Gender disparities in HIV treatment outcomes following release from jail: results from a multicenter study.

OBJECTIVES: We assessed gender differences in longitudinal HIV treatment outcomes among HIV-infected jail detainees transitioning to the community. METHODS: Data were from the largest multisite prospective cohort study of HIV-infected released jail detainees (n = 1270)-the Enhancing Linkages to HIV Primary Care and Services in Jail Setting Initiative, January 2008 and March 2011, which had 10 sites in 9 states. We assessed baseline and 6-month HIV treatment outcomes, stratifying by gender. RESULTS: Of 867 evaluable participants, 277 (31.9%) were women. Compared with men, women were more likely to be younger, non-Hispanic White, married, homeless, and depressed, but were similar in recent alcohol and heroin use. By 6 months postrelease, women were significantly less likely than men to experience optimal HIV treatment outcomes, including (1) retention in care (50% vs 63%), (2) antiretroviral therapy prescription (39% vs 58%) or optimal antiretroviral therapy adherence (28% vs 44%), and (3) viral suppression (18% vs 30%). In multiple logistic regression models, women were half as likely as men to achieve viral suppression. CONCLUSIONS: HIV-infected women transitioning from jail experience greater comorbidity and worse HIV treatment outcomes than men. Future interventions that transition people from jail to community-based HIV clinical care should be gender-specific.

Gender differences in baseline health, needs at release, and predictors of care engagement among HIV-positive clients leaving jail.

Women represent a significant and growing segment of jail detainees and persons living with HIV. This paper examines gender differences in health status, care and social service needs, and care engagement among jail releasees with HIV. Data are from 1,270 participants in the HRSA-funded Enhancing Linkages to HIV Primary Care and Social Services multisite demonstration project (EnhanceLink). Compared to men, more women reported homelessness, reduced adherence to prescribed ART, worse health, more severe substance use disorders, and more chronic health conditions. Men and women generally reported different needs post-release. As the number of expressed needs increased, women were more likely to drop out of care. Our findings suggest that effective and gender-specific strategies are required to identify needs, link services between jails and communities, and sustain retention of women with HIV in programs after release from criminal justice settings.

Crossing over: drug network characteristics and injection risk along the China-Myanmar border.

Border areas are important locations for understanding HIV transmission. This study examines individual and network correlates of border crossing and equipment sharing among methadone maintenance clients in Ruili City, a Chinese city on the Myanmar border. Data are from 298 clients enrolled in the Ruili Methadone Treatment Center. Clients were interviewed about drug use, HIV/AIDS knowledge, treatment motivation, and their social networks. Multinomial and logistic regression analysis were performed. Thirty percent of clients reported injecting in Myanmar. Compared to drug networks that usually inject in China, networks that inject equally in both places (border crossing) are more likely to share equipment. The association between HIV positive status and border-crossing was marginally significant and robust. Results indicate some added degree of risk among clients and drug networks who border-cross to use drugs. More research is needed to understand this phenomenon.

Race and distance effects on regular syringe exchange program use and injection risks: a geobehavioral analysis.

OBJECTIVES: We conducted "geobehavioral" analyses by race to understand how distances among injection drug users' (IDUs') residences, drug purchase and use locations, and syringe exchange programs (SEPs) are associated with injection behaviors. METHODS: Data were from the HIV Prevention Trial Network 037 (2002-2006) site in Philadelphia, Pennsylvania, a randomized study evaluating the efficacy of a network-oriented HIV prevention intervention for IDUs. At prescreening, participants were asked the nearest intersections to their residence, where they buy and use drugs, and about their injection behaviors. RESULTS: Geographic distances had independent and interactive effects on injection risk behaviors and SEP use. Blacks, regardless of distance, were less likely than Whites to inject in public places (odds ratio [OR] = 0.62; 95% confidence interval [CI] = 0.43, 0.90), to use syringes after someone else (OR = 0.27; 95% CI = 0.19, 0.38), and to access syringes from SEPs (OR = 2.08; 95% CI = 1.48, 2.92). Latinos' injection behaviors were more distance-dependent than Blacks' or Whites'. CONCLUSIONS: Distances among IDUs' homes, drug purchase and injecting sites, and prevention resources affected safe injection practices differentially by race. Understanding individuals' geographic relation to the risks and resources that surround them is an important aspect of understanding effects of the environment on health and behavior and the development of targeted interventions.

Differences in sexual identity, risk practices, and sex partners between bisexual men and other men among a low-income drug-using sample.

Men who have sex with men and women (MSMW) represent an important target population for understanding the spread of HIV because of the inherent bridging aspect of their sexual behavior. Despite their potential to spread HIV between gender groups, relatively little recent data have been reported about this population as a subgroup distinct from men who have sex with men only. This paper analyzes data from the Chicago site of Sexual Acquisition and Transmission of HIV Cooperative Agreement Program to characterize 343 MSMW in terms of their demographics, drug use, sexual risk behavior, sexual identity, and sex partners. Results show the MSMW sample to be extremely disadvantaged; to have high rates of drug use, including injection and crack use; to report more female than male sex partners; to not differ from gay and heterosexual men in rates of condom use; and, for the most part, to report sexual identities that are consistent with their sex behavior. MSMW represent an important subpopulation in the HIV epidemic and should be targeted for risk reduction interventions.

Identifying hidden sexual bridging communities in Chicago.

Bridge populations can play a central role in the spread of human immunodeficiency virus (HIV) by providing transmission links between higher and lower prevalence populations. While social network methods are well suited to the study of bridge populations, analyses tend to focus on dyads (i.e., risk between drug and/or sex partners) and ignore bridges between distinct subpopulations. This study takes initial steps toward moving the analysis of sexual network linkages beyond individual and risk group levels to a community level in which Chicago's 77 community areas are examined as subpopulations for the purpose of identifying potential bridging communities. Of particular interest are "hidden" bridging communities; that is, areas with above-average levels of sexual ties with other areas but whose below-average AIDS prevalence may hide their potential importance for HIV prevention. Data for this analysis came from the first wave of recruiting at the Chicago Sexual Acquisition and Transmission of HIV Cooperative Agreement Program site. Between August 2005 through October 2006, respondent-driven sampling was used to recruit users of heroin, cocaine, or methamphetamine, men who have sex with men regardless of drug use, the sex partners of these two groups, and sex partners of the sex partners. In this cross-sectional study of the sexual transmission of HIV, participants completed a network-focused computer-assisted self-administered interview, which included questions about the geographic locations of sexual contacts with up to six recent partners. Bridging scores for each area were determined using a matrix representing Chicago's 77 community areas and were assessed using two measures: non-redundant ties and flow betweenness. Bridging measures and acquired immunodeficiency syndrome (AIDS) case prevalence rates were plotted for each community area on charts representing four conditions: below-average bridging and AIDS prevalence, below-average bridging and above-average AIDS prevalence, above-average bridging and AIDS prevalence, and above-average bridging and below-average AIDS prevalence (hidden bridgers). The majority of the 1,068 study participants were male (63%), African American (74%), and very poor, and the median age was 44 years. Most (85%) were sexually active, and 725 provided useable geographic information regarding 1,420 sexual partnerships that involved 57 Chicago community areas. Eight community areas met or came close to meeting the definition of hidden bridgers. Six areas were near the city's periphery, and all eight areas likely had high inflows or outflows of low-income persons displaced by gentrification. The results suggest that further research on this method is warranted, and we propose a means for public health officials in other cities to duplicate the analysis.

Neighborhood socioeconomic status, personal network attributes, and use of heroin and cocaine.

BACKGROUND: Drug abuse is a significant public health problem because of its association with numerous negative health and social consequences. Examining the social context of drug use represents a burgeoning avenue of research in drug abuse. This study investigates the effects of neighborhood disadvantage and network factors on current heroin and cocaine use among a predominantly African-American adult sample residing in Baltimore City. METHODS: This study employs a cross-sectional, multilevel design using data from two sources: the SHIELD Study, a network-oriented HIV intervention in Baltimore City and the 1990 U.S. Decennial Census. The sample consisted of 1305 adults from 249 neighborhoods (census block groups) across Baltimore City. Multilevel logistic regression analysis was performed to examine personal network and neighborhood effects on current heroin and cocaine use. RESULTS: Neighborhood poverty was significantly associated with current heroin and cocaine use (odds ratio [OR]=1.51, confidence interval [CI]=1.06-2.15). Social support (OR=0.80, CI=0.69-0.92) and having ties to employed people (OR=0.47, CI=0.24-0.92) were protective of current drug use, but did not buffer negative effects of neighborhood poverty in the face of negative drug influences in the network (OR=8.62, CI=5.81-12.79). CONCLUSIONS: The contexts of neighborhoods and networks represent key determinants in understanding the social epidemiology of drug abuse. Network attributes have strong influences on drug use, and neighborhood poverty may increase odds of use. Further research is warranted to determine other aspects of neighborhood environments that may put individuals at risk for drug use and abuse.

Neighborhood social disorder as a determinant of drug injection behaviors: a structural equation modeling approach.

Neighborhood environments are increasingly recognized as a contextual determinant of health, behaviors, and disease; however, the pathways through which neighborhood characteristics impact health behaviors are poorly understood. This article examines pathways to elucidate how neighborhood social disorder may lead to HIV transmission. Data are from a baseline survey of 701 injection drug users from the Self-Help in Eliminating Lethal Diseases Study, an HIV prevention intervention in Baltimore. Structural equation modeling was used to examine the pathways among social disorder, psychological distress, and drug injection behaviors. The relationship between disorder and injection behaviors in the models tested suggests that psychological distress is higher in more socially disordered neighborhoods, that distress leads to greater injection frequency and equipment sharing, and that injection frequency predicts equipment sharing.

Marijuana and cocaine use among female African-American welfare recipients.

A key issue that came to the forefront during the welfare reform debate in the United States during the 1990s concerned the relationship between welfare receipt and drug use and abuse. This paper examines the relationship between persistent welfare assistance, welfare background, and marijuana and cocaine use among African-American women. We hypothesize that women who have received welfare assistance for a period of 5 years or more will be more likely to use drugs compared to those who have never received welfare assistance or who have received it for a shorter duration. Data for this analysis comes from a longitudinal study of African-Americans living in a Chicago community followed from first grade (N = 1242) to age 32. Multinomial logistic regression analyses were performed to examine the relationship between years of welfare receipt and three categories of marijuana and cocaine use (never, past, and current) among female respondents (N = 496). Results indicate an increased risk of past-year cocaine and marijuana use for women who reported receiving welfare benefits for 5 years or more. Growing up in a family that received welfare did not significantly predict adult drug use, but did significantly predict an adult welfare experience. Implications of results are discussed.

Social network approaches to recruitment, HIV prevention, medical care, and medication adherence.

This article reviews the current issues and advancements in social network approaches to HIV prevention and care. Social network analysis can provide a method to understand health disparities in HIV rates, treatment access, and outcomes. Social network analysis is a valuable tool to link social structural factors to individual behaviors. Social networks provide an avenue for low-cost and sustainable HIV prevention interventions that can be adapted and translated into diverse populations. Social networks can be utilized as a viable approach to recruitment for HIV testing and counseling, HIV prevention interventions, optimizing HIV medical care, and medication adherence. Social network interventions may be face-to-face or through social media. Key issues in designing social network interventions are contamination due to social diffusion, network stability, density, and the choice and training of network members. There are also ethical issues involved in the development and implementation of social network interventions. Social network analyses can also be used to understand HIV transmission dynamics.

Not just the needle: the state of HIV-prevention science among substance users and future directions.

Efforts to prevent HIV transmission among substance-using populations have focused primarily among injection drug users, which have produced measurable reductions in HIV incidence and prevalence. By contrast, the majority of substances used worldwide are administered by noninjectable means, and there is a dearth of HIV prevention interventions that target noninjecting substance users. Increased surveillance of trends in substance use, especially cocaine (including crack) and methamphetamine, in addition to new and emerging substances (eg, synthetic cannabinoids, cathinones, and other amphetamine analogs) are needed to develop and scale up effective and robust interventions for populations at risk for HIV transmission via sexual behaviors related to noninjection substance use. Strategies are needed that address unique challenges to HIV prevention for substance users who are HIV infected and those who are HIV uninfected and are at high risk. We propose a research agenda that prioritizes (1) combination HIV-prevention strategies in substance users; (2) behavioral HIV prevention programs that reduce sexual transmission behaviors in nontreatment seeking individuals; (3) medical and/or behavioral treatments for substance abuse that reduce/eliminate substance-related sexual transmission behaviors; and (4) structural interventions to reduce HIV incidence.

Misdirected opposition: Evidence opposing "not in my back yard" arguments against syringe exchange programmes.

BACKGROUND: Despite overwhelming evidence of their effectiveness, the establishment and maintenance of syringe exchange programmes (SEPs) in the US continue to draw opposition from community members, religious and political leaders, and law enforcement officials. One argument against SEPs is that they draw drug activity into the communities where they operate. METHODS: We use 8 years of survey data from participants attending an SEP in Chicago to explore this argument by reviewing responses (N=4827) to a question asking participants the main reason they spend time in the area. RESULTS: Findings show far more participants come to the area to buy drugs (60%) than to exchange needles (3.8%), and differences exist by ethnicity. More whites than blacks or Latinos reported being in the area primarily to buy drugs and use the SEP. CONCLUSION: Re-directing opposition from SEPs to constructive ways of addressing fundamental causes of drug markets is recommended.

"Coming to town": the impact of urbanicity, cigarette advertising, and network norms on the smoking attitudes of black women in Cape Town, South Africa.

This study was conducted to examine the effect of urban living on smoking attitudes among black African women in South Africa. We examine how urbanicity affects attitudes toward smoking and how it moderates the relationship between both advertising exposure and network norms on black women's smoking attitudes. Respondents were 975 black women currently living in Cape Town townships, some of which were raised in rural villages or small towns. Respondents completed a cross-sectional survey, which included data on smoking attitudes, norms, and exposure to cigarette advertising. Multiple linear regression analysis was performed with smoking attitudes as the response variable, and urbanicity, cigarette advertising exposure, and network smoking norms as primary explanatory variables. Interactions were tested to determine whether urbanicity modified the effect of advertising exposure and network norms on smoking attitudes. Independent effects of urbanicity, exposure to cigarette advertising, and greater smoking prevalence within women's networks were associated with more favorable smoking attitudes. In addition, urbanicity moderated the relationship between network smoking norms and smoking attitudes, but not cigarette advertising exposure and smoking attitudes. Urbanicity, cigarette advertising, and networks play important roles in women's attitudes toward smoking, and potentially, smoking behavior. Overall, our results suggest that strong and creative anti-smoking efforts are needed to combat the potential for a smoking epidemic among an increasingly urbanized population of black women in South Africa and similar emerging markets. Additional research is warranted.

The role of depressive symptoms in predicting sex with multiple and high-risk partners.

Existing research examining the role of psychopathology on HIV risk behaviors has relied heavily upon cross-sectional data, making it difficult to assess causal relationships. This paper uses longitudinal data to examine the relationship between depressive symptoms and sexual risk behaviors in a community sample of 332 inner-city drug users. Results from repeated measures analysis using generalized estimating equations suggest that high depressive symptoms may be causally related to having sex with multiple partners (odds ratio = 1.55, CI: 1.12, 2.14) and having sex with injection drug users (odds ratio = 1.57, CI: 1.11, 2.22) and crack users (odds ratio = 1.37, CI: 1.02, 1.86). Findings support greater attention to depressive symptoms in HIV prevention interventions for illicit drug users to reduce sexual risk behaviors.