Evaluation of respondent-driven sampling in seven studies of people who use drugs from rural populations: findings from the Rural Opioid Initiative.

BACKGROUND: Accurate prevalence estimates of drug use and its harms are important to characterize burden and develop interventions to reduce negative health outcomes and disparities. Lack of a sampling frame for marginalized/stigmatized populations, including persons who use drugs (PWUD) in rural settings, makes this challenging. Respondent-driven sampling (RDS) is frequently used to recruit PWUD. However, the validity of RDS-generated population-level prevalence estimates relies on assumptions that should be evaluated. METHODS: RDS was used to recruit PWUD across seven Rural Opioid Initiative studies between 2018-2020. To evaluate RDS assumptions, we computed recruitment homophily and design effects, generated convergence and bottleneck plots, and tested for recruitment and degree differences. We compared sample proportions with three RDS-adjusted estimators (two variations of RDS-I and RDS-II) for five variables of interest (past 30-day use of heroin, fentanyl, and methamphetamine; past 6-month homelessness; and being positive for hepatitis C virus (HCV) antibody) using linear regression with robust confidence intervals. We compared regression estimates for the associations between HCV positive antibody status and (a) heroin use, (b) fentanyl use, and (c) age using RDS-1 and RDS-II probability weights and no weights using logistic and modified Poisson regression and random-effects meta-analyses. RESULTS: Among 2,842 PWUD, median age was 34 years and 43% were female. Most participants (54%) reported opioids as their drug of choice, however regional differences were present (e.g., methamphetamine range: 4-52%). Many recruitment chains were not long enough to achieve sample equilibrium. Recruitment homophily was present for some variables. Differences with respect to recruitment and degree varied across studies. Prevalence estimates varied only slightly with different RDS weighting approaches, most confidence intervals overlapped. Variations in measures of association varied little based on weighting approach. CONCLUSIONS: RDS was a useful recruitment tool for PWUD in rural settings. However, several violations of key RDS assumptions were observed which slightly impacts estimation of proportion although not associations.

Validation of dried blood spots for capturing hepatitis C virus diversity for genomic surveillance.

Dried blood spots (DBS) have emerged as a promising alternative to traditional venous blood for hepatitis C virus (HCV) testing. However, their capacity to accurately reflect the genetic diversity of HCV remains poorly understood. We employed deep sequencing and advanced phylogenetic analyses on paired plasma and DBS samples from two common subtypes to evaluate the suitability of DBS for genomic surveillance. Results demonstrated that DBS captured equivalent viral diversity compared to plasma with no phylogenetic discordance observed. The ability of DBS to accurately reflect the profile of viral genetic diversity suggests it may be a promising avenue for future surveillance efforts to curb HCV outbreaks.

Houselessness and syringe service program utilization among people who inject drugs in eight rural areas across the USA: a cross-sectional analysis.

BACKGROUND: Research conducted in urban areas has highlighted the impact of housing instability on people who inject drugs (PWID), revealing that it exacerbates vulnerability to drug-related harms and impedes syringe service program (SSP) use. However, few studies have explored the effects of houselessness on SSP use among rural PWID. This study examines the relationship between houselessness and SSP utilization among PWID in eight rural areas across 10 states. METHODS: PWID were recruited using respondent-driven sampling for a cross-sectional survey that queried self-reported drug use and SSP utilization in the prior 30 days, houselessness in the prior 6 months and sociodemographic characteristics. Using binomial logistic regression, we examined the relationship between experiencing houselessness and any SSP use. To assess the relationship between houselessness and the frequency of SSP use, we conducted multinomial logistic regression analyses among participants reporting any past 30-day SSP use. RESULTS: Among 2394 rural PWID, 56.5% had experienced houselessness in the prior 6 months, and 43.5% reported past 30-day SSP use. PWID who had experienced houselessness were more likely to report using an SSP compared to their housed counterparts (adjusted odds ratio [aOR] = 1.24 [95% confidence intervals [CI] 1.01, 1.52]). Among those who had used an SSP at least once (n = 972), those who experienced houselessness were just as likely to report SSP use two (aOR = 0.90 [95% CI 0.60, 1.36]) and three times (aOR = 1.18 [95% CI 0.77, 1.98]) compared to once. However, they were less likely to visit an SSP four or more times compared to once in the prior 30 days (aOR = 0.59 [95% CI 0.40, 0.85]). CONCLUSION: This study provides evidence that rural PWID who experience houselessness utilize SSPs at similar or higher rates as their housed counterparts. However, housing instability may pose barriers to more frequent SSP use. These findings are significant as people who experience houselessness are at increased risk for drug-related harms and encounter additional challenges when attempting to access SSPs.

"I would do anything but that": Attitudes towards sex work among rural people who use drugs.

BACKGROUND: Stigma towards people who use drugs and those who engage in sex work is well-documented, leading to consequences such as reduced access to health services and support, especially in rural milieus. Stigma reduction has been recognized as a priority in the opioid overdose crisis, but little attention has been paid to within-group attitudes and beliefs. This study aimed to explore how people who use drugs in rural counties across the United States appraise sex work by themselves or other community members. METHODS: Qualitative interview data came from the Rural Opioid Initiative (ROI), a project coordinated by research teams across 65 rural counties in 10 states. Interviews were individual and conducted from 2018 to 2020. All participants reported past 30-day opioid use and/or any injection drug use. A working group coded the data, then used an iterative inductive-deductive approach to organize data into themes of stigma among people who use drugs, focusing on stigma towards sex work. RESULTS: Across sites, 355 interviews were conducted. Mean participant age was 36, 55 % of participants were male, and 93 % were white. Participants expressed negative attitudes towards sex work as a function of its criminal-legal repercussions or framed sex work as morally transgressive. Many appraisals were gendered, with the behavior conveyed as being "easier" for women who were often described as "whores," with more neutral terms used to describe men. Some viewed sex work as an implicit "exchange" for drugs. Several participants noted a lack of agency as a feature leading to involvement in sex work, with partner power dynamics influencing an individual's behavior. Finally, a few participants acknowledged the circumstances under which they would newly engage in sex work. CONCLUSION: We identified several patterns by which people who use drugs evaluate community members who sell sex. These included gendered and morally-charged forms of stigma, which may represent barriers to community acceptance and support among this subgroup.

Experiences of stigma, mental health, and coping strategies in Lebanon among Lebanese and displaced Syrian men who have sex with men: A qualitative study.

BACKGROUND: In Lebanon, men who have sex with men (MSM) face high rates of stigma, discrimination, and violence. Minority stress, or the unique stressors related to anti-MSM stigma and discrimination, negatively impacts the mental health of MSM. These stressors are heightened for those with intersectional minority identities such as displaced Syrian MSM in Lebanon. METHODS: In this qualitative study conducted in 2020-21, part of a larger study focused on the mental and sexual health risks among MSM, we collected qualitative data from Lebanese and displaced Syrian MSM living in Lebanon and analyzed reports of their experiences with stigma, mental health, and coping strategies. We conducted semi-structured, in-depth interviews with 12 displaced Syrian MSM and 13 Lebanese MSM. RESULTS: Our findings highlight how MSM in Lebanon navigate stigma and the mental health risks that result. Common stressors among Lebanese and displaced Syrian MSM were related to finances, sexual orientation discrimination, and social isolation. Comparing the two groups, we found that stressors specific to displaced Syrian MSM were related to adverse childhood experiences, recent exposure to the Syrian war, displacement, and discrimination in Lebanon based on their intersectional identities as MSM and Syrians. For Lebanese participants, the most common stigma coping strategies were avoidance, drinking alcohol, using drugs, or having sex. As for displaced Syrian MSM, the most common stigma coping strategy was seeking the freely available mental health services offered to them through non-governmental organizations. CONCLUSION: Our findings suggest that increased targeted mental health and social support interventions, informed by the unique experiences of Lebanese and displaced Syrian MSM, are highly needed to improve the coping and mental health resources of all MSM in Lebanon.

Variation in HIV Transmission Behaviors Among People Who Use Drugs in Rural US Communities.

Importance: People who use drugs (PWUD) continue to be at risk of HIV infection, but the frequency and distribution of transmission-associated behaviors within various rural communities is poorly understood. Objective: To examine the association of characteristics of rural PWUD with HIV transmission behaviors. Design, Setting, and Participants: In this cross-sectional study, surveys of PWUD in rural communities in 10 states (Illinois, Kentucky, New Hampshire, Massachusetts, North Carolina, Ohio, Oregon, Vermont, West Virginia, and Wisconsin) were collected January 2018 through March 2020 and analyzed August through December 2022. A chain-referral sampling strategy identified convenience sample seeds who referred others who used drugs. Rural PWUD who reported any past 30-day injection drug use or noninjection opioid use "to get high" were included. Exposures: Individual characteristics, including age, race, gender identity, sexual orientation, partnership status, drug of choice, and location, were collected. Main Outcomes and Measures: Past 30-day frequency of behaviors associated with HIV transmission, including drug injection, syringe sharing, opposite- and same-gender partners, transactional sex, and condomless sex, was assessed. Results: Of 3048 rural PWUD (mean [SD] age, 36.1 [10.3] years; 225 American Indian [7.4%], 96 Black [3.2%], and 2576 White [84.5%] among 3045 with responses; and 1737 men [57.0%] among 3046 with responses), most participants were heterosexual (1771 individuals [86.8%] among 2040 with responses) and single (1974 individuals [68.6%] among 2879 with responses). Opioids and stimulants were reported as drug of choice by 1636 individuals (53.9%) and 1258 individuals (41.5%), respectively, among 3033 individuals with responses. Most participants reported recent injection (2587 of 3046 individuals [84.9%] with responses) and condomless sex (1406 of 1757 individuals [80.0%] with responses), among whom 904 of 1391 individuals (65.0%) with responses indicated that it occurred with people who inject drugs. Syringe sharing (1016 of 2433 individuals [41.8%] with responses) and transactional sex (230 of 1799 individuals [12.8%] with responses) were reported less frequently. All characteristics and behaviors, except the number of men partners reported by women, varied significantly across locations (eg, mean [SD] age ranged from 34.5 [10.0] years in Wisconsin to 39.7 [11.0] years in Illinois; P < .001). In multivariable modeling, younger age (adjusted odds ratio [aOR] for ages 15-33 vs ≥34 years, 1.36; 95% CI, 1.08-1.72) and being single (aOR, 1.37; 95% CI, 1.08-1.74) were associated with recent injection; younger age (aOR, 1.49; 95% CI, 1.20-1.85) and bisexual orientation (aOR vs heterosexual orientation, 2.27; 95% CI, 1.60-3.23) with syringe sharing; gender identity as a woman (aOR vs gender identity as a man, 1.46; 95% CI, 1.01-2.12), bisexual orientation (aOR vs heterosexual orientation, 2.59; 95% CI, 1.67-4.03), and being single (aOR, 1.71; 95% CI, 1.15-2.55) with transactional sex; and bisexual orientation (aOR vs heterosexual orientation, 1.60; 95% CI, 1.04-2.46) and stimulants as the drug of choice (aOR vs opioids, 1.45; 95 CI, 1.09-1.93) with condomless sex with someone who injects drugs. Conclusions and Relevance: This study found that behaviors associated with HIV transmission were common and varied across communities. These findings suggest that interventions to reduce HIV risk among rural PWUD may need to be tailored to locally relevant factors.

Methamphetamine use and utilization of medications for opioid use disorder among rural people who use drugs.

BACKGROUND: Methamphetamine use is common among persons with opioid use disorder. This study evaluated associations between methamphetamine use and treatment with agonist medications for opioid use disorder (MOUD, specifically buprenorphine, and/or methadone) in U.S. rural communities. METHODS: The Rural Opioid Initiative (ROI) is a consortium spanning 10 states and 65 rural counties that included persons who reported past 30-day use of opioids and/or injection drug use between 1/2018 and 3/2020. Analyses were restricted to participants who had ever used opioids and had data on past 30-day methamphetamine use. Multivariable models examined the relationship between methamphetamine use and utilization of agonist MOUD. RESULTS: Among 2899 participants, 2179 (75.2%) also reported recent methamphetamine use. Persons with methamphetamine use compared to those without were younger, more likely to have injected drugs, be unhoused, criminal justice involved, and less likely to have health insurance. Adjusted for age, sex, race, and study site, recent methamphetamine use was associated with lower relative odds of past 30-day methadone treatment (aOR=0.66; 95% CI: 0.45-0.99) and fewer methadone treatment days (aIRR=0.76; 0.57-0.99), but not past 30-day buprenorphine receipt (aOR=0.90; 0.67-1.20), buprenorphine treatment days in past 6 months: aIRR=0.88; 0.69-1.12) or perceived inability to access buprenorphine (aOR=1.12; 0.87-1.44) or methadone (aOR=1.06; 0.76-1.48). CONCLUSION: Methamphetamine use is common among persons who use opioids in rural U.S. areas and negatively associated with current treatment and retention on methadone but not buprenorphine. Future studies should examine reasons for this disparity and reduce barriers to methadone for persons who use opioids and methamphetamine.

Mediation of BMI on 25-Hydroxyvitamin D Levels in U.S. Adults with Sugar-Sweetened Beverages Consumption.

Body mass index (BMI) as well as sugar-sweetened beverages (SSB) has been suggested to independently decrease 25-hydroxyvitamin D (25(OH)D). However, the relationship between SSB, BMI, and 25(OH)D is uncertain. This study aimed to investigate the potential mediating role of BMI in the association between SSB intake and 25(OH)D. A total of 4505 representative U.S. adults aged above 20 years and without liver conditions were selected from the 2013-2014 NHANES. All analyses were performed under survey modules with appropriate sampling weights. The prevalence of 25(OH)D insufficiency and deficiency was 37.8% and 24.1% in U.S. adults, respectively. Compared with non-SSB consumers, an increased risk of vitamin D deficiency was found in either heavy SSB consumers or soda consumers, respectively (aOR = 2.10, 95% CI = 1.25-3.54 in heavy SSB consumers; aOR = 1.61, 95% CI = 1.06-2.44 in soda consumers). Around 21.3% of the total effect of sugar intake from SSB on decreased 25(OH)D was explained by BMI. In conclusion, high total sugar intake from SSB and BMI independently contribute to lower 25(OH)D, and BMI mediates the inverse association between total sugar intake from SSB intake and 25(OH)D. Furthermore, an increased risk of having vitamin D deficiency was found in the population who consumed higher levels of sugar from SSB or soda drinks.

Validation of Dried Blood Spots for Capturing Hepatitis C Virus Diversity for Genomic Surveillance.

Dried blood spots (DBS) have emerged as a promising alternative to traditional venous blood for HCV testing. However, their capacity to accurately reflect the genetic diversity of HCV remains poorly understood. We employed deep sequencing and advanced phylogenetic analyses on paired plasma and DBS samples to evaluate the suitability of DBS for genomic surveillance. Results demonstrated that DBS captured equivalent viral diversity compared to plasma with no phylogenetic discordance observed. The ability of DBS to accurately reflect the profile of viral genetic diversity suggests it may be a promising avenue for future surveillance efforts to curb HCV outbreaks.

"I am not a junkie": Social categorization and differentiation among people who use drugs.

BACKGROUND: Substance use stigma is a form of group-based exclusion, and delineating pathways from stigma to poor health requires a deeper understanding of the social dynamics of people who use drugs (PWUD). Outside of recovery, scant research has examined the role of social identity in addiction. Framed by Social Identity Theory/Self-Categorization Theory, this qualitative study investigated strategies of within-group categorization and differentiation among PWUD and the roles these social categories may play in shaping intragroup attitudes, perceptions, and behaviors. METHODS: Data come from the Rural Opioid Initiative, a multi-site study of the overdose epidemic in rural United States. We conducted in-depth interviews with people who reported using opioids or injecting any drug (n=355) living in 65 counties across 10 states. Interviews focused on participants' biographical histories, past and current drug use, risk behaviors, and experiences with healthcare providers and law enforcement. Social categories and dimensions along which categories were evaluated were inductively identified using reflexive thematic analysis. RESULTS: We identified seven social categories that were commonly appraised by participants along eight evaluative dimensions. Categories included drug of choice, route of administration, method of attainment, gender, age, genesis of use, and recovery approach. Categories were evaluated by participants based on ascribed characteristics of morality, destructiveness, aversiveness, control, functionality, victimhood, recklessness, and determination. Participants performed nuanced identity work during interviews, including reifying social categories, defining 'addict' prototypicality, reflexively comparing self to other, and disidentifying from the PWUD supra-category. CONCLUSION: We identify several facets of identity, both behavioral and demographic, along which people who use drugs perceive salient social boundaries. Beyond an addiction-recovery binary, identity is shaped by multiple aspects of the social self in substance use. Patterns of categorization and differentiation revealed negative intragroup attitudes, including stigma, that may hinder solidary-building and collective action in this marginalized group.

Examining the Awareness, Acceptability, and Adoption of Conventional and non-conventional Forms of Pre-Exposure Prophylaxis (PrEP) for HIV Prevention Among jail-involved Black Sexual Minority men (BSMM) and Black Transgender Women (BTW) in Two Diverse US Cities.

Black sexual minority men (BSMM) and Black transgender women (BTW) are disproportionately impacted by HIV and incarceration in the United States. In-depth interviews (N=34) and ongoing thematic analysis guided by the Exploration Phase of the Exploration, Preparation, Implementation, Sustainment framework were conducted to uncover key themes focused on the awareness, acceptability, and early adoption of conventional (i.e., daily oral pill) and non-conventional forms of PrEP (i.e., long-acting injectable, e-prescription for pick up post release) among jail-involved BSMM and BTW in Chicago, Illinois and Baton Rouge, Louisiana. The majority of participants were cisgender BSMM (88%) and were enrolled in Chicago (65%). There was greater awareness, availability, and adoption of conventional PrEP and non-conventional PrEP e-prescription for pick up post release among Chicago participants compared with Baton Rouge participants. Participants were largely receptive to all three forms of PrEP and stated a high need for HIV prevention in jails and immediately following release. PrEP stigma emerged as a major barrier to conventional daily PrEP adoption while incarcerated; potential misuse (e.g., pill selling) as a potential barrier to PrEP eprescription; and needle aversion and added clinic time as potential barriers to longacting injectable (LAI)-PrEP. Participants indicated that PrEP e-prescription could help support continuity of care post release and highlighted reduced stigma, convenience, and longer-term HIV protection as benefits for LAI-PrEP. Study findings provided context-specific information to inform the implementation of future PrEP interventions for jail-involved BSMM and BTW in two highly HIV-impacted jurisdictions.

The Rural Opioid Initiative Consortium description: providing evidence to Understand the Fourth Wave of the Opioid Crisis.

OBJECTIVE: To characterize and address the opioid crisis disproportionately impacting rural U.S. regions. METHODS: The Rural Opioid Initiative (ROI) is a two-phase project to collect and harmonize quantitative and qualitative data and develop tailored interventions to address rural opioid use. The baseline quantitative survey data from people who use drugs (PWUD) characterizes the current opioid epidemic (2018-2020) in eight geographically diverse regions. RESULTS: Among 3,084 PWUD, 92% reported ever injecting drugs, 86% reported using opioids (most often heroin) and 74% reported using methamphetamine to get high in the past 30 days; 53% experienced homelessness in the prior 6 months; and 49% had ever overdosed. Syringe service program use varied by region and 53% had ever received an overdose kit or naloxone prescription. Less than half (48%) ever received medication for opioid use disorder (MOUD). CONCLUSIONS: The ROI combines data across eight rural regions to better understand drug use including drivers and potential interventions in rural areas with limited resources. Baseline ROI data demonstrate extensive overlap between opioid and methamphetamine use, high homelessness rates, inadequate access to MOUD, and other unmet needs among PWUD in the rural U.S. By combining data across studies, the ROI provides much greater statistical power to address research questions and better understand the syndemic of infectious diseases and drug use in rural settings including unmet treatment needs.

Sociodemographic characteristics and HIV risk behaviors of native-born and displaced Syrian men and transgender women who have sex with men in Lebanon.

HIV rates among men and transgender women who have sex with men (MTWSM) in Lebanon are consistent with a concentrated epidemic. Geopolitical and social circumstances leave these communities vulnerable to HIV spread. To document this risk encountered by Lebanese native and displaced Syrian MTWSM, participants, recruited by respondent driven sampling beginning with Syrian seeds, completed a survey with questions covering sociodemographic, behavioral, medical, and stigma, followed by opt-out HIV testing. Analyses included descriptive statistics and linear regression to differentiate between native Lebanese and Syrians who migrated after the onset of the civil war to identify correlations among sociodemographic factors, stigma, and risk behavior as a function of country of birth. Experienced and internalized stigmas were higher in the Syrian born MTWSM and correlated with elements of HIV risk. Combatting the intersectional stigmas of Syrian MTWSM in Lebanon would be most beneficial in mitigating HIV risk for these individuals.

RESUMEN: Las tasas de VIH entre hombres y mujeres transgénero que tienen sexo con hombres (HMTSH) en el Líbano son consistentes con una epidemia concentrada. Las circunstancias geopolíticas y sociales dejan a estas comunidades vulnerables a la propagación del VIH. Para documentar este riesgo al que se enfrentan los HMTSH nativos libaneses y HMTSH sirios desplazados, los participantes, reclutados mediante un muestreo impulsado por los encuestados que comenzó con semillas sirias, completaron una encuesta con preguntas que cubrían aspectos sociodemográficos, conductuales, médicos y de estigma, seguidas de una prueba de VIH de exclusión voluntaria. Los análisis incluyeron estadísticas descriptivas y regresión lineal para diferenciar entre libaneses nativos y sirios que emigraron después del inicio de la guerra civil para identificar correlaciones entre factores sociodemográficos, estigma y comportamiento de riesgo como función del país de nacimiento. Los estigmas experimentados e internalizados fueron más altos en los HMTSH nacidos en Siria y se correlacionaron con elementos de riesgo de VIH. Combatir los estigmas interseccionales de los HMTSH sirios en el Líbano sería lo más beneficioso para mitigar el riesgo de VIH para estos individuos.

Multilevel Understanding of the Impact of Individual- and School-Level Determinants on Lipid Profiles in Adolescents: The Cross-Level Interaction of Food Environment and Body Mass Index.

Adolescents with comparable personal risk factors may have different lipid profiles because of the school's context. Lipid determinants in adolescents should be considered using a multilevel perspective. This multilevel study investigated the effects of individual-level and school-level factors on lipid profiles in adolescents and evaluated the cross-level influence of lipid determinants. A representative adolescent cohort (n = 2727) was randomly selected from 36 schools in three diverse economic areas in Taiwan and assessed for their personal dietary patterns, physical parameters, and lipid profiles. For individual-level factors, both low physical activity and high body mass index (BMI) were associated with elevated triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), and total cholesterol (TC) levels, and a sugar-sweetened beverage intake of >500 mL/day was associated with increases of 5.97 and 6.12 mg/dL in LDL-C and TC levels, respectively, compared with abstinence. Regarding school-level factors, students in schools with ≥2 health promotion programs per year had a 5.27 mg/dL lower level of LDL-C than those in schools with 0−1 program, and students in schools with ≥46 food outlets within 600 m of the school had 6.90 and 13.3 mg/dL higher levels of TG and TC, respectively, than those in schools with <46 food outlets. School context modified the individual-level positive correlation between BMI and TG level (the p-value for the random-slope effect was 0.003). In conclusion, individual-level and school-level factors exert a multilevel effect on adolescent lipid profiles. The food environment near the school has a stronger cross-level impact on individual TG levels in adolescents with a high BMI than in those with a normal BMI.

Stability and Transformation of Metabolic Syndrome in Adolescents: A Prospective Assessment in Relation to the Change of Cardiometabolic Risk Factors.

Underlying pathophysiological mechanisms drive excessive clustering of cardiometabolic risk factors, causing metabolic syndrome (MetS). MetS status may transform as adolescents transition to young adulthood. This study investigated the latent clustering structure and its stability for MetS during adolescence, and assessed the anthropometric and clinical metabolic determinants for MetS transformation. A community-based representative adolescent cohort (n = 1516) was evaluated for MetS using four diagnostic criteria, and was followed for 2.2 years to identify new-onset MetS. The clustering structure underlying cardiometabolic parameters was stable across adolescence; both comprised a fat-blood pressure (BP)-glucose three-factor structure (total variance explained: 68.8% and 69.7% at baseline and follow-up, respectively). Among adolescents with MetS-negative at baseline, 3.2-4.4% had incident MetS after 2.2 years. Among adolescents with MetS-positive at baseline, 52.0-61.9% experienced MetS remission, and 38.1-48.0% experienced MetS persistence. Increased systolic BP (SBP) was associated with a high MetS incidence risk, while decreased levels of SBP and glucose were associated with MetS remission. Compared with adolescents with a normal metabolic status at baseline, those with an initial abdominal obesity and increased triglycerides level had a 15.0- and 5.7-fold greater risk for persistent abnormality, respectively. Abdominal obesity and low high-density lipoprotein cholesterol are two abnormal MetS components that highly persist during adolescence, and are the intervention targets for reducing the future risk of cardiometabolic disorders.

Sugar-Sweetened Beverages Intake, Abdominal Obesity, and Inflammation among US Adults without and with Prediabetes-An NHANES Study.

Excessive sugar-sweetened beverages (SSB) consumption and abdominal obesity have been independently linked to numerous disorders, including diabetes and elevated C-reactive protein (CRP). This study aimed to explore the association between SSB intake, abdominal obesity, and inflammation in normal and prediabetic adults. Sugar intake from SSBs was calculated from 24-h dietary recalls and further classified into non-, medium-, and high-intake. The status of non- and prediabetes was identified based on hemoglobin A1c level. All analyses were performed under a survey module with appropriate sampling weights to control for the complex survey design. A total of 5250 eligible adults without diabetes were selected from the 2007-2010 NHANES. A 1.31-fold increased risk of developing prediabetes was observed in people who consumed high sugar from SSBs when compared to non-SSB consumers. Among individuals with prediabetes, adults who consumed a high amount of sugar from SSB had a 1.57-fold higher risk to increase CRP when compared to non-SSB consumers, even after adjusting for abdominal obesity. Furthermore, the association between the high amount of sugar intake from SSBs and elevated CRP was strengthened by abdominal obesity in prediabetes (p for interaction term = 0.030). Our findings highlight that a positive association between sugar intake from SSBs and CRP levels was only observed in US adults with prediabetes. Abdominal obesity may strengthen this effect in prediabetic adults with a high amount of sugar intake from SSBs.

Qualitative Review of Organizational Responses to Rumors in the 2014-2016 Ebola Virus Disease Outbreak in Liberia and Sierra Leone.

INTRODUCTION: Rumors and misperceptions were a persistent challenge in the response to the 2014-2016 Ebola Virus Disease (EVD) outbreak in West Africa. This study aimed to document organizational approaches to identifying and addressing rumors and provide practical recommendations for future outbreaks. METHODS: We conducted semistructured interviews with 34 individuals who participated in the EVD response in Liberia and/or Sierra Leone. Interviews focused on the general organizational approach and organizational response to specific rumors. Interviews were recorded and transcribed verbatim. RESULTS: Most respondents reported that rumors were considered an organizational priority and their importance increased over time. Formal rumor identification systems using community-level reporters were described in Liberia and Sierra Leone as well as varied informal systems. A wide range of approaches was used to address rumors including Community Led Ebola Action, Community Led Total Sanitation, drama performances, Ebola Treatment Center/Unit-based approaches, radio, leveraging community leaders as an information source, and organization change. Interpersonal and community-led approaches were described most often. Staff whose professional roles did not involve rumor management reported informally addressing rumors with colleagues and beneficiaries. Rumors reflecting valid concerns with the EVD response, such as potential infection in health care facilities, were addressed through organizational change and improvement. DISCUSSION: Interpersonal and community-led approaches were considered effective by participants and hold promise for future outbreaks. Informal systems developed at Ebola Treatment Centers/Units highlighted how these facilities may be utilized as an information hub. Professionals who interact with beneficiaries, especially local staff, are likely to address rumors informally and organizations may benefit from considering local staff an asset in rumor management. Rumors alerted responders to issues in the EVD response, but this may not be the most efficient mechanism to receive and address concerns.

Hepatitis C Treatment Knowledge and Practice Among Family Medicine Physicians in Wisconsin During the Current Hepatitis C Epidemic.

BACKGROUND: Curative treatment for hepatitis C virus (HCV) exists, making elimination of HCV possible. However, most people with HCV have not received treatment. One barrier is limited access to treatment providers. HCV treatment can be effectively provided by primary care providers and, since 2017, Wisconsin Medicaid allows nonspecialists to prescribe treatment. We surveyed family medicine physicians in Wisconsin to evaluate capacity for the provision of HCV treatment. METHODS: We mailed a survey to family medicine physicians in Wisconsin from June 25, 2018 through September 7, 2018. Physicians were asked whether they prescribe HCV treatment and about their knowledge regarding HCV treatment and relevant statewide Medicaid policy. Using multivariable logistic regression, we evaluated physician characteristics associated with prescribing HCV treatment. RESULTS: Of 1,333 physicians surveyed, 600 (45%) responded. Few respondents reported prescribing HCV treatment independently (1%; n = 4) or in consultation with a specialist (6%; n = 35). Only 6% (n = 36) reported having a "great deal" of knowledge about HCV treatment. Most (86%; n = 515) were not aware that family medicine physicians can now prescribe HCV treatment covered by Medicaid. Physicians who practiced in offices affiliated with health systems were less likely to prescribe HCV treatment than physicians who practiced in an independent office or a Rural Health Clinic. CONCLUSIONS: Among family medicine physicians in Wisconsin, experience with and knowledge of HCV treatment was limited. Developing knowledge and skills among primary care providers is needed to expand treatment access and make progress toward HCV elimination. Studies are needed to evaluate treatment access in primary care offices affiliated with health systems.

Age difference in the combined effect of soda drinks consumption and body adiposity on hyperuricaemia in US adults.

OBJECTIVE: To evaluate age-related differences in the independent/combined association of added sugar intake from soda and body adiposity with hyperuricaemia in gender-stratified US adults. DESIGN: Consumption of added sugar from soda was calculated from 24-h dietary interviews and categorised into none, regular and excessive consumption. Hyperuricaemia was defined as serum uric acid levels >417 mmol/l in men and >357 mmol/l in women. Multiple regression models with interaction terms and logistic models adjusted for covariates were conducted under survey-data modules. SETTING: National Health and Nutrition Examination Survey during 2007-2016. PARTICIPANTS: 15 338 adults without gout, failing kidneys, an estimated glomerular filtration rate < 30 or diabetes were selected. RESULTS: The age-stratified prevalence rate of hyperuricaemia was 18·8-20·4 % in males and 6·8-17·3 % in females. Hyperuricaemia prevalence of approximately 50 % was observed in young and middle age males who consumed excessive added sugar from soda. Excessive added sugar intake was observed to be associated with 1·5- to 2·0-fold and 2·0- to 2·3-fold increased risk of the probability of hyperuricaemia in young and middle age males and middle age females, respectively. Study participants, regardless of age or gender, who were obese and consumed excessive added sugar from soda had the highest risk of having hyperuricaemia. CONCLUSIONS: Our study revealed that the association between hyperuricaemia and consumption of excessive added sugar from soda may vary by age and gender. Obese adults who consumed excessive added sugar from soda had the highest risk of hyperuricaemia, a finding that was found across all age-specific groups for both genders.

Contribution of insulin resistance to the relationship between sugar-sweetened beverage intake and a constellation of cardiometabolic abnormalities in adolescents.

BACKGROUND: Insulin resistance (IR) is a pathophysiological construct that derives a series of metabolic disturbances that promote cardiometabolic dysfunction. This study evaluated mediating and modifying effects of homeostatic model assessment-based IR (HOMA-IR) on the association between sugar-sweetened beverage (SSB) consumption and a constellation of adolescent cardiometabolic abnormalities. METHODS: Comprehensive data on sociodemographics, diet, physical activity, and anthropometric and biochemical parameters for 1454 adolescents were obtained from a large-scale representative study for adolescent metabolic syndrome (MetS) conducted in Taiwan. The original (HOMA1-IR) and updated nonlinear (HOMA2-IR) HOMA-IR indicators were used as IR biomarkers. Principal component (PC) analysis was employed to create reduced groups of variables and risk scores for retained PCs. RESULTS: Higher SSB intake was associated with higher levels of HOMA1-IR and HOMA2-IR, and the two IR biomarkers were positively correlated with metabolic dysfunction clustering. Compared with SSB nondrinkers, adolescents who consumed >500 mL/day of hand-shaken high-fructose corn syrup beverages (HHB) had a 0.22 increase in the number of abnormal MetS components, and HOMA-IR mediation explained 33.9-37.9% of the effect. IR biomarkers accounted for 26.5-31.0% of the relationship between >500 mL/day of SSB consumption and bodyweight-enhanced PC scores. The effects of HOMA-IR indicators on all bodyweight-related factors were consistently intensified among >350 mL/day HHB drinkers (all Pinteraction < 0.05). CONCLUSIONS: Fructose-rich SSB intake correlates with a constellation of cardiometabolic abnormalities in adolescents, and this association may be partly mediated by HOMA-IR levels. The adverse effects of HOMA-IR on bodyweight-associated cardiometabolic risk factors depend on the type of SSB consumption, with enhanced risks observed in the intake of high amounts of HFCS-containing SSBs.