Julia Raifman

Difference-in-Differences Analysis of the Association Between State Same-Sex Marriage Policies and Adolescent Suicide Attempts

Importance Suicide is the second leading cause of death among adolescents between the ages of 15 and 24 years. Adolescents who are sexual minorities experience elevated rates of suicide attempts. Objective To evaluate the association between state same-sex marriage policies and adolescent suicide attempts. Design, Setting, and Participants This study used state-level Youth Risk Behavior Surveillance System (YRBSS) data from January 1, 1999, to December 31, 2015, which are weighted to be representative of each state that has participation in the survey greater than 60%. A difference-in-differences analysis compared changes in suicide attempts among all public high school students before and after implementation of state policies in 32 states permitting same-sex marriage with year-to-year changes in suicide attempts among high school students in 15 states without policies permitting same-sex marriage. Linear regression was used to control for state, age, sex, race/ethnicity, and year, with Taylor series linearized standard errors clustered by state and classroom. In a secondary analysis among students who are sexual minorities, we included an interaction between sexual minority identity and living in a state that had implemented same-sex marriage policies. Interventions Implementation of state policies permitting same-sex marriage during the full period of YRBSS data collection. Main Outcomes and Measures Self-report of 1 or more suicide attempts within the past 12 months. Results Among the 762 678 students (mean [SD] age, 16.0 [1.2] years; 366 063 males and 396 615 females) who participated in the YRBSS between 1999 and 2015, a weighted 8.6% of all high school students and 28.5% of students who identified as sexual minorities reported suicide attempts before implementation of same-sex marriage policies. Same-sex marriage policies were associated with a 0.6–percentage point (95% CI, –1.2 to –0.01 percentage points) reduction in suicide attempts, representing a 7% relative reduction in the proportion of high school students attempting suicide owing to same-sex marriage implementation. The association was concentrated among students who were sexual minorities. Conclusions and Relevance State same-sex marriage policies were associated with a reduction in the proportion of high school students reporting suicide attempts, providing empirical evidence for an association between same-sex marriage policies and mental health outcomes.

Implementation of Preexposure Prophylaxis for Human Immunodeficiency Virus Prevention Among Men Who Have Sex With Men at a New England Sexually Transmitted Diseases Clinic.

Background Preexposure prophylaxis (PrEP) is efficacious in preventing human immunodeficiency virus (HIV) among men who have sex with men (MSM). We assessed PrEP uptake among MSM presenting for services at a sexually transmitted diseases (STD) clinic. Methods Men who have sex with men presenting to the Rhode Island STD Clinic between October 2013 and November 2014 were educated about, and offered, PrEP. We categorized PrEP engagement using an implementation cascade to describe gaps in uptake which described MSM who: (1) were educated about PrEP, (2) indicated interest, (3) successfully received follow-up contact, (4) scheduled an appointment, (5) attended an appointment, and (6) initiated PrEP (ie, received a prescription). Bivariate and multivariable logistic regression models were used to examine predictors of PrEP initiation. Results A total of 234 MSM were educated about PrEP; of these, 56% expressed interest. Common reasons for lack of interest were low HIV risk perception (37%), wanting more time to consider (10%), concern about side effects (7%), and financial barriers (3%). Among those interested, 53% followed up. Of those, 51% scheduled an appointment. The most common reason patients did not schedule an appointment was low HIV risk perception (38%). Seventy-seven percent of those with an appointment attended the appointment; of those, 93% initiated PrEP. Patients with higher HIV-risk perception (adjusted odds ratios, 2.17; 95% confidence interval, 1.29–3.64) and a history of sex with an HIV-positive partner (adjusted odds ratios, 7.08; 95% confidence interval, 2.35–21.34) had significantly higher odds of initiating PrEP. Conclusions Low HIV-risk perception was the most significant barrier to PrEP uptake among MSM attending a public STD clinic.

Healthcare Provider Contact and Pre-exposure Prophylaxis in Baltimore Men Who Have Sex With Men.

INTRODUCTION Pre-exposure prophylaxis (PrEP) safely and effectively prevents HIV in populations at high risk, including men who have sex with men (MSM). PrEP scale-up depends upon primary care providers and community-based organizations (CBOs) sharing PrEP information. This study aimed to determine whether healthcare provider or CBO contact was associated with PrEP awareness among Baltimore MSM. METHODS This study used 2014 Baltimore MSM National HIV Behavioral Surveillance data, which included data on health care, HIV and sexually transmitted infection testing, and receipt of condoms from CBOs. In 2015, associations were estimated between healthcare contacts and PrEP awareness through logistic regression models controlling for age, race, and education and clustering by venue. Comparative analyses were conducted with HIV testing as outcome. RESULTS There were 401 HIV-negative participants, of whom 168 (42%) were aware of PrEP. Visiting a healthcare provider in the past 12 months, receiving an HIV test from a provider, and having a sexually transmitted infection test in the past 12 months were not significantly associated with PrEP awareness. PrEP awareness was associated with being out to a healthcare provider (OR=2.97, 95% CI=1.78, 4.96, p<0.001); being tested for HIV (OR=1.50, 95% CI=1.06, 2.13, p=0.023); and receiving condoms from an HIV/AIDS CBO (OR=2.59, 95% CI=1.43, 4.64, p=0.001). By contrast, HIV testing was significantly associated with most forms of healthcare contact. CONCLUSIONS PrEP awareness is not associated with most forms of healthcare contact, highlighting the need for guidelines and trainings to support provider discussion of PrEP with MSM.

Insurance Coverage and Utilization at a Sexually Transmitted Disease Clinic in a Medicaid Expansion State

Background In Rhode Island, the Patient Protection and Affordable Care Act has led to over 95% of the states population being insured. We evaluated insurance coverage and barriers to insurance use among patients presenting for services at the Rhode Island sexually transmitted disease (STD) clinic. Methods We analyzed factors associated with insurance coverage and utilization among patients presenting for STD services between July and December 2015. Results A total of 692 patients had insurance information available; of those, 40% were uninsured. Patients without insurance were more likely than those with insurance to be nonwhite (50% among uninsured, compared with 40% among insured; P = 0.014) and Hispanic or Latino/a (25%, compared with 16%; P = 0.006), and less likely to be men who have sex with men (27%, compared with 39%; P = 0.001). Of those with health insurance, 26% obtained coverage as a result of the Affordable Care Act, and 56% of those were previously uninsured. Among uninsured individuals, barriers to obtaining health insurance included cost and unemployment. Among those with insurance, 43% reported willingness to use insurance for STD services. Barriers to insurance use included concerns about anonymity and out-of-pocket costs. Conclusions Despite expanded insurance access, many individuals presenting to the Rhode Island STD Clinic were uninsured. Among those who were insured, significant barriers still existed to using insurance. STD clinics continue to play an important role in providing safety-net STD services in states with low uninsured rates. Both public and private insurers are needed to address financial barriers and optimize payment structures for services.

US Guidelines That Empower Women to Prevent HIV with Preexposure Prophylaxis

EMPOWERING WOMEN TO PREVENT HIVSince the early days of the human immunodeficiency virus (HIV) epidemic, health care providers have sought methods of preventing HIV that empower women to protect their health.1,2 Now preexposure prophylaxis (PrEP), a daily pill that prevents HIV, can empower women wit

How well are aid agencies evaluating programs? An assessment of the quality of global health evaluations

ABSTRACT Evaluations are key to learning and accountability. We assessed the methodological quality of 37 randomly selected programme evaluations from 5 major global health funders. Two researchers rated each evaluation for relevance, validity, and reliability and met to resolve discrepancies. Most evaluations asked questions relevant to the health programme, but less than 40 per cent of impact evaluations and less than 10 per cent of performance evaluations used relevant data, followed accepted social science methods for sampling, or had high analytical validity and reliability. There is a need to improve the methodological quality of programme evaluations.

Association of State Laws Permitting Denial of Services to Same-Sex Couples With Mental Distress in Sexual Minority Adults: A Difference-in-Difference-in-Differences Analysis

Importance Recent evidence suggests that state policies affecting sexual minorities are associated with health disparities. Twelve states have laws permitting the denial of services to same-sex couples, and the US Supreme Court is considering whether states can prohibit the denial of services to same-sex couples. Objective We investigated whether state laws permitting individuals to refuse services to sexual minorities were associated with changes in the proportion of sexual minority adults reporting mental distress. Design, Setting, and Participants This difference-in-difference-in-differences linear regression analysis with state fixed effects used Behavioral Risk Factor Surveillance System (BRFSS) data from 2014 through 2016 from adults aged 18 to 64 years in 3 states that implemented laws permitting the denial of services to same-sex couples (Utah, Michigan, and North Carolina) and 6 nearby control states (Idaho and Nevada, Ohio and Indiana, and Virginia and Delaware, respectively). Sexual minority adults were defined as those who identified as gay, lesbian, bisexual, or not sure of their sexual orientation under a module on sexual orientation that BRFSS implemented in 2014 and each state could opt to include. Analysis controlled for year and individual-level sex, race, ethnicity, age group, educational attainment, income, employment, and marital status. A permutation test was conducted to precisely estimate statistical significance. Exposures An interaction term indicating whether individuals identified as a sexual minority and lived in a state with a law permitting denial of services to same-sex couples in 2015. Main Outcomes and Measures Mental distress, defined as poor mental health on 14 or more of the past 30 days. Results Of 109 089 participants, 4656 (4.8%; all percentages incorporate survey weights) identified as sexual minorities, 86141 (72.1%) were non-Hispanic white, and ages were uniformly distributed between 18 and 64 years. In 2014, 2038 of 16637 heterosexual adults (12.6%) and 156 of 815 sexual minority adults (21.9%) in the 3 same-sex denial states reported mental distress. The proportion of sexual minority adults reporting mental distress increased by 10.1 percentage points (95% CI, 1.8 to 18.5 percentage points, permutation-adjusted P value = .046) between 2014 and 2016 in states that passed laws permitting denial of services to same-sex couples compared with control states, a 46% relative increase in sexual minority adults experiencing mental distress. Laws permitting denial of services to same-sex couples were not associated with significant changes in heterosexual adults experiencing mental distress (−0.36 percentage points, 95% CI, −1.73 to 1.01 percentage points). Conclusions and Relevance Laws permitting denial of services to same-sex couples, which exist in 12 states and are under consideration by the US Supreme Court, are associated with a 46% increase in sexual minority adults experiencing mental distress.

The New US “Conscience and Religious Freedom Division”: Imposing Religious Beliefs on Others

An editorial is presented which addresses U.S. President Donald Trumps administration and the creation of Americas Conscience and Religious Freedom Division (CRFD) within the nations Department of Health and Human Services Office for Civil Rights, and it mentions how the CRFD accepts complaints from health care providers regarding participation in medical procedures that violate their religious values. The imposition of religious beliefs on others is assessed, along with LGBT patients.

Evaluating Evaluations: Assessing the Quality of Aid Agency Evaluations in Global Health

Evaluations are key to learning and accountability yet the quality of those evaluations are critical to their usefulness. We assessed the methodological quality of global health program evaluations commissioned or conducted by five major funders and published between 2009 and 2014. From a universe of 299 large-scale global health program evaluations, we randomly selected 37 evaluations stratified by whether they were performance evaluations or impact evaluations and applied a systematic assessment approach with two reviewers scoring each evaluation. We found that most evaluations did not meet social science methodological standards in terms of using methods and data that would simultaneously assure relevance, validity, and reliability. Most evaluations (76 percent) asked questions relevant to the health program, but 43 percent of evaluations failed to collect relevant data. In addition, only about a fifth of the evaluations followed accepted social science methods for sampling. We also assessed whether evaluations took a systematic analytical approach and considered potential confounding variables. In this regard, only 16 percent of evaluations in our sample had high analytical validity and reliability. The study provides ten recommendations for improving the quality of evaluations, including a robust finding that early planning of evaluations is associated with better quality and noting the value of better sampling approaches in data collection and disclosure of potential conflicts of interest and data.

Improving insurance and healthcare systems to ensure better access to sexually transmitted disease testing and prevention

Despite ongoing national efforts and advances in testing and treatment, sexually transmitted diseases (STDs) including human immunodeficiency virus (HIV), chlamydia, gonorrhea, and syphilis remain a significant public health challenge in the United States.1 Approximately 20 million cases of STDs and 40,000 cases of HIV are diagnosed annually,2,3 contributing an estimated