Janie Simmons

I love you ... and heroin: care and collusion among drug-using couples

BackgroundRomantic partnerships between drug-using couples, when they are recognized at all, tend to be viewed as dysfunctional, unstable, utilitarian, and often violent. This study presents a more nuanced portrayal by describing the interpersonal dynamics of 10 heroin and cocaine-using couples from Hartford, Connecticut.ResultsThese couples cared for each other similarly to the ways that non-drug-using couples care for their intimate partners. However, most also cared by helping each other avoid the symptoms of drug withdrawal. They did this by colluding with each other to procure and use drugs. Care and collusion in procuring and using drugs involved meanings and social practices that were constituted and reproduced by both partners in an interpersonal dynamic that was often overtly gendered. These gendered dynamics could be fluid and changed over time in response to altered circumstances and/or individual agency. They also were shaped by and interacted with long-standing historical, economic and socio-cultural forces including the persistent economic inequality, racism and other forms of structural violence endemic in the inner-city Hartford neighborhoods where these couples resided. As a result, these relationships offered both risk and protection from HIV, HCV and other health threats (e.g. arrest and violence).ConclusionA more complex and nuanced understanding of drug-using couples can be tapped for its potential in shaping prevention and intervention efforts. For example, drug treatment providers need to establish policies which recognize the existence and importance of interpersonal dynamics between drug users, and work with them to coordinate detoxification and treatment for both partners, whenever possible, as well as provide additional couples-oriented services in an integrated and comprehensive drug treatment system.

Oral pre-exposure prophylaxis (PrEP) for prevention of HIV in serodiscordant heterosexual couples in the United States: opportunities and challenges.

Oral HIV pre-exposure prophylaxis (PrEP) is a promising new biomedical prevention approach in which HIV-negative individuals are provided with daily oral antiretroviral medication for the primary prevention of HIV-1. Several clinical trials have demonstrated efficacy of oral PrEP for HIV prevention among groups at high risk for HIV, with adherence closely associated with level of risk reduction. In the United States (US), three groups have been prioritized for initial implementation of PrEP-injection drug users, men who have sex with men at substantial risk for HIV, and HIV-negative partners within serodiscordant heterosexual couples. Numerous demonstration projects involving PrEP implementation among MSM are underway, but relatively little research has been devoted to study PrEP implementation in HIV-serodiscordant heterosexual couples in the US. Such couples face a unique set of challenges to PrEP implementation at the individual, couple, and provider level with regard to PrEP uptake and maintenance, adherence, safety and toxicity, clinical monitoring, and sexual risk behavior. Oral PrEP also provides new opportunities for serodiscordant couples and healthcare providers for primary prevention and reproductive health. This article provides a review of the critical issues, challenges, and opportunities involved in the implementation of oral PrEP among HIV-serodiscordant heterosexual couples in the US.

Retrospective accounts of injection initiation in intimate partnerships

BACKGROUND The influence of family members, peers and sexual partners on initiation to injection drug use is well established. Furthermore, research on gender differences in injection initiation has recognized the increased vulnerability of women, in particular, to injection-related health risks, and the gendered nature of the injection initiation experience. Yet more research is needed on the interpersonal and structural dynamics that shape injection initiation within intimate partnerships. METHODS This paper draws on narrative data from semi-structured ethnographic interviews with 25, relatively stable, drug-using couples from two New York City neighbourhoods. The study was conducted between 2007 and 2009. Our analyses focus on retrospective accounts of injection initiation from IDUs who were initiated to injection (or initiated their partners) in current or former intimate partnerships. In particular we analyse narratives of injection initiation events where both partners participated as initiates or initiators. RESULTS Transition to injection within intimate partnerships was common, especially for women, and occurred in specific contexts. Structural and interpersonal dynamics, including the ubiquity of drugs in poor communities and the gendered nature of drug acquisition and use strategies, as well as the problem of increased drug tolerance, situational impediments to drug access, and the perceived cost-benefit of injecting, all influenced the process of initiation to injection drug use within couples. The data also suggest that, even when risks associated with injection initiation were understood, both pragmatic and emotional considerations within relationships tended to offset concerns about potential dangers. CONCLUSION The findings suggest the need for a broad range of interventions (including couples-focussed interventions) to minimize rates of injection initiation within intimate partnerships.

The Challenges of Street Research on Drug Use, Violence, and Aids Risk

Violence is a regular and consequential event in the lives of street drug users, commonly beginning at an early age and continuing throughout their drug careers. Growing evidence indicates that involvement in violence, of various kinds, including as victim, perpetrator, and witness, is a factor in the initiation and continuation of drug use, as well as in AIDS risk behaviours associated with illicit drug consumption. As a result, improving our understanding of the role that violence plays in drug use is critical to drug research, prevention and treatment initiatives, and the development of effective public health efforts designed to reduce the spread of HIV/AIDS and other drug-related diseases. Paying closer attention to violence in qualitative research, however, raises a number of methodological and other problems for drug researchers. This paper, based on an ongoing ethno-epidemiological study of the relationship of violence to drug use and AIDS risk among not-in-treatment Puerto Rican street drug users in Hartford, Connecticut, examines ethical, methodological, human resource, and related issues encountered in studying the intersection of these intimately linked epidemics. Specifically, the paper examines the challenges presented to ethnographic researchers by the everyday violence in the lives of study participants. In other words, this paper is concerned with the study of violence among at-risk drug users and the ways in which a focus on violence challenges our personal, intellectual, emotional, and ethical capacities to undertake this research.

Barriers to Drug Treatment for IDU Couples: The Need for Couple-Based Approaches

This qualitative study examines the interpersonal and structural barriers to drug treatment program entry, retention, and outcomes experienced by injection drug-using couples, and the program policies regarding injection drug-using couples seeking treatment in New York, New York. Our findings reveal a mismatch between the substantial need for concurrent and coordinated treatment for partnered injection-drug users and programmatic policies that are antithetical to such treatment approaches. This discrepancy can be attributed to the lack of viable options for couple-focused treatment approaches that fit within the current drug treatment system. We provide a rationale and a roadmap for the development of innovative approaches for couple-based drug treatment.

Increasing Faculty Capacity: Findings from an Evaluation of Simulation Clinical Teaching

AIM To compare how the use of different “doses” of simulation in undergraduate clinical teaching affect faculty capacity. BACKGROUND Since 2008, the NYU College of Nursing has used a “high dose” of simulation to substitute for 50 percent of the clinical hours in core medical‐surgical courses to address a shortage of faculty and clinical sites. Johns Hopkins University School of Nursing has used limited, “low‐dose” simulation hours to supplement clinical hours. METHOD The evaluation included program data and surveys and qualitative interviews with faculty and students in each program. RESULTS Implementing “high‐dose” clinical simulation resulted in a nearly 50 percent increase in faculty capacity at NYU, expanding undergraduate enrollment from 613 students in 2007 to 900 in 2012, with no negative impacts on faculty work life or student outcomes. CONCLUSION Substituting simulation for traditional clinical hours can be a sustainable and educationally sound option to increase faculty capacity.

Determinants of physical and global functioning in adult HIV-positive heterosexual men

Little is known about the psychosocial factors that might impact the functioning ability of heterosexual men living with HIV. We examined positive and negative coping, social support, and HIV stigma as predictors of physical and global functioning in a cross-sectional sample of 317 HIV-infected adult heterosexual male patients recruited from clinical and social service agencies in New York City. Study participants were primarily minority and low income. Sixty-four percent were African-American, 55% were single, and 90% were 40 years of age or older. The majority had long-term HIV (LTHIV), with an average duration of 15 years since diagnosis. After controlling for participant characteristics, structural equation modeling analyses revealed that positive coping and social support had a significant positive direct effect on global functioning, while stigma had a significant negative direct effect on global functioning. The physical functioning model revealed that negative coping and HIV stigma had significant negative direct effects, whereas social support had a significant positive indirect effect. Age and duration of HIV diagnosis were not associated with physical and global functioning. In conclusion, we found that heterosexual men living with LTHIV who have ineffective coping, less social support, and greater stigma have reduced functioning ability. Study findings have implications for developing interventions aimed at increasing and retaining functioning ability with the end goal of improving successful aging in this population.

A Collaborative Methodology for Investigating the Ethical Conduct of Research on Female Sex Workers in the Philippines

Designing research in an ethical, non-exploitative manner that investigates concerns around privacy, confidentiality, and voluntariness is imperative for female sex work populations (Shaver, 2005; Urada & Simmons, 2014). Some community-led interventions, especially those focused on empowerment, education, and economic independence, have been effective with female sex workers across the globe (Biradavolu, Blankenship, Jena, Dhungana, 2012; Kerrigan et al., 2006; Swendeman, Basu, Das, Jana, & Rotheram-Borus, 2009; Sherman et al., 2000). To avoid disillusionment from sex workers and their managers when they do not see positive changes resulting from research, designing and adapting interventions is a critical research aim for this population. This article is a companion publication with “Social and Structural Constraints on Disclosure and Informed Consent for HIV Survey Research Involving Female Sex Workers and their Managers in the Philippines” (Urada & Simmons, 2014), a study examining the contextual factors that influence participants’ disclosure of sensitive topics in non-governmental survey interviews and their consent to participate in HIV prevention intervention research. However, the collaborative methodology in this study may be useful for research carried out with female sex workers in other similar contexts. This paper focuses on the collaborative aspects of the methodology in the aforementioned study. The more general methodological approach is summarized in the companion paper noted above. This qualitative study explored the ethical issues of female sex workers’ participation in HIV prevention research. The studys main findings included the following. Informed consent was constrained by perceived government coercion and skepticism that research results would translate into community benefits. Disclosure was also constrained by distrust; sex workers did not trust that confidentiality would be maintained. They also felt many of the survey questions were intrusive, particularly those that were meant to elicit information about substance use and sex work. Structural constraints imposed by police also played a significant role in non-disclosure. Police raids were common and sex workers and managers were frustrated by the government’s inability to stop police from using condoms as evidence of prostitution. In conclusion, HIV interventions must move beyond didactic prevention workshops, include female sex workers in intervention design and implementation, and aim to reduce social and structural constraints on participation. As indicated in the main paper, our methodological aims were to be as transparent and participatory as possible, without causing harm to participants through heightened visibility or extensive time commitments. Sex work is highly stigmatized and illegal in the Philippines, as is common elsewhere, and women commonly do not disclose sex work to family members. The sex workers who participated in the study were also especially concerned about losing clients and the money they generated. Even the relatively small fees for work permits from the health department were difficult for women to pay. Collaboration with our Community Advisory Boards and the Peer Ed ME PAMACQ (Peer Educators Movement for Empowerment of Pasay, Manila, Caloocan and Quezon City) enhanced recruitment efforts, the development of rapport with the female sex workers and their managers, and helped to produce relevant findings and continued collaboration.

Potential Risks of Ecological Momentary Assessment Among Persons Who Inject Drugs

ABSTRACT Background: Ecological momentary assessment (EMA)—which often involves brief surveys delivered via mobile technology—has transformed our understanding of the individual and contextual micro-processes associated with legal and illicit drug use. However, little empirical research has focused on participants perspective on the probability and magnitude of potential risks in EMA studies. Objectives: To garner participant perspectives on potential risks common to EMA studies of illicit drug use. Methods: We interviewed 38 persons who inject drugs living in San Diego (CA) and Philadelphia (PA), United States. They completed simulations of an EMA tool and then underwent a semi-structured interview that systematically explored domains of risk considered within the proposed revisions to the Federal Policy for the Protection of Human Subjects or the “Common Rule.” Interviews were transcribed verbatim and coded systematically to explore psychological, physical, social, legal, and informational risks from participation. Results: Participants perceived most risks to be minimal. Some indicated that repetitive questioning about mood or drug use could cause psychological (i.e., anxiety) or behavioral risks (i.e., drug use relapse). Ironically, the questions that were viewed as risky were considered motivational to engage in healthy behaviors. The most cited risks were legal and social risks stemming from participant concerns about data collection and security. Importance: Improving our understanding of these issues is an essential first step to protect human participants in future EMA research. We provide a brief set of recommendations that can aid in the design and ethics review of the future EMA protocol with substance using populations.

Implementation of online opioid overdose prevention, recognition and response trainings for professional first responders: Year 1 survey results

BACKGROUND This article reports on the first web-based implementation of an opioid-overdose prevention, recognition and response training for professional first responders. The training was disseminated nationally over one listserv in November 2014. The same year, following Act 139, which mandated the provision of an online training for police officers in Pennsylvania, the Pennsylvania Department of Health approved the training. It was subsequently adopted as the primary training tool for police and other first responders in Pennsylvania and has been used as a training tool by first responders nationally. METHODS Analyses employed descriptive statistics to report characteristics of a sample of 387 professional first responders who completed a survey about their experience with the online training. Z-ratios were used to compare independent proportions related to overdose, naloxone, and satisfaction with the training between key subgroups, and paired t-tests were used to compare participant responses to a range of items pre- and post-participation in the training. RESULTS Between January-October 2015, 4804 first responders took the training; 1697 (35.3%) agreed to be contacted; of these, 387 (22.8%) completed a survey about the training and subsequent overdose response experiences. The majority (86.4%) were from Pennsylvania, with police representing over half of the sample. Analysis of the post-training survey indicates high satisfaction with content, format and mode of delivery, and high satisfaction with items related to confidence and overdose reversal preparedness. CONCLUSIONS This study demonstrates the feasibility and acceptability of implementing online training for first responders in overdose prevention, recognition and response.