Associations between police harassment and distrust in and reduced access to healthcare among Black sexual minority men: A longitudinal analysis of HPTN 061.

OBJECTIVE: Evaluate associations between racialized and homophobia-based police harassment (RHBPH) and healthcare distrust and utilization among Black Sexual Minority Men (BSMM). METHODS: We utilized data from a longitudinal cohort study from HIV Prevention Trials Network (HPTN) 061 with baseline, six and 12 month follow-up assessments. Using multivariable analysis, we evaluated associations between RHBPH and healthcare distrust and utilization reported at the 6 and 12 month visits. RESULTS: Of 1553 BSMM present at baseline, 1160 were available at six-month follow-up. In multivariable analysis, increasing frequency of RHBPH was associated with increasing levels of distrust in healthcare providers (aOR 1.31, 95% CI: 1.00, 1.74) and missing 50% or more of healthcare visits at six-month follow-up (aOR 1.93, 95% CI: 1.09, 3.43). CONCLUSIONS: Recent experiences of RHBPH are associated with reduced trust in and access to healthcare among BSMM, with more frequent RHBPH associated with greater vulnerability.

COVID-19 stigmatization after the development of effective vaccines: Vaccination behavior, attitudes, and news sources.

OBJECTIVE: To compare COVID-19 stigmatization at two pandemic time points (1) August 2020-during lockdowns and prior to vaccine rollout, and (2) May 2021-during vaccine rollout, when approximately half of U.S. adults were vaccinated. METHODS: Comparison of COVID19-related stigmatization and associated factors in two national internet surveys conducted in August 2020 (N = 517) and May 2021 (N = 812). Factors associated with endorsing stigmatization were identified using regression analysis. The main outcomes included endorsement of stigmatization and behavioral restrictions towards persons with COVID-19 and towards persons of Chinese descent. A previously developed "stigmatizing attitudes and behavioral restrictions" scale was adapted to measure the intersection of negative attitudes toward COVID-19 disease and negative attitudes toward persons of Chinese descent. RESULTS: COVID-19 related stigmatization declined significantly from August 2020 to May 2021. Many factors were associated with stigmatizing in both surveys: full time employment, Black race, Hispanic ethnicity, worry about contracting COVID-19, probable depression, and Fox News and social media as sources of information (all positively associated), and self-assessed knowledge about COVID-19, contact with Chinese individuals, and publicly funded news as sources (all negatively associated). Positive attitudes toward vaccination were associated with stigmatization. CONCLUSIONS: COVID-19 related stigmatization reduced substantially over these two points in the pandemic, with many continuities in the factors associated with stigmatizing. Despite the reduction in stigmatizing, however, some stigmatizing attitudes for both COVID-19 and Chinese individuals remained.

Does the Association Between Stimulant use and High Risk Sexual Behavior Vary by Injection Drug Use, Sexual Minority Status, or HIV Infection Status? A Meta-analysis.

There is strong evidence linking stimulant use, namely methamphetamine use, to sexual risk behavior among sexual minority men (SMM); we do not, however, have a good understanding of this relationship among other at-risk populations. In this study, we systematically reviewed associations between stimulant use (i.e., methamphetamine, crack cocaine, cocaine) and sexual risk behaviors among populations facing elevated risk of HIV transmission and acquisition (i.e., SMM, people who inject drugs (PWID), and people living with HIV/AIDS (PLWH)). Random-effects meta-analyses and sensitivity analyses that included crude and adjusted estimates separately were conducted to evaluate the impact of potential confounding variables. The results showed strong relationships between stimulant use and condomless sex, transactional sex, and multiple sexual partners. Results were broadly consistent when analyses were stratified by type of stimulant (methamphetamine, crack cocaine, and other stimulants) and risk group. Sensitivity analyses with confounding variables did not greatly impact results. The results indicate that stimulant use is associated with numerous sexual risk behaviors regardless of risk group, suggesting prevention efforts focused on reducing methamphetamine-related HIV risk should target a range of at-risk populations.

Using large-scale respondent driven sampling to monitor the end of an HIV epidemic among persons who inject drugs in Hai Phong, Viet Nam.

AIMS: To describe the use of large-scale respondent driven sampling (RDS) surveys to demonstrate the "end of an HIV epidemic" (HIV incidence < 0.5/100 person-years) among persons who inject drugs (PWID) in a middle-income country. Large sample sizes are needed to convincingly demonstrate very low incidence rates. METHODS: 4 large surveys (Ns approximately 1500 each) were conducted among PWID in Hai Phong, Vietnam in 2016-2019. Respondent driven sampling (RDS) with a modification to add snowball sampling was used for recruiting participants. HIV incidence was measured through recency testing, repeat participants across multiple surveys and in a cohort study of PWID recruited from the surveys. RDS analytics (time to equilibria and homophilies for major variables) were used to assess similarities/differences in RDS only versus RDS plus snowball recruiting. Characteristics were compared among respondents recruited through standard RDS recruitment versus through snowball sampling. An overall assessment of the robustness of RDS to modification was made when adding a snowball sampling recruitment. RESULTS: RDS recruiting was very efficient in the first 5 weeks of each survey with approximately 180 respondents recruited per week. Recruiting then slowed considerably, and snowball sampling (permitting an individual respondent to recruit large numbers of new respondents) was added to the existing RDS recruiting. This led to recruiting within 13-14 weeks of 1383, 1451, 1444 and 1268 respondents, close to the target of 1500 respondents/survey. Comparisons of participants recruited through standard RDS method and respondents recruited through snowball methods showed very few significant differences. RDS analytics (quickly reaching equilibria, low homophilies) were favorable for both RDS recruited and total numbers of participants in each survey. DRug use and Infections in ViEtnam (DRIVE) methods have now been officially adopted in other provinces. CONCLUSIONS: RDS appears to be quite robust with respect to adding a modest number of participants recruited through snowball sampling. Large sample sizes can provide compelling evidence for "ending an HIV epidemic" to policy makers in a PWID population in a middle income country setting.

Pre-Exposure Prophylaxis (PrEP) Awareness Among Black Men Who Have Sex with Men with a History of Criminal Justice Involvement in Six U.S. Cities: Findings from the HPTN 061 Study.

Transition from detention to the community for Black men who have sex with men with criminal justice involvement (BMSM-CJI) represents a particularly vulnerable period for HIV acquisition and transmission. We examined levels of HIV PrEP awareness among BMSM-CJI. PrEP awareness among BMSM-CJI was low (7.9%) with evidence of lower awareness levels among those with STI. There was evidence that HIV testing history was associated with higher PrEP awareness. Study findings highlight needs for further assessment of PrEP knowledge among BMSM-CJI. The strong association between HIV testing and PrEP awareness underscores an opportunity to integrate PrEP education within HIV/STI testing services.

Ending an HIV epidemic among persons who inject drugs in a middle-income country: extremely low HIV incidence among persons who inject drugs in Hai Phong, Viet Nam.

OBJECTIVE: To determine whether it is possible to 'end an HIV epidemic' among persons who inject drugs (PWID) in a low/middle income country. DESIGN: Serial cross-sectional surveys with a cohort of HIV seronegative participants with 6-month follow-up visits recruited from surveys. METHODS: Surveys of PWID using respondent driven and snowball sampling were conducted in 2016, 2017, 2018, and 2019 (N = 1383, 1451, 1444, and 1268). HIV recency testing was used to identify possible seroconversions in the window period prior to study entry. Structured interviews covering drug use histories, current drug use, and use of HIV-related services were administered by trained interviewers. Urinalysis was used to confirm current drug use. HIV and hepatitis C virus testing were conducted. Electronic fingerprint readers were used to avoid multiple participation in each survey and to link participants across surveys. A cohort of HIV seronegative participants with 6-month follow-up visits was recruited from the surveys, 480 from 2016, 233 from 2017, and 213 from 2018. RESULTS: Participants were predominantly male (95%), mean age approximately 40, all reported injecting heroin, HIV prevalence ranged between 26 and 30%. We had three seroconversions in 1483 person-years at risk (PYAR) in the cohort study, and 0 in 696 PYAR among repeat survey participants, and 0 seroconversions in 1344 PYAR in recency testing. Overall HIV incidence was 0.085/100 PYAR, 95% confidence interval 0.02-0.25/100 PYAR. CONCLUSION: The data from Hai Phong clearly demonstrate that it is possible to achieve very low HIV incidence - 'end an HIV epidemic' - among PWID in a middle-income country.

Changes in quality of life (WHOQOL-BREF) and addiction severity index (ASI) among participants in opioid substitution treatment (OST) in low and middle income countries: an international systematic review.

BACKGROUND: Opioid substitution treatment (OST) can increase quality of life (WHOQOL-BREF) and reduce addiction severity index (ASI) scores among participants over time. OST program participants have noted that improvement in quality of life is one of the most important variables to their reduction in drug use. However, there is little systematic understanding of WHOQOL-BREF and ASI domain changes among OST participants in low and middle-income countries (LMIC). METHODS: Utilizing PRISMA guidelines we conducted a systematic literature search to identify OST program studies documenting changes in WHOQOL-BREF or ASI domains for participants in buprenorphine or methadone programs in LMIC. Standardized mean differences for baseline and follow-up domain scores were compared along with relationships between domain scores, OST dosage, and length of follow-up. RESULTS: There were 13 OST program studies with 1801 participants from five countries eligible for inclusion in the review. Overall, statistically significant changes were noted in all four WHOQOL-BREF domain and four of the seven ASI domain scores (drug, psychological, legal, and family) documented in studies. Dosage of pharmacologic medication and length of follow-up did not affect changes in domain scores. CONCLUSION: WHOQOL-BREF and ASI domain scoring is a useful tool in measuring overall quality of life and levels of addiction among OST participants. Coupled with measurements of blood-borne infection, drug use, relapse, and overdose, WHOQOL-BREF and ASI represent equally important tools for evaluating the effects of OST over time and should be further developed as integrated tools in the evaluation of participants in LMIC.

High coverage needle/syringe programs for people who inject drugs in low and middle income countries: a systematic review.

BACKGROUND: Persons who inject drugs (PWID) are at an elevated risk for human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection. In many high-income countries, needle and syringe exchange programs (NSP) have been associated with reductions in blood-borne infections. However, we do not have a good understanding of the effectiveness of NSP in low/middle-income and transitional-economy countries. METHODS: A systematic literature review based on PRISMA guidelines was utilized to collect primary study data on coverage of NSP programs and changes in HIV and HCV infection over time among PWID in low-and middle-income and transitional countries (LMICs). Included studies reported laboratory measures of either HIV or HCV and at least 50% coverage of the local injecting population (through direct use or through secondary exchange). We also included national reports on newly reported HIV cases for countries that had national level data for PWID in conjunction with NSP scale-up and implementation. RESULTS: Studies of 11 NSPs with high-coverage from Bangladesh, Brazil, China, Estonia, Iran, Lithuania, Taiwan, Thailand and Vietnam were included in the review. In five studies HIV prevalence decreased (range -3% to -15%) and in three studies HCV prevalence decreased (range -4.2% to -10.2%). In two studies HIV prevalence increased (range +5.6% to +14.8%). HCV incidence remained stable in one study. Of the four national reports of newly reported HIV cases, three reported decreases during NSP expansion, ranging from -30% to -93.3%, while one national report documented an increase in cases (+37.6%). Estimated incidence among new injectors decreased in three studies, with reductions ranging from -11/100 person years at risk to -16/100 person years at risk. CONCLUSIONS: While not fully consistent, the data generally support the effectiveness of NSP in reducing HIV and HCV infection in low/middle-income and transitional-economy countries. If high coverage is achieved, NSP appear to be as effective in LMICs as in high-income countries. Additional monitoring and evaluation research is needed for NSPs where reductions in HIV/HCV infection among PWID are not occurring in order to identify and correct contributing problems.

Transitions from injection-drug-use-concentrated to self-sustaining heterosexual HIV epidemics: patterns in the international data.

BACKGROUND: Injecting drug use continues to be a primary driver of HIV epidemics in many parts of the world. Many people who inject drugs (PWID) are sexually active, so it is possible that high-seroprevalence HIV epidemics among PWID may initiate self-sustaining heterosexual transmission epidemics. METHODS: Fourteen countries that had experienced high seroprevalence (<20%) HIV epidemics among PWID and had reliable data for injection drug use (IDU) and heterosexual cases of HIV or AIDS were identified. Graphs of newly reported HIV or AIDS cases among PWID and heterosexuals were constructed to identify temporal relationships between the two types of epidemics. The year in which newly reported cases among heterosexuals surpassed newly reported cases among PWID, aspects of the epidemic curves, and epidemic case histories were analyzed to assess whether it was "plausible" or "highly unlikely" that the HIV epidemic among PWID might have initiated the heterosexual epidemic in each country. RESULTS: Transitions have occurred in 11 of the 14 countries. Two types of temporal relationships between IDU and heterosexual HIV epidemics were identified, rapid high incidence transitions vs. delayed, low incidence transitions. In six countries it appears "plausible" that the IDU epidemic initiated a heterosexual epidemic, and in five countries it appears "highly unlikely" that the IDU epidemic initiated a heterosexual epidemic. A rapid decline in incidence among PWID after the peak year of new cases and national income were the best predictors of the "highly unlikely" initiation of a heterosexual epidemic. DISCUSSION: Transitions from IDU concentrated epidemics to heterosexual epidemics are common in countries with high seroprevalence among PWID though there are distinct types of transitions. Interventions to immediately reduce HIV incidence among PWID may reduce the likelihood that an IDU epidemic may initiate a heterosexual epidemic.

Are females who inject drugs at higher risk for HIV infection than males who inject drugs: an international systematic review of high seroprevalence areas.

OBJECTIVE: There are multiple reasons why females who inject drugs may be more likely to become infected with HIV than males who inject drugs. Where this is the case, special HIV prevention programs for females would be needed. DESIGN: International systematic review and meta-analysis of studies across 14 countries. METHODS: Countries with high seroprevalence (>20%) HIV epidemics among persons who inject drugs (PWID) were identified from the Reference Group to the UN on HIV and Injecting Drug Use. Systematic literature reviews collected data on HIV prevalence by gender for these countries. Non-parametric and parametric tests along with meta-analytic techniques examined heterogeneity and differences in odds ratios (OR) across studies. RESULTS: Data were abstracted from 117 studies in 14 countries; total sample size N = 128,745. The mean weighted OR for HIV prevalence among females to males was 1.18 [95% CI 1.10-1.26], with high heterogeneity among studies (I(2)= 70.7%). There was a Gaussian distribution of the log ORs across studies in the sample. CONCLUSION: There was a significantly higher HIV prevalence among females compared to males who inject drugs in high seroprevalence settings, but the effect size is extremely modest. The high level of heterogeneity and the Gaussian distribution suggest multiple causes of differences in HIV prevalence between females and males, with a specific difference determined by local factors. Greater understanding of factors that may protect females from HIV infection may provide insights into more effective HIV prevention for both females and males who inject drugs.