Changing Places and Partners: Associations of Neighborhood Conditions With Sexual Network Turnover Among African American Adults Relocated From Public Housing.

Neighborhood conditions and sexual network turnover have been associated with the acquisition of HIV and other sexually transmitted infections (STIs). However, few studies investigate the influence of neighborhood conditions on sexual network turnover. This longitudinal study used data collected across 7 visits from a predominantly substance-misusing cohort of 172 African American adults relocated from public housing in Atlanta, Georgia, to determine whether post-relocation changes in exposure to neighborhood conditions influence sexual network stability, the number of new partners joining sexual networks, and the number of partners leaving sexual networks over time. At each visit, participant and sexual network characteristics were captured via survey, and administrative data were analyzed to describe the census tracts where participants lived. Multilevel models were used to longitudinally assess the relationships of tract-level characteristics to sexual network dynamics over time. On average, participants relocated to neighborhoods that were less economically deprived and violent, and had lower alcohol outlet densities. Post-relocation reductions in exposure to alcohol outlet density were associated with fewer new partners joining sexual networks. Reduced perceived community violence was associated with more sexual partners leaving sexual networks. These associations were marginally significant. No post-relocation changes in place characteristics were significantly associated with overall sexual network stability. Neighborhood social context may influence sexual network turnover. To increase understanding of the social-ecological determinants of HIV/STIs, a new line of research should investigate the combined influence of neighborhood conditions and sexual network dynamics on HIV/STI transmission over time.

Public Housing Relocations and Partnership Dynamics in Areas With High Prevalences of Sexually Transmitted Infections.

BACKGROUND: We investigated the implications of one structural intervention--public housing relocations--for partnership dynamics among individuals living areas with high sexually transmitted infection (STI) prevalence. High-prevalence areas fuel STI endemicity and are perpetuated by spatially assortative partnerships. METHODS: We analyzed 7 waves of data from a cohort of black adults (n = 172) relocating from 7 public housing complexes in Atlanta, Georgia. At each wave, data on whether participants' sexual partners lived in the neighborhood were gathered via survey. Participant addresses were geocoded to census tracts, and measures of tract-level STI prevalence, socioeconomic conditions, and other attributes were created for each wave. "High-prevalence tracts" were tracts in the highest quartile of STI prevalence in Georgia. Descriptive statistics and hierarchical generalized linear models examined trajectories of spatially assortative partnerships and identified predictors of assortativity among participants in high-prevalence tracts. RESULTS: All 7 tracts containing public housing complexes at baseline were high-prevalence tracts; most participants relocated to high-prevalence tracts. Spatially assortative partnerships had a U-shaped distribution: the mean percent of partners living in participants' neighborhoods at baseline was 54%; this mean declined to 28% at wave 2 and was 45% at wave 7. Participants who experienced greater postrelocation improvements in tract-level socioeconomic conditions had a lower odds of having spatially assortative partnerships (adjusted odds ratio, 1.55; 95% confidence interval [95% CI], 1.06-2.26). CONCLUSIONS: Public housing relocation initiatives may disrupt high-prevalence areas if residents experience significant postrelocation gains in tract-level socioeconomic conditions.

"I Created Something New with Something that Had Died": Photo-Narratives of Positive Transformation Among Women with HIV.

A dearth of research describes the strengths of women living with HIV (WLH), yet understanding these strengths can promote women's well-being and healthy behavior. This analysis explores positive life transformations among WLH through photo-stories. WLH (N = 30) from three U.S. cities participated in a pilot photovoice project to tell their story of HIV. The project included three group meetings, an individual interview, and a public exhibit. Using qualitative strategies of theme and narrative analysis we identified positive transformations in women's photo-stories. Participants were African American (83 %) and low income (83 %). Women described four major positive transitions in their lives including transformations related to healthfulness, spirituality, self-acceptance, and confidence. Despite challenges, WLH experience positive transformation and growth experiences. Understanding these transformative changes can shed light on women's motivation to make healthy life changes and thus frame strengths-based interventions for WLH. Photovoice itself is a potential strategy to promote WLH's strengths and health.

Changes in Exposure to Neighborhood Characteristics are Associated with Sexual Network Characteristics in a Cohort of Adults Relocating from Public Housing.

Ecologic and cross-sectional multilevel analyses suggest that characteristics of the places where people live influence their vulnerability to HIV and other sexually-transmitted infections (STIs). Using data from a predominately substance-misusing cohort of African-American adults relocating from US public housing complexes, this multilevel longitudinal study tested the hypothesis that participants who experienced greater post-relocation improvements in economic disadvantage, violent crime, and male:female sex ratios would experience greater reductions in perceived partner risk and in the odds of having a partner who had another partner (i.e., indirect concurrency). Baseline data were collected from 172 public housing residents before relocations occurred; three waves of post-relocation data were collected every 9 months. Participants who experienced greater improvements in community violence and in economic conditions experienced greater reductions in partner risk. Reduced community violence was associated with reduced indirect concurrency. Structural interventions that decrease exposure to violence and economic disadvantage may reduce vulnerability to HIV/STIs.

Impact of public housing relocations: are changes in neighborhood conditions related to STIs among relocaters?

BACKGROUND: Cross-sectional and ecologic studies suggest that place characteristics influence sexual behaviors and sexually transmitted infections (STIs). Using data from a predominately substance-misusing cohort of African American adults relocating from US public housing complexes, this multilevel longitudinal study tested the hypothesis that participants who experienced greater postrelocation improvements in neighborhood conditions (i.e., socioeconomic disadvantage, social disorder, STI prevalence, and male/female sex ratios) would have reduced the odds of testing positive for an STI over time. METHODS: Baseline data were collected in 2009 from 172 public housing residents before relocations occurred; 3 waves of postrelocation data were collected every 9 months thereafter. Polymerase chain reaction methods were used to test participants' urine for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. Individual-level characteristics were assessed via survey. Administrative data described the census tracts where participants lived at each wave (e.g., sex ratios, violent crime rates, and poverty rates). Hypotheses were tested using multilevel models. RESULTS: Participants experienced improvements in all tract-level conditions studied and reductions in STIs over time (baseline: 29% tested STI positive; wave 4: 16% tested positive). Analyses identified a borderline statistically significant relationship between moving to tracts with more equitable sex ratios and reduced odds of testing positive for an STI (odds ratio, 0.16; 95% confidence interval, 0.02-1.01). Changes in other neighborhood conditions were not associated with this outcome. DISCUSSION: Consonant with past research, our findings suggest that moving to areas with more equitable sex ratios reduces the risk of STI infection. Future research should study the extent to which this relationship is mediated by changes in sexual network dynamics.

Perspectives of middle-aged African-American women in the Deep South on antiretroviral therapy adherence.

Despite evidence of stabilization in some areas of the USA, HIV infection in black women is not declining in the Deep South. Using a phenomenological approach to qualitative inquiry, we investigated women's experiences influencing their adherence to highly active antiretroviral therapy (HAART) in an urban setting. Inclusion criteria specified black women who had been aware of their HIV status for at least two years and were engaged in HIV outpatient care. Twelve single face-to-face confidential in-depth semi-structured interviews were conducted from a sample of predominantly middle-aged women retained in care at an HIV clinic in Atlanta, Georgia. Data were analyzed by two independent reviewers and three themes emerged from the group of women's accounts of their experiences. First, sentinel events led to changes in perspective and motivated women to adhere to HAART. Second, recognition that one had the personal strength necessary to cope with HIV fostered adherence. Finally, relationships with healthcare providers especially trust issues surrounding this relationship, impacted adherence both positively and negatively. These findings suggest that HAART adherence is a complex issue among middle-aged urban black women with HIV in the Deep South. Providers caring for this patient population should recognize that sentinel events, personal strength, and positive healthcare relationships are opportunities to improve adherence.

The aftermath of public housing relocations: relationships between changes in local socioeconomic conditions and depressive symptoms in a cohort of adult relocaters.

USA is experiencing a paradigm shift in public housing policy: while policies used to place people who qualified for housing assistance into spatially concentrated housing complexes, they now seek to geographically disperse them, often to voucher-subsidized rental units in the private market. Programs that relocate residents from public housing complexes tend to move them to neighborhoods that are less impoverished and less violent. To date, studies have reached conflicting findings about the relationship between public housing relocations and depression among adult relocaters. The present longitudinal multilevel analysis tests the hypothesis that pre-/postrelocation improvements in local economic conditions, social disorder, and perceived community violence are associated with declines in depressive symptoms in a cohort of African-American adults; active substance misusers were oversampled. We tested this hypothesis in a cohort of 172 adults who were living in one of seven public housing complexes scheduled for relocation and demolition in Atlanta, GA; by design, 20% were dependent on substances and 50% misused substances but were not dependent. Baseline data captured prerelocation characteristics of participants; of the seven census tracts where they lived, three waves of postrelocation data were gathered approximately every 9 months thereafter. Surveys were administered at each wave to assess depressive symptoms measured using the Center for Epidemiologic Studies Depression Scale (CES-D), perceived community violence, and other individual-level covariates. Participants' home addresses were geocoded to census tracts at each wave, and administrative data sources were used to characterize tract-level economic disadvantage and social disorder. Hypotheses were tested using multilevel models. Between waves 1 and 2, participants experienced significant improvements in reported depressive symptoms and perceived community violence and in tract-level economic disadvantage and social disorder; these reductions were sustained across waves 2-4. A 1 standard deviation improvement in economic conditions was associated with a 1-unit reduction in CES-D scores; the magnitude of this relationship did not vary by baseline substance misuse or gender. Reduced perceived community violence also predicted lower CES-D scores. Our objective measure of social disorder was unrelated to depressive symptoms. We found that relocaters who experienced greater pre-/postrelocation improvements in economic conditions or in perceived community violence experienced fewer depressive symptoms. Combined with past research, these findings suggest that relocation initiatives should focus on the quality of the places to which relocaters move; future research should also identify pathways linking pre-/postrelocation changes in place characteristics to changes in mental health.

Access to health services and sexually transmitted infections in a cohort of relocating African American public housing residents: an association between travel time and infection.

BACKGROUND: High incidence and prevalence of sexually transmitted infection (STI) in blacks have been attributed to multiple factors. However, few articles have discussed spatial access to healthcare as a driver of disparities. The objective of this analysis was to evaluate the relationship between travel time to a healthcare provider and the likelihood of testing positive for 1 of 3 STIs in a sample of adults living in public housing. METHODS: One hundred and eight black adults in Atlanta, GA from November 2008 to June 2009, completed a survey that queried sexual behavior and healthcare use and had urine tested for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis by molecular methods. Travel time was a continuous variable capturing the number of minutes it took to reach the place where participants received most of their care. Multivariate analyses tested the hypothesis that individuals reporting longer travel times would be more likely to test positive for an STI. Travel time was squared to linearize its relationship to the outcome. RESULTS: Thirty-six residents (37.5%) tested positive for ≥1 STI. A curvilinear relationship existed between travel time and STI status. When travel time was <48 minutes, a positive relationship existed between travel time and the odds of testing positive for an STI. An inverse relationship existed when travel time was ≥48 minutes. CONCLUSION: Residents of impoverished communities experience a curvilinear relationship between travel time and STI status. We discuss possible factors that might have created this curvilinear relationship, including voluntary social isolation.

An HIV/AIDS fellowship program for minority physicians.

The human immunodeficiency virus (HIV)/AIDS epidemic disproportionately affects African Americans and Latinos in the United States, but there are limited numbers of minority physicians providing primary medical care to these patients. An HIV Medicine Association (HIVMA) Minority Clinical fellowship began training the first cohort of minority physicians in July 2007 to help provide care in the face of these health disparities. This report chronicles the experience of Dr Loida Bonney as a fellow caring for people living with HIV/AIDS at the Grady Health System in urban Atlanta, Georgia, and demonstrates that such fellowships can be successful mechanisms to train physicians with expertise in HIV medicine. It is important to develop an expanded number of flexible, innovative programs for building the HIV medicine workforce.

Racial/ethnic sexual health disparities among incarcerated women.

Rates of sexually transmitted infections (STIs) in women in U.S. corrections facilities are higher than rates in community samples. Research that combines behavioral correlates of STI with STI history by race/ethnicity has not been done in incarcerated women. The purpose of this study was to compare by race/ethnicity self-reported sexual risk behaviors with self-reported history of STI in an incarcerated sample. An interviewer administered a questionnaire to 428 incarcerated women. Blacks were more likely to report consistent condom use in the three months prior to incarceration (47% vs. 28%, p < 0.05), and Hispanics were less likely to report sex work than were whites (16% vs. 39%, p < 0.05). Whites were more likely than blacks to report having had an unplanned pregnancy (88% vs. 67%, p < 0.05). Despite having lower self-reported risk on several measures, Blacks were more likely to report history of STI (65% vs. 40%, p < 0.05). The correctional setting is an opportune place to better understand and address the complex issue of sexual health disparities.

Vaccination in juvenile correctional facilities: state practices, hepatitis B, and the impact on anticipated sexually transmitted infection vaccines.

OBJECTIVES: Juvenile correctional facilities are an ideal setting to provide preventive vaccines to adolescents who are at risk. In many instances of incarceration, facilities overcome the need for parental consent by making young people wards of the state and the state providing consent. The authors investigated current state practices for administering hepatitis B vaccine to incarcerated adolescents. These may impact the delivery of anticipated sexually transmitted infection (STI) vaccines to incarcerated adolescents. METHODS: From June to August 2004, interviews were conducted with state Immunization Program Managers by telephone about hepatitis B vaccination and consent policies in juvenile correctional facilities. RESULTS: Forty-five states were able to provide information about hepatitis B immunization in publicly funded juvenile correctional facilities. Forty-one of the 45 states offered hepatitis B vaccine to adolescents who were sentenced and thereby considered to be wards of the state. Of those 41 states, 20 also made hepatitis B vaccine easily accessible to detained adolescents (no parental consent required). Those 20 states considered detained adolescents as wards of the state (n=13), or allowed them to self-consent for the vaccine (n=7). CONCLUSIONS: Most states offer hepatitis B vaccination to sentenced adolescents in correctional facilities. Just over half of these states also vaccinate detained adolescents. Juvenile correctional facilities have experience administering vaccines, and this might allow for expansion of vaccination services when new STI vaccines become available. Still, there are major barriers to universal vaccination of incarcerated adolescents, including the issue of consent.

Public Housing Relocations and Relationships of Changes in Neighborhood Disadvantage and Transportation Access to Unmet Need for Medical Care.

INTRODUCTION: Cross-sectional research suggests that neighborhood characteristics and transportation access shape unmet need for medical care. This longitudinal analysis explores relationships of changes in neighborhood socioeconomic disadvantage and trans- portation access to unmet need for medical care. METHODS: We analyzed seven waves of data from African American adults (N = 172) relocating from severely distressed public housing complexes in Atlanta, Georgia. Surveys yielded individual-level data and admin- istrative data characterized census tracts. We used hierarchical generalized linear models to explore relationships. RESULTS: Unmet need declined from 25% pre-relocation to 12% at Wave 7. Post-relocation reductions in neighborhood disadvantage were inversely associated with reductions in unmet need over time (OR = 0.71, 95% CI = 0.51-0.99). More frequent transportation barriers predicted unmet need (OR = 1.16, 95% CI = 1.02-1.31). CONCLUSION: These longitudinal findings support the importance of neighborhood environments and transportation access in shaping unmet need and suggest that improvements in these exposures reduce unmet need for medical care in this vulnerable population.

Changes in healthcare access and utilization among participants in a public housing relocation program in Atlanta, Georgia.

Using survey data from participants in a public housing relocation program in Atlanta, Georgia, we examine post-relocation changes in healthcare access (having a usual source of care, having an unmet need) and utilization (receiving a medical exam). Although participants moved to safer, less impoverished neighborhoods, some participants experienced improvements in access and utilization whereas others experienced declines. The supply of healthcare providers in the new neighborhood and having health insurance were associated with improvements in access for this population. Future relocation efforts may seek to assist individuals with choosing a new neighborhood that has accessible healthcare resources for low-income populations.

People and places: Relocating to neighborhoods with better economic and social conditions is associated with less risky drug/alcohol network characteristics among African American adults in Atlanta, GA.

BACKGROUND: Few studies assess whether place characteristics are associated with social network characteristics that create vulnerability to substance use. METHODS: This longitudinal study analyzed 7 waves of data (2009-2014) from a predominantly substance-using cohort of 172 African American adults relocated from public housing complexes in Atlanta, GA, to determine whether post-relocation changes in exposure to neighborhood conditions were associated with four network characteristics related to substance use: number of social network members who used illicit drugs or alcohol in excess in the past six months ("drug/alcohol network"), drug/alcohol network stability, and turnover into and out of drug/alcohol networks. Individual- and network-level characteristics were captured via survey and administrative data were used to describe census tracts where participants lived. Multilevel models were used to assess relationships of census tract-level characteristics to network outcomes over time. RESULTS: On average, participants relocated to census tracts that had less economic disadvantage, social disorder, and renter-occupied housing. Post-relocation reductions in exposure to economic disadvantage were associated with fewer drug/alcohol network members and less turnover into drug/alcohol networks. Post-relocation improvements in exposure to multiple census tract-level social conditions and reductions in perceived community violence were associated with fewer drug/alcohol network members, less turnover into drug/alcohol networks, less drug/alcohol network stability, and more turnover out of drug/alcohol networks. CONCLUSION: Relocating to neighborhoods with less economic disadvantage and better social conditions may weaken relationships with substance-using individuals.

Human papillomavirus awareness among HIV-infected drug users in two urban areas.

Human papillomavirus (HPV) is the cause of cervical and anal cancer. Human immunodeficiency virus (HIV) infection and cocaine use are associated with increased risk for HPV infection and associated diseases, but little is known about HIV-infected drug users' awareness of HPV. We investigate HPV awareness among HIV-infected, sexually-active crack cocaine users from two inner-city hospitals in Florida and Georgia during their inpatient stays. Multivariate logistic regression analysis was used to examine potential correlates of HPV awareness. We interviewed 215 participants (110 women; 105 men) about their awareness of HPV infection. Overall, only 25% of respondents reported having heard of HPV. The odds of having heard of HPV were greater for respondents having a high-school degree or higher, having ever gone to an HIV provider for HIV care, and having two or more sexual partners. Despite increased susceptibility to HPV infection and HPV-related cancers, our study findings suggest that sexually-active HIV-infected crack cocaine users have little awareness of HPV and highlight the need for programmes targeting HPV education for HIV-infected crack cocaine drug users.

The aftermath of public housing relocation: relationship to substance misuse.

INTRODUCTION: Several cross-sectional studies have examined relationships between neighborhood characteristics and substance misuse. Using data from a sample of African-American adults relocating from U.S. public housing complexes, we examined relationships between changes in exposure to local socioeconomic conditions and substance misuse over time. We tested the hypothesis that adults who experienced greater post-relocation improvements in local economic conditions and social disorder would have a lower probability of recent substance misuse. METHODS: Data were drawn from administrative sources to describe the census tracts where participants lived before and after relocating. Data on individual-level characteristics, including binge drinking, illicit drug use, and substance dependence, were gathered via survey before and after the relocations. Multilevel models were used to test hypotheses. RESULTS: Participants (N=172) experienced improvements in tract-level economic conditions and, to a lesser degree, in social disorder after moving. A one standard-deviation improvement in tract-level economic conditions was associated with a decrease in recent binge drinking from 34% to 20% (p=0.04) and with a decline in using illicit drugs weekly or more from 37% to 16% (p=0.02). A reduction in tract-level alcohol outlet density of >3.0 outlets per square mile predicted a reduction in binge drinking from 32% to 18% at p=0.05 significance level. DISCUSSION: We observed relationships between improvements in tract-level conditions and declines in substance misuse, providing further support for the importance of the local environment in shaping substance misuse. These findings have important implications for public housing policies and future research.

Public housing relocations in Atlanta, Georgia, and declines in spatial access to safety net primary care.

This analysis investigates changes in spatial access to safety-net primary care in a sample of US public housing residents relocating via the HOPE VI initiative from public housing complexes to voucher-subsidized rental units; substance misusers were oversampled. We used gravity-based models to measure spatial access to care, and used mixed models to assess pre-/post-relocation changes in access. Half the sample experienced declines in spatial access of ≥ 79.83%; declines did not vary by substance misuse status. Results suggest that future public housing relocation initiatives should partner with relocaters, particularly those in poor health, to help them find housing near safety-net clinics.

Correlates of acceptance of a hypothetical gonorrhea vaccine by incarcerated women.

OBJECTIVES: This study sought to identify correlates of acceptance of a hypothetical Neisseria gonorrhea (GC) vaccine in a high-risk sample of incarcerated women. GOALS: The goal of this study was to inform efforts to promote acceptance of STI vaccines in development. STUDY DESIGN: This study consisted of a cross-sectional survey using a structured questionnaire. RESULTS: The majority (79%) of incarcerated women surveyed would accept GC vaccine. In multivariate analyses that controlled for demographics, significant health belief model psychosocial correlates of higher acceptance were perceived severity of infection (OR = 3.33) and vulnerability to infection (OR = 2.85). Fear of vaccination was significantly correlated with lower acceptance (OR = 0.42). CONCLUSIONS: Incarcerated women's willingness to accept a hypothetical GC vaccine is explained by components of the health belief model and a component of the theory of reasoned action.