 0.82) and CRAI (OR=0.30, 95% CI 0.19 to 0.47 and OR=0.35, 95% CI 0.2 to 0.62) compared with main partnerships (n=126 or 27.2%). Additionally, HIV-positive seroconcordant (n=25 or 5.4%, OR=4.05, 95% CI 1.44 to 11.40) and injection-drug using partnerships (n=25 or 5.4%, OR=3.66, 95% CI 1.34 to 9.95) were found to be significantly associated with an increased odds of CIAI among participants compared with HIV-negative seroconcordant (n=330 or 71.1%) and non-using partnerships (n=338 or 72.8%), respectively. CONCLUSION: Young transwomen, like other populations, engage in condomless sex more often with main than casual and commercial partners, suggesting a need for interventions that address sexual practices with steady main partners.

Psychometric properties of measures of substance use: a systematic review and meta-analysis of reliability, validity and diagnostic test accuracy.

BACKGROUND: Synthesis of psychometric properties of substance use measures to identify patterns of use and substance use disorders remains limited. To address this gap, we sought to systematically evaluate the psychometric properties of measures to detect substance use and misuse. METHODS: We conducted a systematic review and meta-analysis of literature on measures of substance classes associated with HIV risk (heroin, methamphetamine, cocaine, ecstasy, alcohol) that were published in English before June 2016 that reported at least one of the following psychometric outcomes of interest: internal consistency (alpha), test-retest/inter-rater reliability (kappa), sensitivity, specificity, positive predictive value, and negative predictive value. We used meta-analytic techniques to generate pooled summary estimates for these outcomes using random effects and hierarchical logistic regression models. RESULTS: Findings across 387 paper revealed that overall, 65% of pooled estimates for alpha were in the range of fair-to-excellent; 44% of estimates for kappa were in the range of fair-to-excellent. In addition, 69, 97, 37 and 96% of pooled estimates for sensitivity, specificity, positive predictive value, and negative predictive value, respectively, were in the range of moderate-to-excellent. CONCLUSION: We conclude that many substance use measures had pooled summary estimates that were at the fair/moderate-to-excellent range across different psychometric outcomes. Most scales were conducted in English, within the United States, highlighting the need to test and validate these measures in more diverse settings. Additionally, the majority of studies had high risk of bias, indicating a need for more studies with higher methodological quality.

Low PrEP Awareness and Use Among People Who Inject Drugs, San Francisco, 2018.

We examined PrEP awareness and use among people who inject drugs (PWID) in San Francisco in 2018. Of 397 respondents not known to be HIV positive, 56.7% had heard of PrEP, 38.9% knew that PrEP can prevent HIV transmission from sharing injection equipment, 13.6% had discussed PrEP with a health care provider, and 3.0% had used PrEP in the last 12 months. All seven male PWID who had used PrEP were also men who had sex with men. There is urgent need to improve messaging on PrEP's effectiveness for PWID and to tailor ways of engaging PWID in PrEP programs.

Perceived Causes of Personal versus Witnessed Overdoses among People who Inject Opioids.

Background: Studies show that people who inject drugs (PWID) underestimate their overdose risk. We sought to explore this phenomenon by comparing how PWID perceive causes of personal overdoses compared to witnessed overdoses. Methods: We analyzed 40 interviews from participants enrolled in a randomized-controlled behavioral intervention to reduce overdose among at-risk PWID in San Francisco from 2014 to 2016. Subjects were current illicit opioid injectors with opioid use disorder, had received take-home naloxone, and had overdosed within five years. Interviews were audio-recorded and transcribed verbatim. Using thematic content analysis, three analysts coded the interviews and measured interrater reliability. The analysts developed a codebook of a priori and inductively generated codes, and applied it to all interviews. Coding discrepancies were discussed. Results: We used two theoretical frameworks - actor observer bias (AOB) and intragroup stigma - to analyze participants' descriptions of personal and witnessed overdoses. AOB suggests individuals may assign responsibility of their actions to external factors, while assigning responsibility for others' actions to internal mechanisms. Intragroup stigma describes the process whereby people perpetuate stigma within their own group. Related to these concepts, two principal themes were used to describe personal overdose: (1) drug volatility and (2) ascribing blame to others, and witnessed overdoses: (1) greed and (2) inexperience/foolishness. Conclusion/Importance: The differences in perceived causes of personal versus witnessed overdose align with AOB and intragroup stigma. Understanding how these theories shape overdose experiences may improve behavioral interventions by introducing peer based supports and encouraging PWIDs to employ evidence-based safety precautions when using opioids.

Drug use patterns and predictors among homeless youth: Results of an ecological momentary assessment.

BACKGROUND: Alcohol and drug use is associated with significant morbidity and mortality and is highly prevalent among homeless youth. Ecological Momentary Assessments (EMA) have been used to examine the effect of urges on drug use, though not among homeless youth. OBJECTIVES: We assessed the patterns of drug use and the correlation between real-time contextual factors and drug use using EMA collected daily. We identified predictors of drug use among a sample of homeless youth 18-25 years old in Houston, Texas. METHODS: Homeless youth (n = 66, 62% male) were recruited from a drop-in center between September 2015 and May 2016. We used generalized linear mixed models and cross-validation methods to determine the best predictive model of drug use. RESULTS: The overall drug use was high: 61% and 32% of participants reported using drugs or alcohol at least one day, respectively. Marijuana and synthetic marijuana use (i.e., Kush, K2, incense packs) were reported most frequently; 86% and 13% of the total drug use EMAs, respectfully. Drug use urge was reported on 26% of days and was the highest on drug use days. Drug use was predicted by discrimination, pornography use, alcohol use, and urges for drugs, alcohol, and to steal. CONCLUSIONS: EMA can be used to predict drug use among homeless youth. Drug use treatment among homeless youth should address the role of experiencing discrimination, pornography and alcohol use, and urge management strategies on drug use. Research is needed to determine if EMA informed just-in-time interventions targeting these predictors can reduce use.

Correlates of Validity of Self-Reported Methamphetamine Use among a Sample of Dependent Adults.

BACKGROUND: Self-reported data are widely used in substance-use research, yet few studies have assessed the validity of self-reported methamphetamine use compared to biological assays. OBJECTIVES: We sought to assess the validity and correlates of validity of self-reported methamphetamine use compared to urine toxicology (UTOX). METHODS: Using a sample of methamphetamine-dependent individuals enrolled in a randomized controlled pharmacotherapy trial in the United States (n = 327 visits among 90 participants), we calculated sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and the kappa coefficient of self-reported methamphetamine use in the past 3 days compared to UTOX, as well as the NPV of self-reported methamphetamine use over an extended recall period of 1 month. We used multivariable logistic regression models to assess correlates of concordance between self-reported methamphetamine use and UTOX. RESULTS: The sensitivity of self-reported methamphetamine use in the past 3 days was 86.7% (95% confidence intervals (95%CI): 81.4%-91.4%), the specificity was 85.3% (77.7-91.3), the PPV was 91.5% (86.9-94.8), and the NPV was 78.0% (69.4-86.1), compared to UTOX (kappa = 0.71). The NPV over the extended recall period was 70.6% (48.0-85.7). In multivariable analyses, validity of self-reported methamphetamine use was higher for older participants but lower during follow-up compared to baseline and when polysubstance use or depressive symptoms were reported. Conclusions/Importance: Our sample of methamphetamine-dependent adults reported recent methamphetamine use with high validity compared to UTOX. Validity increased with age but decreased when participants reported depressive symptoms or polysubstance use as well as later in the study timeline and during longer recall periods.

Reductions in access to HIV prevention and care services are associated with arrest and convictions in a global survey of men who have sex with men.

OBJECTIVES: Men who have sex with men (MSM) are disproportionately impacted by HIV. Criminalisation of homosexuality may impede access to HIV services. We evaluated the effect of the enforcement of laws criminalising homosexuality on access to services. METHODS: Using data from a 2012 global online survey that was published in a prior paper, we conducted a secondary analysis evaluating differences in perceived accessibility to health services (ie, 'how accessible are ____' services) between MSM who responded 'yes'/'no' to: 'have you ever been arrested or convicted for being gay/MSM?' RESULTS: Of the 4020 participants who completed the study and were included in the analysis, 8% reported ever being arrested or convicted under laws relevant to being MSM. Arrests and convictions were most common in sub-Saharan Africa (23.6% (58/246)), Eastern Europe/Central Asia (18.1% (123/680)), the Caribbean (15% (15/100)), Middle East/North Africa (13.2% (10/76)) and Latin America (9.7% (58/599)). Those arrested or convicted had significantly lower access to sexually transmitted infection treatment (adjusted OR (aOR)=0.81; 95% CI 0.67 to 0.97), condoms (aOR=0.77; 95% CI 0.61 to 0.99) and medical care (aOR=0.70; 95% CI 0.54 to 0.90), compared with other MSM, while accounting for clustering by country and adjusting for age, HIV status, education and country-level income. CONCLUSIONS: Arrests and convictions under laws relevant to being MSM have a strong negative association with access to HIV prevention and care services. Creating an enabling legal and policy environment, and increasing efforts to mitigate antihomosexuality stigma to ensure equitable access to HIV services are needed, along with decriminalisation of homosexuality, to effectively address the public health needs of this population.

Acceptability of Naloxone Co-Prescription Among Primary Care Providers Treating Patients on Long-Term Opioid Therapy for Pain.

BACKGROUND: Naloxone co-prescription is recommended for patients on long-term opioids for pain, yet there are few data on the practice. OBJECTIVE: To explore naloxone co-prescribing acceptability among primary care providers for patients on long-term opioids. DESIGN: We surveyed providers at six safety-net primary care clinics in San Francisco that had initiated naloxone co-prescribing. Providers were encouraged to offer naloxone to patients on long-term opioids or otherwise at risk of witnessing or experiencing an overdose. Surveys were administered electronically 4 to 11 months after co-prescribing began. KEY RESULTS: One hundred eleven providers (69 %) responded to the survey, among whom 41.4 % were residents; 40.5 % practiced internal medicine and 55.0 % practiced family medicine. Most (79.3 %) prescribed naloxone, to a mean of 7.7 patients; 99.1 % were likely to prescribe naloxone in the future. Providers reported they were likely to prescribe naloxone to most patients, including those on low doses, defined as <20 morphine equivalent mg daily (59.8 %), ≥65 years old (83.9 %), with no overdose history (80.7 %), and with no substance use disorder (73.6 %). Most providers felt that prescribing naloxone did not affect their opioid prescribing, 22.5 % felt that they might prescribe fewer opioids, and 3.6 % felt that they might prescribe more. Concerns about providing naloxone were largely administrative, relating to time and pharmacy or payer logistics. Internists (incidence rate ratio [IRR] = 0.49, 95 % CI = 0.26-0.93, p = 0.029), those licensed for 5-20 years (IRR = 2.10, 95 % CI = 1.35-3.25, p = 0.001), and those with more patients prescribed long-term opioids (IRR = 1.10, 95 % CI = 1.05-1.14, p <0.001) were independently more likely to prescribe a greater number of naloxone compared to participants without these exposures. CONCLUSIONS: Naloxone co-prescription is considered acceptable among primary care providers. Barriers such as time and dispensing logistics may be alleviated by novel naloxone formulations intended for laypersons recently approved by the U.S. Food and Drug Administration.

Nonrandomized Intervention Study of Naloxone Coprescription for Primary Care Patients Receiving Long-Term Opioid Therapy for Pain.

BACKGROUND: Unintentional overdose involving opioid analgesics is a leading cause of injury-related death in the United States. OBJECTIVE: To evaluate the feasibility and effect of implementing naloxone prescription to patients prescribed opioids for chronic pain. DESIGN: 2-year nonrandomized intervention study. SETTING: 6 safety-net primary care clinics in San Francisco, California. PARTICIPANTS: 1985 adults receiving long-term opioid therapy for pain. INTERVENTION: Providers and clinic staff were trained and supported in naloxone prescribing. MEASUREMENTS: Outcomes were proportion of patients prescribed naloxone, opioid-related emergency department (ED) visits, and prescribed opioid dose based on chart review. RESULTS: 38.2% of 1985 patients receiving long-term opioids were prescribed naloxone. Patients prescribed higher doses of opioids and with an opioid-related ED visit in the past 12 months were independently more likely to be prescribed naloxone. Patients who received a naloxone prescription had 47% fewer opioid-related ED visits per month in the 6 months after receipt of the prescription (incidence rate ratio [IRR], 0.53 [95% CI, 0.34 to 0.83]; P = 0.005) and 63% fewer visits after 1 year (IRR, 0.37 [CI, 0.22 to 0.64]; P < 0.001) compared with patients who did not receive naloxone. There was no net change over time in opioid dose among those who received naloxone and those who did not (IRR, 1.03 [CI, 0.91 to 1.27]; P = 0.61). LIMITATION: Results are observational and may not be generalizable beyond safety-net settings. CONCLUSION: Naloxone can be coprescribed to primary care patients prescribed opioids for pain. When advised to offer naloxone to all patients receiving opioids, providers may prioritize those with established risk factors. Providing naloxone in primary care settings may have ancillary benefits, such as reducing opioid-related adverse events. PRIMARY FUNDING SOURCE: National Institutes of Health.

Availability and Use of Substance Abuse Treatment Programs Among Substance-Using Men Who Have Sex With Men Worldwide.

BACKGROUND: Substance use is common among men who have sex with men (MSM) worldwide, and epidemiologic data suggest that alcohol/substance-using MSM are at greater risk for HIV. However, there are scarce data on substance abuse treatment programs (SATPs) for substance-using MSM. OBJECTIVES: We examined proportions of substance use as well as SATP availability and use. We used multivariable regression models, controlling for potential confounders, to examine behavioral and demographic correlates of SATP availability and use. METHODS: This is a cross-sectional study of a multi-region, online sample of substance-using MSM. RESULTS: In this sample, 75% were substance-using MSM of whom 36% reported at-least-weekly use. Substance use was most prevalent among respondents from Eastern Europe/Central Asia (86%) and Latin America (79%). Among substance-using MSM, 96% and 33% reported alcohol intoxication and other substance use, respectively; 11% reported having high SATP availability; and 5% reported using SATPs. Controlling for global region of origin and age, high SATP availability was associated with high access to HIV risk-reduction education (aOR = 3.19; CI = 1.48-6.89), mental health services (aOR = 2.53; CI = 1.32-4.83), and medical care (aOR = 2.32; CI = 1.12-4.80); less than college-level education (aOR = 0.32; CI = 0.18-0.54); and higher comfort levels with providers (aOR = 1.75; CI = 1.30-2.37). Controlling for substance use frequency and personal income additionally, using SATPs was associated with higher levels of connection to the gay community (aOR = 2.76; CI = 1.22-6.22). CONCLUSION: In this global sample of MSM, we found high alcohol intoxication and other substance use proportions. Few substance-using MSM report SATP availability, highlighting the need to develop novel substance use programs outside traditional treatment settings.

Primary Care Patient Experience with Naloxone Prescription.

PURPOSE: Notwithstanding a paucity of data, prescription of the opioid antagonist naloxone to patients prescribed opioids is increasingly recommended in opioid stewardship guidelines. The aim of this study was to evaluate chronic pain patients' attitudes toward being offered a naloxone prescription and their experience with naloxone. METHODS: We interviewed 60 patients who received naloxone prescriptions across 6 safety-net primary care clinics (10 patients per clinic) from October 2013 to October 2015. We used a standardized questionnaire to collect information on substance use, perception of personal overdose risk, history of overdose, and experiences with naloxone prescription, including initial reaction, barriers to filling the prescription, storage and use of naloxone, associated behavioral changes, and opinions about future prescribing. RESULTS: Respondents were demographically similar to all clinic patients receiving opioid prescriptions. Ninety percent had never previously received a naloxone prescription, 82% successfully filled a prescription for naloxone, and 97% believed that patients prescribed opioids for pain should be offered naloxone. Most patients had a positive (57%) or neutral (22%) response to being offered naloxone, and 37% reported beneficial behavior changes after receiving the prescription; there were no harmful behavior changes reported. Although 37% had personally experienced an opioid-poisoning event (17% of which were described as bad reactions but consistent with an overdose) and 5% reported that the prescribed naloxone had been used on them, 77% estimated their risk of overdose as low. CONCLUSIONS: Primary care patients on opioids reported that receiving a prescription for naloxone was acceptable, the prescription reached patients who had not had access to naloxone, and having naloxone may be associated with beneficial changes in opioid use behaviors. Patients prescribed opioids may not interpret the terminology describing overdose to imply unintentional opioid poisoning.

Examining progress toward the UNAIDS 90-90-90 framework among men who have sex with men, San Francisco, 2014.

The Joint United Nations Programme on HIV/AIDS (UNAIDS) has published treatment goals toward ending the HIV epidemic. The worldwide goals are 90% of HIV-infected individuals diagnosed, 90% of those diagnosed taking anti-retroviral treatment and 90% of those on anti-retroviral treatment virally suppressed. In light of the UNAIDS goals and that five years have passed since the adoption of early HIV treatment, we examined the progress toward the 90-90-90 indicators among men who have sex with men (MSM) in San Francisco in 2014. Our data suggest that overall MSM have not yet reached the 90-90-90 goals. Our data also suggest that Black and Latino MSM are further from the goals than White MSM.