Crystal Fuller Lewis

Higher risk of incident hepatitis C virus among young women who inject drugs compared with young men in association with sexual relationships: a prospective analysis from the UFO Study cohort

Background Female injection drug users (IDUs) may report differences in injection behaviours that put them at greater risk for hepatitis C virus (HCV). Few studies have examined these in association with HCV incidence. Methods Longitudinal data from a cohort of 417 HCV-uninfected IDU aged 30 or younger were analysed. Cox proportional hazards was used to model female sex as a predictor of new HCV infection. General estimating equation (GEE) analysis was used to model female sex as a predictor of HCV-associated risk behaviour prospectively. Results Women were significantly more likely than men to become infected with HCV during study follow-up (HR 1.4, p<0.05), and were also more likely than men to report high-risk injecting behaviours, especially in the context of sexual and injecting relationships. Sex differences in injecting behaviours appeared to explain the relationship between sex and HCV infection. Conclusions Young women’s riskier injection practices lead to their higher rates of HCV infection. Further study on the impact of intimate partnership on women’s risk behaviour is warranted.

Internalized stigma and sterile syringe use among people who inject drugs in New York City, 2010-2012.

BACKGROUND Little is known on the effect of stigma on the health and behavior of people who inject drugs (PWID). PWID may internalize these negative attitudes and experiences and stigmatize themselves (internalized stigma). With previous research suggesting a harmful effect of internalized stigma on health behaviors, we aimed to determine socio-demographic characteristics and injection risk behaviors associated with internalized PWID-related stigma in New York City (NYC). METHODS Three NYC pharmacies assisted in recruiting PWID. Pharmacy-recruited PWID syringe customers received training in recruiting up to three of their peers. Participants completed a survey on injection behaviors and PWID-related stigma. Among HIV-negative PWID (n=132), multiple linear regression with GEE (to account for peer network clustering) was used to examine associations with internalized PWID-related stigma. RESULTS Latinos were more likely to have higher internalized stigma, as were those with lower educational attainment. Those with higher internalized stigma were more likely to not use a syringe exchange program (SEP) recently, although no association was found with the recent use of pharmacies for syringes. Lastly, higher internalized stigma was related to less than 100% use of pharmacies or SEPs for syringe needs. CONCLUSIONS These data suggest that PWID with higher internalized stigma are less likely to consistently use sterile syringe sources in urban settings with multiple sterile syringe access points. These results support the need for individual- and structural-level interventions that address PWID-related stigma. Future research is needed to examine why PWID with higher internalized stigma have less consistent use of public syringe access venues.

Assessing the Geographic Coverage and Spatial Clustering of Illicit Drug Users Recruited through Respondent-Driven Sampling in New York City

We assess the geographic coverage and spatial clustering of drug users recruited through respondent-driven sampling (RDS) and discuss the potential for biased RDS prevalence estimates. Illicit drug users aged 18–40 were recruited through RDS (N = 401) and targeted street outreach (TSO) (N = 210) in New York City. Using the Google Maps API™, we calculated travel distances and times using public transportation between each participant’s recruitment location and the study office and between RDS recruiter–recruit pairs. We used K function analysis to evaluate and compare spatial clustering of (1) RDS vs. TSO respondents and (2) RDS seeds vs. RDS peer recruits. All participant recruitment locations clustered around the study office; however, RDS participants were significantly more likely to be recruited within walking distance of the study office than TSO participants. The TSO sample was also less spatially clustered than the RDS sample, which likely reflects (1) the van’s ability to increase the sample’s geographic heterogeneity and (2) that more TSO than RDS participants were enrolled on the van. Among RDS participants, individuals recruited spatially proximal peers, geographic coverage did not increase as recruitment waves progressed, and peer recruits were not less spatially clustered than seeds. Using a mobile van to recruit participants had a greater impact on the geographic coverage and spatial dependence of the TSO than the RDS sample. Future studies should consider and evaluate the impact of the recruitment approach on the geographic/spatial representativeness of the sample and how spatial biases, including the preferential recruitment of proximal peers, could impact the precision and accuracy of estimates.

Clinical Characteristics of Synthetic Cannabinoid Use in a Large Urban Psychiatric Emergency Setting

ABSTRACT Background: Increasing reports of synthetic cannabinoid (SC)-related adverse events have largely comprised case reports and analyses of calls to poison control centers. Existing studies have also mostly involved white male populations. Objectives: The purpose of this study is to systematically describe clinical characteristics of SC use in a relatively large, diverse, urban sample presenting to a psychiatric emergency setting. Methods: SC users (n = 110) were identified by reviewing charts (n = 948) from the psychiatric emergency service of a large, urban public hospital in the United States for November 2014, which was randomly selected from the 12 months of that year. Sociodemographic data were collected from administrative databases and clinical data were collected from the electronic medical record. Results: SC users were mostly non-white (90.0%) males (95.5%), who were likely to be police-involved (34.5%) and homeless (84.5%). SC users also had significant and often pre-existing psychiatric and substance use comorbidity, including acute psychotic symptoms (70.0%), more than one comorbid psychiatric diagnosis (31.8%) and primary psychotic disorder diagnosis (40.0%), past psychiatric visits to the hospital (70.9%), comorbid substance use (62.7%), agitation requiring intervention (22.7%), and the need for extended psychiatric observation (15.5%) and inpatient admission (34.5%). Relatively limited medical complications were identified. Conclusions/Importance: In this sample, SC use affected a sociodemographically disadvantaged and mentally ill population, likely exacerbating existing psychiatric problems. This is one of the only studies to systematically examine the clinical effects of SC use in a significant clinical sample, and the first study in an urban, racial/ethnic minority, and vulnerable sample.

Characteristics associated with synthetic cannabinoid use among patients treated in a public psychiatric emergency setting

ABSTRACT Background: Growing evidence of adverse outcomes following synthetic cannabinoid use has engendered interest into populations at risk. The existing literature reports that synthetic cannabinoid use is predominant among young, white males. However, reports from local Departments of Health have found contrary evidence, showing that synthetic cannabinoid use is prevalent in populations other than those of young, white men. Objectives: This study sought to examine sociodemographic characteristics associated with self-reported synthetic cannabinoid use among a clinical psychiatric population within a public hospital in New York City. Methods: A cross-sectional medical record review was conducted on synthetic cannabinoid users and non-users in an emergency psychiatric setting. A total of 948 patients who presented at the emergency psychiatric setting in 2014 were included in this sample, 110 (11.6%) of whom were synthetic cannabinoid users. Logistic regressions were used to determine the sociodemographic correlates of synthetic cannabinoid use. Results: The most prominent correlate of synthetic cannabinoid use was homelessness/residing in a shelter during time of treatment (AOR = 17.77, 95% CI = 9.74–32.5). Male (AOR = 5.37, 95% CI = 2.04–14.1), non-white (AOR = 2.74, 95% CI = 1.36–5.54), and younger age (AOR = .961, 95% CI = .940–.980) were also significant correlates of synthetic cannabinoid use. Conclusion: Synthetic cannabinoid use among the homeless and mentally ill is a growing public health concern, representing a population with unique clinical and social needs. Areas and populations with high rates of homelessness should be targeted for synthetic cannabinoid prevention and treatment efforts, particularly in urban and racial/ethnic minority communities.

Factors associated with HIV stigma and the impact of a nonrandomized multi-component video aimed at reducing HIV stigma among a high-risk population in New York City

We examined characteristics associated with HIV stigma and evaluated a multi-component video designed to normalize HIV and reduce HIV stigma. Three pharmacies located in heavy, drug-active neighborhoods in New York City and registered to sell nonprescription syringes were trained to recruit their nonprescription syringe customers who inject drugs and their under/uninsured customers. Syringe customer participants were trained to recruit up to three of their peers. As part of a larger intervention to increase HIV testing, participants in two of three study arms viewed the “Health Screenings for Life” video and were administered pre/post-video surveys capturing HIV stigma. Participants in the nonvideo arm were administered one assessment of HIV stigma. Log-binomial regression with generalized estimating equations to account for clustering of peer networks was used to: (1) determine factors associated with HIV stigma and (2) determine differences in HIV stigma by study arm. A total of 716 participants were recruited. Factor analyses showed HIV stigma measures loading on two factors: HIV blame and HIV shame. After adjustment, HIV blame was positively associated with younger age (PR: 1.24; 95% CI: 1.07–1.43) and inversely associated with educational attainment (PR: 0.66; 95% CI: 0.58–0.76) and employment (PR: 0.76; 95% CI: 0.60–0.96). HIV shame was inversely associated with educational attainment (PR: 0.75; 95% CI: 0.62–0.92), HIV-positive status (PR: 0.60; 95% CI: 0.39–0.92), and injecting drugs (PR: 0.72; 95% CI: 0.54–0.94) and was positively associated with multiple sex partnerships (PR: 1.24; 95% CI: 1.01–1.52). Those who viewed the video were also less likely to report HIV blame and HIV shame, post-video, compared to those in the nonvideo arm. These data provide evidence of an association between HIV stigma and lower socioeconomic status groups, and between HIV stigma and HIV sexual risk. These data also provide evidence that a multi-component video aimed at normalizing HIV may assist in reducing HIV stigma in heavy, drug-active neighborhoods.

Pharmacy-randomized intervention delivering HIV prevention services during the syringe sale to people who inject drugs in New York City

BACKGROUND Pharmacy syringe access may be an opportunity to provide HIV prevention resources to persons who inject drugs (PWID). We examined the impact of a pharmacy-randomized intervention to reduce injection risk among PWID in New York City. METHODS Pharmacies (n=88) were randomized into intervention, primary control, and secondary control arms. Intervention pharmacies received in-depth harm reduction training, recruited syringe customers who inject drugs into the study, and provided additional services (i.e., HIV prevention/medical/social service referrals, syringe disposal containers, and harm reduction print materials). Primary control pharmacies recruited syringe customers who inject drugs and did not offer additional services, and secondary control pharmacies did not recruit syringe customers (and are not included in this analysis) but participated in a pharmacy staff survey to evaluate intervention impact on pharmacy staff. Recruited syringe customers underwent a baseline and 3-month follow-up ACASI. The intervention effect on injection risk/protective behavior of PWID was examined. RESULTS A total of 482 PWID completed baseline and follow-up surveys. PWID were mostly Hispanic/Latino, male, and mean age of 43.6 years. After adjustment, PWID in the intervention arm were more likely to report always using a sterile syringe vs. not (PR=1.24; 95% CI: 1.04-1.48) at 3-month follow-up. CONCLUSIONS These findings present evidence that expanded pharmacy services for PWID can encourage sterile syringe use which may decrease injection risk in high HIV burdened Black and Latino communities.

The association between neighborhood socioeconomic disadvantage and high-risk injection behavior among people who inject drugs

BACKGROUND Although much research has been conducted on the determinants of HIV risk behavior among people who inject drugs (PWID), the influence of the neighborhood context on high-risk injection behavior remains understudied. To address this gap in the literature, we measured associations between neighborhood socioeconomic disadvantage and high-risk injection behavior, and determined whether these associations were modified by drug-related police activity and syringe exchange program (SEP) accessibility. METHODS Our sample was comprised of 484 pharmacy-recruited PWID in New York City. Measures of neighborhood socioeconomic disadvantage were created using data from the 2006-2010 American Community Survey. Associations with high-risk injection behavior were estimated using multivariable Poisson regression. Effect modification by drug-related police activity and SEP accessibility was assessed by entering cross-product terms into adjusted models of high-risk injection behavior. RESULTS Neighborhood socioeconomic disadvantage was associated with decreased receptive syringe sharing and unsterile syringe use. In neighborhoods with high drug-related police activity, associations between neighborhood disadvantage and unsterile syringe use were attenuated to the null. In neighborhoods with high SEP accessibility, neighborhood disadvantage was associated with decreased acquisition of syringes from an unsafe source. CONCLUSIONS PWID in disadvantaged neighborhoods reported safer injection behaviors than their counterparts in neighborhoods that were relatively better off. The contrasting patterns of effect modification by SEP accessibility and drug-related police activity support the use of harm reduction approaches over law enforcement-based strategies for the control of blood borne virus transmission among PWID in disadvantaged urban areas.

Physical Victimization and High-Risk Sexual Partners among Illicit Drug-Using Heterosexual Men in New York City

Physical victimization has been linked to high-risk sexual partnerships in women. Although illicit drug-using heterosexual men are at high-risk of physical victimization, the association between violence and high-risk partners in heterosexual men has received little attention in the published literature. We examined the association between experience of severe physical victimization and acquisition of a high-risk sexual partner (i.e., a partner who injected drugs or participated in transactional sex) 1 year later among illicit drug-using men in New York City (2006–2009) using secondary cross-sectional data. Injection and non-injection drug-using men (n = 280) provided a retrospectively recalled history of risk behavior and violence for each year over the past 4 years. Our primary outcome was acquisition of a high-risk sexual partner in any year following the baseline year. Our primary exposure was severe physical victimization (i.e., threatened with a knife or gun, beaten up, shot, or stabbed) in the prior year. Frequency of cocaine, heroin, and crack use and sexual victimization were also assessed. Log-binomial logistic regression with generalized estimating equation (GEE) methods was used to account for repeated measures for up to four time points. After adjustment for important covariates, participants that experienced physical victimization were significantly more likely to have acquired a high-risk sexual partner 1 year later (relative risk (RR), 3.73; 95 % confidence interval (CI), 1.55–8.97). Our study challenges gender-based stereotypes surrounding physical victimization and provides support for multidisciplinary programs that address both violence and HIV risk among illicit drug-using heterosexual men.