Pharmacy Intervention to Improve HIV Testing Uptake Using a Comprehensive Health Screening Approach.

OBJECTIVE: HIV testing is increasingly available, yet barriers to HIV testing persist for low-income black and Latino people, especially those who use illicit drugs. HIV exceptionalism, or the idea that a positive HIV diagnosis is drastically different from a diagnosis for any other disease, may influence HIV testing-related stigma, resulting in reduced willingness to undergo HIV testing. This pharmacy-based intervention combined HIV testing with less stigmatized chronic disease screening tests (e.g., blood pressure, glucose, and cholesterol) to equate the concept of an HIV diagnosis with other diagnoses. METHODS: Three pharmacies located in low-income, minority neighborhoods in New York City were enrolled in an intervention to provide (1) HIV testing, chronic disease screening, and a healthy lifestyles video that normalized all screening tests and destigmatized HIV as a fatal disease (comprehensive arm); (2) HIV testing and the video (video arm); and (3) HIV testing only (control arm). Injection drug users (IDUs) and pharmacy staff recruited un- and underinsured pharmacy customers, IDUs, and IDU peers from 2010 to 2012. Participants in the control group were compared with those in the comprehensive and video intervention groups. RESULTS: Participants in the comprehensive arm (prevalence ratio [PR] = 1.61, 95% confidence interval [CI] 1.03, 2.49, p=0.08) and the video arm (PR=1.59, 95% CI 1.00, 2.53, p=0.09) were marginally significantly more likely to receive an HIV test in the pharmacy compared with those in the control arm after adjustment. CONCLUSIONS: These findings suggest that adoption of strategies that destigmatize and normalize HIV testing can improve uptake. Implementation of this strategy in low-access, minority communities with high HIV prevalence and among high-risk populations may help reduce racial/ethnic disparities in HIV.

Community Impact of Pharmacy-Randomized Intervention to Improve Access to Syringes and Services for Injection Drug Users.

OBJECTIVES: In an effort to reduce HIV transmission among injection drug users (IDUs), New York State deregulated pharmacy syringe sales in 2001 through the Expanded Syringe Access Program by removing the requirement of a prescription. With evidence suggesting pharmacists' ability to expand their public health role, a structural, pharmacy-based intervention was implemented to determine whether expanding pharmacy practice to include provision of HIV risk reduction and social/medical services information during the syringe sale would (a) improve pharmacy staff attitudes toward IDUs (b) increase IDU syringe customers, and (c) increase prescription customer base in New York City neighborhoods with high burden of HIV and illegal drug activity. METHODS: Pharmacies (n = 88) were randomized into intervention (recruited IDU syringe customers into the study and delivered intervention activities), primary control (recruited IDU syringe customers only) and secondary control (did not recruit IDUs or deliver intervention activities) arms. RESULTS: Pharmacy staff in the intervention versus secondary control pharmacies showed significant decreases in the belief that selling syringes to IDUs causes community loitering. CONCLUSIONS: Structural interventions may be optimal approaches for changing normative attitudes about highly stigmatized populations.

Racial/Ethnic Differences in Recent Drug Detoxification Enrollment and the Role of Discrimination and Neighborhood Factors.

Drug detoxification and long-term drug treatment utilization is lower for drug-dependent minorities than Whites. Log-binomial regression was used to assess discrimination and neighborhood-level factors on past 6-month drug treatment utilization among 638 New York City (NYC) drug users between 2006 and 2009. Drug-use discrimination was positively associated with detoxification and long-term treatment. Participants in higher concentrated Black neighborhoods were less likely to attend long-term treatment. Significantly fewer Blacks versus Whites and Hispanics reported drug-use discrimination, which may systematically filter drug users into treatment. More research is needed to understand social forms of discrimination and drug treatment.

The Relationship Between Multiple Forms of Discrimination, Neighborhood Characteristics, and Depression Among Illicit Drug Users in New York City.

It is plausible that features of the social environment combined with experiences of discrimination may help further explain experiences of depression among illicit drug users. We examined the influence of census tract-level characteristics and multiple forms of individual-level discrimination on lifetime depression among illicit drug users in New York City enrolled in the "Social Ties Associated With Risk of Transition" study. Population average models accounted for clustering of individuals within census tracts. Discrimination based on prior incarceration explained Hispanic/White differences in depression and was independently associated with depression after accounting for neighborhood characteristics. Neighborhood poverty was only marginally related to lifetime depression. These data provide evidence supporting the influence of discrimination on depression among drug users. Research is needed to confirm these findings and highlight specific mechanisms through which discrimination and neighborhood socioeconomic status may operate to influence mental health.

Attitudes toward Web application supporting pharmacist-clinician comanagement of postexposure prophylaxis patients.

OBJECTIVES: To qualitatively explore clinician and pharmacist attitudes toward using a Web application virtual pharmacist-clinician partnership (VPCP) to assist with comanaged care of illicit drug-using patients prescribed postexposure prophylaxis (PEP). DESIGN: Qualitative, descriptive, nonexperimental study. SETTING: New York City (NYC) from February 2011 to March 2012. PARTICIPANTS: Four pharmacists and nine clinicians. INTERVENTION: In-depth interviews. MAIN OUTCOME MEASURES: Potential impact of the VPCP on pharmacist-clinician communication and potential barriers to use of the VPCP when comanaging PEP patients among pharmacists and clinicians. RESULTS: Pharmacists and clinicians were supportive of an interactive Web application that would expand the role of pharmacists to include assistance with PEP access and patient management. Participants noted that the VPCP would facilitate communication between pharmacists and clinicians and have potential to support adherence among patients. Pharmacists and clinicians were concerned about not having time to use the VPCP and security of patient information on the site. Pharmacist and clinician concerns informed final development of the VPCP, including creation of a user-friendly interface, linkage to users' e-mail accounts for timeline notification, and attention to security. CONCLUSION: Use of Web-based technology to support communication between pharmacists and clinicians was seen as being a potentially feasible method for improving patient care, particularly in the delivery of PEP to drug users and other high-risk groups. These findings highlight the need for further study of a technology-supported partnership, particularly for comanagement of patients who face challenges with adherence.

Randomized, community-based pharmacy intervention to expand services beyond sale of sterile syringes to injection drug users in pharmacies in New York City.

Structural interventions may help reduce racial/ethnic disparities in HIV. In 2009 to 2011, we randomized pharmacies participating in a nonprescription syringe access program in minority communities to intervention (pharmacy enrolled and delivered HIV risk reduction information to injection drug users [IDUs]), primary control (pharmacy only enrolled IDUs), and secondary control (pharmacy did not engage IDUs). Intervention pharmacy staff reported more support for syringe sales than did control staff. An expanded pharmacy role in HIV risk reduction may be helpful.

Social network members' roles and use of mental health services among drug users in New York City.

Depression is more common among drug users (15-63 %) than the general population (5-16 %). Lack of social support network members may be associated with low mental health service (MHS) use rates observed among drug users. We investigated the relationship between social network members' roles and MHS use among frequent drug users using Social Ties Associated with Risk of Transition into Injection Drug Use data (NYC 2006-2009). Surveys assessed depression, MHS use, demographics, drug use and treatment, and social network members' roles. Participants reporting lifetime depressive episode with start/end dates and information on social/risk network members were included (n = 152). Adjusting for emotional support and HIV status, having one or more informational support network members remained associated with MHS use at last depressive episode (adjusted odds ratio (AOR) 3.37, 95 % confidence interval (CI) 1.38-8.19), as did history of drug treatment (AOR 2.75, 95 % CI 1.02-7.41) and no legal income (AOR 0.23, 95 % CI 0.08-0.64). These data suggest that informational support is associated with MHS utilization among depressed drug users.

The importance of measuring and accounting for potential biases in respondent-driven samples.

Respondent-driven sampling (RDS) is often viewed as a superior method for recruiting hard-to-reach populations disproportionately burdened with poor health outcomes. As an analytic approach, it has been praised for its ability to generate unbiased population estimates via post-stratified weights which account for non-random recruitment. However, population estimates generated with RDSAT (RDS Analysis Tool) are sensitive to variations in degree weights. Several assumptions are implicit in the degree weight and are not routinely assessed. Failure to meet these assumptions could result in inaccurate degree measures and consequently result in biased population estimates. We highlight potential biases associated with violating the assumptions implicit in degree weights for the RDSAT estimator and propose strategies to measure and possibly correct for biases in the analysis.

Individual and neighborhood correlates of membership in drug using networks with a higher prevalence of HIV in New York City (2006-2009).

PURPOSE: To identify individual- and neighborhood-level correlates of membership within high HIV prevalence drug networks. METHODS: We recruited 378 New York City drug users via respondent-driven sampling (2006-2009). Individual-level characteristics and recruiter-recruit relationships were ascertained and merged with 2000 tract-level U.S. Census data. Descriptive statistics and population average models were used to identify correlates of membership in high HIV prevalence drug networks (>10.54% vs. <10.54% HIV). RESULTS: Individuals in high HIV prevalence drug networks were more likely to be recruited in neighborhoods with greater inequality (adjusted odds ratio [AOR], 5.85; 95% confidence interval [CI], 1.40-24.42), higher valued owner-occupied housing (AOR, 1.48; 95% CI, 1.14-1.92), and a higher proportion of Latinos (AOR, 1.83; 95% CI, 1.19-2.80). They reported more crack use (AOR, 7.23; 95% CI, 2.43-21.55), exchange sex (AOR, 1.82; 95% CI, 1.03-3.23), and recent drug treatment enrollment (AOR, 1.62; 95% CI, 1.05-2.50) and were less likely to report cocaine use (AOR, 0.40; 95% CI, 0.20-0.79) and recent homelessness (AOR, 0.32; 95% CI, 0.17-0.57). CONCLUSIONS: The relationship between exchange sex, crack use, and membership within high HIV prevalence drug networks may suggest an ideal HIV risk target population for intervention. Coupling network-based interventions with those adding risk-reduction and HIV testing/care/adherence counseling services to the standard of care in drug treatment programs should be explored in neighborhoods with increased inequality, higher valued owner-occupied housing, and a greater proportion of Latinos.

The relationship between perceived discrimination and high-risk social ties among illicit drug users in New York City, 2006-2009.

Discrimination can influence risk of disease by promoting unhealthy behaviors (e.g., smoking, alcohol use). Whether it influences the formation of high-risk social ties that facilitate HIV transmission is unclear. Using cross-sectional data from a cohort of illicit drug users, this study examined the association between discrimination based on race, drug use and prior incarceration and risky sex and drug ties. Negative binomial regression models were performed. Participants who reported discrimination based on race and drug use had significantly more sex and drug-using ties. But, after accounting for both racial and drug use discrimination, only racial discrimination was associated with increased sex, drug-using, and injecting ties. Drug users who experience discrimination and subsequently develop more sex and drug-using ties, increase their risk of contracting HIV. Future longitudinal studies illuminating the pathways linking discrimination and social network development may guide intervention development and identify drug-using subpopulations at high risk for disease transmission.

Social and individual risk determinants of HIV testing practices among noninjection drug users at high risk for HIV/AIDS.

HIV testing services and research among drug users has largely focused on injection drug users (IDUs); yet noninjection drug users (NIDUs) are also at increased risk for HIV due to high-risk sexual behaviors and overlapping networks with IDUs. This study examined drug use, sexual risk, and social network characteristics associated with recent HIV testing (testing within past year) among NIDUs. Interviewer-administered questionnaires were conducted among 418 NIDUs and log-binomial regression models were used to identify correlates of recent HIV testing. Prevalence ratios (PR) with 95% confidence intervals (CI) were reported. Nearly 97% of NIDUs reported having ever been tested for HIV and most participants (85.7%) indicated testing for HIV within the past year. Factors independently associated with recent HIV testing were higher educational attainment (PR: 1.86; 95% CI: 1.03, 3.34) and networks to discuss health and medical services (PR: 1.84; 95% CI: 1.06, 1.20). A prior positive sexually transmitted infection was associated with decreased likelihood of recent HIV test (PR: 0.43; 95% CI 0.25, 0.74). Identifying specific social network characteristics may be effective in facilitating HIV testing and prevention strategies targeting NIDUs.

The influence of neighborhood characteristics on the relationship between discrimination and increased drug-using social ties among illicit drug users.

Social discrimination may isolate drug users into higher risk relationships, particularly in disadvantaged neighborhood environments where drug trade occurs. We used negative binomial regression accounting for clustering of individuals within their recruitment neighborhood to investigate the relationship between high-risk drug ties with various forms of social discrimination, neighborhood minority composition, poverty and education. Results show that experiencing discrimination due to drug use is significantly associated with more drug ties in neighborhoods with fewer blacks. Future social network and discrimination research should assess the role of neighborhood social cohesion.

Individual, study, and neighborhood level characteristics associated with peer recruitment of young illicit drug users in New York City: optimizing respondent driven sampling.

Recruiting a representative sample using respondent driven sampling (RDS) relies on successful peer recruitment. While prior studies have identified individual-level characteristics associated with peer recruitment, study- and neighborhood-level factors may also influence peer recruitment. This analysis aimed to identify individual-, study-, and neighborhood-level factors associated with RDS peer recruitment. 390 young adult (18-40 years) heroin, crack and/or cocaine users in New York City (NYC) were recruited via RDS into a cohort study aiming to identify social risk factors for transitioning from non-injection to injection drug use (2006-2009). Individual-level baseline characteristics (demographics, drug use, and network characteristics) and study factors (number of recruitment coupons received and participant attendance at RDS training sessions (RDST) on peer recruitment) were ascertained. Aggregate measures of neighborhood attitudes about drug use, drug users, and HIV were obtained from a separate anonymous NYC resident random-digit-dialing survey (2002) and linked with baseline data by zip code. Descriptive statistics and multilevel modeling were used to identify factors associated with peer recruitment. After adjustment, recruiting each additional eligible peer recruit was associated with receiving additional recruitment coupons, RDST attendance, and a greater proportion of community residents in one's recruitment neighborhood believing that clean needles should be made available to IDUs; heroin use was negatively associated with recruiting additional eligible peers. After adjustment, recruiting each additional peer (regardless of eligibility) was associated with receiving additional recruitment coupons and RDST attendance. Our data highlight the importance of neighborhood factors and suggest that RDS may not be as effective in areas characterized by negative attitudes about drug use. Group-facilitated recruitment training sessions may help counter negative social norms when implementing RDS in drug user studies.

The association between parental risk behaviors during childhood and having high risk networks in adulthood.

BACKGROUND: Prior research suggests that both social networks and parent drug use influence individual drug use among adolescents and that peers continue to influence drug use among adults. This analysis aims to determine whether parent drug use during childhood is associated with having drug-using networks in adulthood after adjusting for individual adult drug use. METHODS: 650 young adult drug users were recruited through targeted street outreach and respondent-driven sampling in New York City (2006-2009). Baseline surveys ascertained demographics, network characteristics, drug use behaviors, and parental drug use during childhood. Negative binomial regression was used to evaluate this association. RESULTS: The median age was 33 years, 22% injected, 49% were Black, and during childhood 26% of mothers, 32% of fathers, and 13% of primary caregivers used drugs. After adjustment, having >1 parent who used drugs was associated with having a greater proportion of drug using (Adjusted Prevalence Ratio [APR]=1.18; 95%CI: 1.01-1.38) and specifically crack-smoking networks (APR=1.71; 95%CI: 1.21-2.43) in adulthood. Females' networks consisted of more drug users (APR=1.18; 95%CI: 1.01-1.38), injectors (APR=1.44; 95%CI: 1.09-1.90), crack smokers (APR=1.48; 95%CI: 1.18-1.87) and heroin users (APR=1.43; 95%CI: 1.13-1.81); blacks had a greater proportion of crack smoking (APR=1.41; 95%CI: 1.09-1.82), but a smaller proportion of injecting (APR=0.64; 95%CI: 0.43-0.94) and heroin smoking (APR=0.60; 95%CI: 0.47-0.77) networks as adults. CONCLUSIONS: These data suggest that parental drug use is independently associated with having drug-using networks in adulthood. Interventions that target parents and caregivers and that promote drug cessation could impede risky network formation in both adolescents and adults.

Does respondent driven sampling alter the social network composition and health-seeking behaviors of illicit drug users followed prospectively?

Respondent driven sampling (RDS) was originally developed to sample and provide peer education to injection drug users at risk for HIV. Based on the premise that drug users' social networks were maintained through sharing rituals, this peer-driven approach to disseminate educational information and reduce risk behaviors capitalizes and expands upon the norms that sustain these relationships. Compared with traditional outreach interventions, peer-driven interventions produce greater reductions in HIV risk behaviors and adoption of safer behaviors over time, however, control and intervention groups are not similarly recruited. As peer-recruitment may alter risk networks and individual risk behaviors over time, such comparison studies are unable to isolate the effect of a peer-delivered intervention. This analysis examines whether RDS recruitment (without an intervention) is associated with changes in health-seeking behaviors and network composition over 6 months. New York City drug users (N = 618) were recruited using targeted street outreach (TSO) and RDS (2006-2009). 329 non-injectors (RDS = 237; TSO = 92) completed baseline and 6-month surveys ascertaining demographic, drug use, and network characteristics. Chi-square and t-tests compared RDS- and TSO-recruited participants on changes in HIV testing and drug treatment utilization and in the proportion of drug using, sex, incarcerated and social support networks over the follow-up period. The sample was 66% male, 24% Hispanic, 69% black, 62% homeless, and the median age was 35. At baseline, the median network size was 3, 86% used crack, 70% used cocaine, 40% used heroin, and in the past 6 months 72% were tested for HIV and 46% were enrolled in drug treatment. There were no significant differences by recruitment strategy with respect to changes in health-seeking behaviors or network composition over 6 months. These findings suggest no association between RDS recruitment and changes in network composition or HIV risk, which supports prior findings from prospective HIV behavioral surveillance and intervention studies.

Subpopulations of illicit drug users reached by targeted street outreach and respondent-driven sampling strategies: implications for research and public health practice.

PURPOSE: To determine whether illicit drug users recruited through respondent-driven sampling (RDS) and targeted street outreach (TSO) differ by comparing two samples recruited concurrently with respect to sample selection and potential recruitment biases. METHODS: Two hundred seventeen (217) heroin, crack, and cocaine users aged 18-40 years were recruited through TSO in New York City (2006-2009). Forty-six RDS seeds were recruited similarly and concurrently, yielding a maximum of 14 recruitment waves and 357 peer recruits. Baseline questionnaires ascertained sociodemographic, drug use, and drug network characteristics. Descriptive statistics and log-binomial regression were used to compare RDS and TSO samples. RESULTS: RDS recruits were more likely to be male (prevalence ratio [PR]:1.28), Hispanic (PR:1.45), black (PR: 1.58), older (PR: 1.02), homeless (PR: 1.19), and crack users (PR: 1.37). RDS recruited fewer injectors (PR:0.35) and heroin users (PR:0.74). Among injectors, RDS recruits injected less frequently (PR:0.77) and were less likely to use Needle Exchange Programs (PR:0.35). CONCLUSION: These data suggest that RDS and TSO strategies reach different subgroups of drug users. Understanding the differing capabilities of each recruitment strategy will enable researchers and public health practitioners to select an appropriate recruitment tool for future research and public health practice.

Individual- and neighborhood-level characteristics associated with support of in-pharmacy vaccination among ESAP-registered pharmacies: pharmacists' role in reducing racial/ethnic disparities in influenza vaccinations in New York City.

New York State (NYS) passed legislation authorizing pharmacists to administer immunizations in 2008. Racial/socioeconomic disparities persist in vaccination rates and vaccine-preventable diseases such as influenza. Many NYS pharmacies participate in the Expanded Syringe Access Program (ESAP), which allows provision of non-prescription syringes to help prevent transmission of HIV, and are uniquely positioned to offer vaccination services to low-income communities. To understand individual and neighborhood characteristics of pharmacy staff support for in-pharmacy vaccination, we combined census tract data with baseline pharmacy data from the Pharmacies as Resources Making Links to Community Services (PHARM-Link) study among ESAP-registered pharmacies. The sample consists of 437 pharmacists, non-pharmacist owners, and technicians enrolled from 103 eligible New York City pharmacies. Using multilevel analysis, pharmacy staff who expressed support of in-pharmacy vaccination services were 69% more likely to support in-pharmacy HIV testing services (OR, 1.69; 95% CI 1.39-2.04). While pharmacy staff who worked in neighborhoods with a high percent of minority residents were less likely to express support of in-pharmacy vaccination, those in neighborhoods with a high percent of foreign-born residents were marginally more likely to express support of in-pharmacy vaccination. While educational campaigns around the importance of vaccination access may be needed among some pharmacy staff and minority community residents, we have provided evidence supporting scale-up of vaccination efforts in pharmacies located in foreign-born/immigrant communities which has potential to reduce disparities in vaccination rates and preventable influenza-related mortality.

Comparison of HIV risk by duration of injection drug use.

Early studies documented an inverse association between the HIV risk and duration of injection among injection drug users (IDUs). Results from subsequent studies have been inconsistent. To examine this issue, we conducted interviews with 395 street-recruited active IDUs from 38 neighborhoods in New York City during 2005 and 2008. We observed no significant differences in drug or risky sex behaviors by duration of drug use among these IDUs. Despite this, continuing to tailor HIV prevention programs for these recent-onset IDUs is prudent. The study's limitations are noted.

HIV risk behaviors among young drug using women who have sex with women (WSWs) in New York City.

Previous research has suggested that multiple stressors may work in tandem to affect the health of women who have sex with women (WSWs). WSWs have been a part of the HIV epidemic in New York City since the beginning, making it an ideal setting to further explore these women's risk. Among a sample of 375 heroin, crack and/or cocaine using women recruited from economically disadvantaged communities in New York City, we examined HIV seroprevalence and risk behaviors among WSWs as compared to women who have sex with men only (WSMOs). We also explore differences between WSWs and WSMOs with respect to potential stressors (i.e., decreased access to resources and health care utilization and violence victimization) that might contribute overall HIV risk. The study's limitations are noted.