Alexandra Duncan

The influence of substance use, social sexual environment, psychosocial factors, and partner characteristics on high-risk sexual behavior among young Black and Latino men who have sex with men living with HIV: A qualitative study.

Understanding the sexual risk behaviors of youths living with HIV/AIDS is critical to secondary prevention of HIV. As part of a larger qualitative study of youths living with HIV, in-depth interviews were conducted with 27 African American and Latino, HIV-infected young men who have sex with men, aged 16-24 years, living in New York City. The study explored the role of substance use, the social-sexual-environmental, and psychological contexts in which sexual risk behaviors occurred. Since learning of their HIV infection, the majority of participants had reduced their risky sexual behaviors; however, a subset (26%) of participants continued to have unprotected sex, in most cases with multiple partners. Substance use, the social environmental context of the sexual encounter, the psychological impact of HIV on sexual behavior, and partner characteristics were associated with high-risk sexual behaviors in this group. Among high-risk participants, factors associated with risky sexual behaviors clustered, with 57% reporting two or more factors. More intensive interventions are needed for this subset of youths living with HIV, including assessment and treatment for substance use and mental health issues, strategies for stress reduction, and partner interventions.

Latent class analysis of polysubstance use, sexual risk behaviors, and infectious disease among South African drug users.

BACKGROUND HIV transmission risk among non-injection drug users is high due to the co-occurrence of drug use and sexual risk behaviors. The purpose of the current study was to identify patterns of drug use among polysubstance users within a high HIV prevalence population. METHODS The study sample included 409 substance users from the Pretoria region of South Africa. Substances used by 20% or more the sample included: cigarettes, alcohol, marijuana and heroin in combination, marijuana and cigarettes in combination, and crack cocaine. Latent class analysis was used to identify patterns of polysubstance use based on types of drugs used. Multivariate logistic regression analyses compared classes on demographics, sexual risk behavior, and disease status. RESULTS Four classes of substance use were found: MJ+Cig (40.8%), MJ+Her (30.8%), Crack (24.7%), and Low Use (3.7%). The MJ+Cig class was 6.7 times more likely to use alcohol and 3 times more likely to use drugs before/during sex with steady partners than the Crack class. The MJ+Cig class was 16 times more likely to use alcohol before/during sex with steady partners than the MJ+Her class. The Crack class was 6.1 times more likely to engage in transactional sex and less likely to use drugs before/during steady sex than the MJ+Her class. CONCLUSIONS Findings illustrate patterns of drug use among a polysubstance using population that differ in sexual risk behavior. Intervention strategies should address substance use, particularly smoking as a route of administration (ROA), and sexual risk behaviors that best fit this high-risk population.

“Unplugged”: A school-based randomized control trial to prevent and reduce adolescent substance use in the Czech Republic

BACKGROUND The Czech Unplugged Study, inspired by the European Drug Addiction Prevention Trial, is a prospective, school-based, randomized controlled prevention trial designed to reduce the risk of alcohol, tobacco, inhalant, and illegal drug use in 6th graders in the Czech Republic. The intervention uses the comprehensive social influence model to affect alcohol and drug using norms among primary school students. METHODS Descriptive statistics and chi-square analyses were used to assess differences between the experimental and control groups on demographic characteristics and study outcomes. Multilevel techniques were used to take the hierarchical structure of the data into account. Prevalence odds ratios using the Bonferroni correction were calculated to assess the differences between the experimental (N = 914) and control (N = 839) groups on each outcome 1, 3, 12, 15, and 24 months after the end of the intervention. RESULTS Multilevel analysis using the Bonferroni correction showed statistically significant intervention effects at the final follow-up for any smoking (OR = 0.75, 99.2% CI 0.65-0.87), daily smoking (OR = 0.62, 99.2% CI 0.48-0.79), heavy smoking (OR = 0.48, 99.2% CI 0.28-0.81), any cannabis use (OR = 0.57 99.2% CI 0.42-0.77), frequent cannabis use (OR = 0.57, 99.2% CI 0.36-0.89), and any drug use (OR = 0.78, 99.2% CI 0.65-0.94). CONCLUSIONS This study adds new evidence on the effectiveness of the Unplugged school-based prevention program for primary school students in the Czech Republic.

Neighborhood Environment and Marijuana Use in Urban Young Adults

Risk factors for marijuana use in older adolescents and young adults have focused primarily on family environment and peer affiliation. A growing body of work has examined the relationship between environmental context and young adult substance use. This study builds on previous research linking neighborhood environment to young adult marijuana use by exploring two distinct features of neighborhoods, namely the physical (e.g., broken windows) and social environment (e.g., adults watching youth). Data were obtained from a longitudinal sample of 398 predominately African American young adults living in an urban environment. The data also included observational measures of physical and social order and disorder collected on the young adult’s residential block. Exploratory structural equation modeling (ESEM) was utilized to test hypothesized relationships between these two features of the neighborhood environment and past year young adult marijuana use. A two-factor model of neighborhood environment with good fit indices was selected (CFI = 0.97, RMSEA = 0.037). There was a positive and significant direct effect from neighborhood physical disorder to marijuana use (0.219, p < 0.05) controlling for gender, race, and free and reduced price meal (FARPM) status. The direct effect from neighborhood social environment to marijuana use was not significant. These results converge with previous research linking vacant housing with young adult marijuana use but do not provide empirical support for the neighborhood social environment as a determinant of drug taking. Better explication of the social environment is needed to understand its relationship to drug use.

Sex specific trajectories in cigarette smoking behaviors among students participating in the Unplugged school-based randomized control trial for substance use prevention

OBJECTIVES Understanding the developmental pathways and sex differences in cigarette smoking behaviors in adolescents has the potential to positively impact substance abuse prevention and to reduce smoking-related health problems. Using data from the Unplugged school-based prevention trial, we investigated different patterns of smoking behavior development among secondary school students in the Czech Republic. METHODS Growth mixture modeling was used to examine different trajectories in cigarette smoking behaviors among male and female students (N=1874 6th graders; 50.4% male, mean age 11.8 years at baseline) participating in the Unplugged school-based randomized control trial for substance use prevention. RESULTS A two-class model characterized cigarette use as a function of sex and Unplugged intervention status. More rapid cigarette use increases were observed in females (OR=1.17, p=0.01 in both rapid/moderate and slow smoking escalator classes) as compared to males. Further, in both classes, more rapid increases in smoking were observed for the control group as compared to the intervention group (OR=1.22, p<0.01 slow escalators; OR=1.54, p=0.08 rapid/moderate escalators). There was no difference in sex distribution when comparing the two classes (OR=1.02, p=0.98). CONCLUSIONS This study adds to a growing literature on developmental and sex differences in cigarette use among adolescents. This research supports additional multi-year prevention strategies aimed at adolescent females and early treatment programs for adolescent smokers to prevent increasing cigarette use with age.

Racial Disparities in Substance Abuse Treatment and the Ecological Fallacy

This study examined engagement in treatment in substance abuse treatment programs that treated primarily either African American or White clients. Findings showed higher levels of engagement in White programs; however, engagement of African Americans in White programs was similar to that of Whites and was greater than Whites in African American programs. No significant differences emerged when a mixed model analysis considered additional variables of staff consensus (regarding treatment elements), treatment climate, acceptance of Medicaid clients, the proportion mandated to treatment, and the quality of the physical space. Although African American programs may show poorer levels of engagement than White programs, attribution of engagement in treatment to client level race/ethnicity should be made with caution.

Gender Power Inequality and Continued Sexual Risk Behavior among Racial/Ethnic Minority Adolescent and Young Adult Women Living with HIV.

Adolescent and young adult minority women account for approximately 20% of new cases of HIV in this age group each year in the United States. It is vital to understand factors that influence sexual risk behavior in this population in order to prevent secondary transmission of HIV. As part of a larger qualitative study of youths living with HIV, in- depth interviews were conducted with 26 Black and Latina young women aged 16 to 24 years, infected with HIV through heterosexual transmission. The study explored factors related to continued unprotected sex with male partners. Since learning of their HIV infection, 23% reported multiple episodes of unprotected vaginal and/or anal sex, 27% reported condom use for some but not all of the time, 42% reported condom use all of the time and 7% were not sexually active. Among the highest risk participants partner refusal to use a condom, having the same HIV sero-status as partner, negative attitudes toward condoms, beliefs about HIV transmission, and fear of disclosure to new partners were associated with risky sex. The data suggests that more research is needed to develop more intensive interventions that address the role of gender power inequity for this sub-set of young women living with HIV.

Triangulating syndemic services and drug treatment policy: Improving drug treatment portal locations in Baltimore City

Abstract:The Problem: The prevalence of injection drug use (IDU) and incidence of human immunodeficiency virus (HIV) remain high in Baltimore, where IDU is a primary HIV risk factor. Substance use disorders and HIV are related syndemically—their causes and consequences interact synergistically. Baltimore is increasingly considering the syndemic relationship of substance use disorders, IDU, and HIV in making decisions about drug treatment funding and location.Purpose of Article: Our goal was to empirically identify the optimal location of new drug treatment programs through the development and application of a novel, practical tool.Key Points: Syndemic triangles were constructed to measure and visualize unmet need for drug treatment services. These data were used to determine priority zones for new treatment centers.Conclusions: The application of this tool helped inform strategies for locating drug treatment services in Baltimore, and its successful use suggests its potential value in other metropolitan areas.

The role of substance use in adherence to HIV medication and medical appointments.

dolescents and young adults ages 15 to 24 yearsconstitute half of all new cases of HIV worldwide(Joint United Nations Programme on HIV/AIDS,2009). In the United States in 2009, more than8,000 new cases of HIV were diagnosed in youthages 13 to 24 years (Centers for Disease Controland Prevention, 2011). Further, at the end of 2009,16,743 cumulative cases of HIV were reportedamong New York City youth ages 13 to 24 years(New York City Department of Health and MentalHygiene, 2011).Adherence to HIV medications and adherence toHIV primary care appointments are necessary forgood health in this population. Quarterly medicalappointments are recommended to monitor CD

Posttreatment Drug Use Abstinence: Does the Majority Program Clientele Matter?

The current study examines differences in organizational characteristics and client posttreatment drug use abstinence in residential substance abuse treatment programs serving clients with high or low levels of legal coercion to participate in treatment. The findings show that low legal coercion programs have higher counselor caseloads (Z = 59, p < .05) than high coercion programs. Although the results showed that programs with a large proportion of African American clients (β = 14.26, p < .0001) and high legal coercion programs (β = 19.99, p < .05) predicted longer abstinence posttreatment, the final models suggest organizational factors are the key predictors of client posttreatment abstinence.