Katie B. Biello

The effect of psychosocial syndemic production on 4-year HIV incidence and risk behavior in a large cohort of sexually active men who have sex with men

Background:Cross-sectional studies have suggested that co-occurring epidemics or “syndemics” of psychosocial health problems may accelerate HIV transmission among men who have sex with men (MSM) in the United States. We aimed to assess how 5 syndemic conditions (depressive symptoms, heavy alcohol use, stimulant use, polydrug use, and childhood sexual abuse) affected HIV incidence and sexual risk behavior over time. Methods:Eligible men in a large prospective cohort of sexually active HIV-uninfected MSM completed HIV testing and behavioral surveys at baseline and every 6 months for 48 months. We examined interrelationships between psychosocial problems and whether these interactions increased the odds of HIV risk behaviors and risk of seroconversion over study follow-up. Results:Among 4295 men, prevalence of psychosocial conditions was substantial at baseline and was positively associated with each other. We identified a statistically significant positive dose–response relationship between numbers of syndemic conditions and HIV seroconversion for all comparisons (with the greatest hazard among those with 4–5 conditions, adjusted hazard ratio = 8.69; 95% confidence interval: 4.78 to 15.44). The number of syndemic conditions also predicted increased HIV-related risk behaviors over time, which mediated the syndemic–HIV seroconversion association. Conclusions:The accumulation of syndemic psychosocial problems predicted HIV-related sexual risk behaviors and seroconversion in a large sample of US MSM. Given the high prevalence of syndemic conditions among MSM and the moderate effect sizes attained by traditional brief behavioral interventions to date, the HIV prevention agenda requires a shift toward improved assessment of psychosocial comorbidities and stronger integration with mental health and substance abuse treatment services.

Like Father, Like Son: The Intergenerational Cycle of Adolescent Fatherhood

OBJECTIVES Strong evidence exists to support an intergenerational cycle of adolescent fatherhood, yet such a cycle has not been studied. We examined whether paternal adolescent fatherhood (i.e., father of study participant was age 19 years or younger when his first child was born) and other factors derived from the ecological systems theory predicted participant adolescent fatherhood. METHODS Data included 1496 young males who were interviewed annually from the National Longitudinal Survey of Youth 1997. Cox regression survival analysis was used to determine the effect of paternal adolescent fatherhood on participant adolescent fatherhood. RESULTS Sons of adolescent fathers were 1.8 times more likely to become adolescent fathers than were sons of older fathers, after other risk factors were accounted for. Additionally, factors from each ecological domain-individual (delinquency), family (maternal education), peer (early adolescent dating), and environment (race/ethnicity, physical risk environment)-were independent predictors of adolescent fatherhood. CONCLUSIONS These findings support the need for pregnancy prevention interventions specifically designed for young males who may be at high risk for continuing this cycle. Interventions that address multiple levels of risk will likely be most successful at reducing pregnancies among partners of young men.

Suboptimal awareness and comprehension of published preexposure prophylaxis efficacy results among physicians in Massachusetts

In 2010, the centre for the AIDS Programme of Research in South Africa (CAPRISA)004 and iPrEx trials (microbicide gel containing tenofovir and oral pill containing tenofovir–emtricitabine, respectively) demonstrated that antiretroviral preexposure prophylaxis (PrEP) reduced the risk of HIV acquisition among high-risk individuals. To determine the facilitators and barriers to PrEP provision by health-care providers, we conducted an online, quantitative survey of Massachusetts-area physicians following the publication of the CAPRISA and iPrEx results. We assessed awareness and comprehension of efficacy data, prescribing experience, and anticipated provision of oral and topical PrEP among physicians, as well as demographic and behavioral factors associated with PrEP awareness and prescribing intentions. The majority of HIV specialists and generalist physicians were aware of data from these PrEP trials and able to correctly interpret the results, however, correct interpretation of findings tended to vary according to specialty (i.e., HIV specialists had greater awareness than generalists). In addition, provider concerns regarding PrEP efficacy and safety, as well its ability to divert funds from other HIV prevention resources, were associated with decreased intentions to prescribe both oral and topical PrEP. Findings suggest that a substantial proportion of physicians who may have contact with at-risk individuals may benefit from interventions that provide accurate data on the risks and benefits of PrEP in order to facilitate effective PrEP discussions with their patients. Future studies to develop and test interventions aimed at health-care providers should be prioritized to optimize implementation of PrEP in clinical settings.

Psychosocial risk factors for HIV sexual risk among Indian men who have sex with men

Indian men who have sex with men (MSM) are at increased risk for HIV compared to the general Indian population. Psychosocial factors may be uniquely associated with HIV risk among Indian MSM and may moderate the beneficial impact of standard HIV prevention approaches. Psychiatric diagnostic interviews and psychosocial and sexual risk assessments were conducted among 150 MSM in Mumbai, India. Logistic regression was employed to examine the association of psychiatric disorders and psychosocial problems to recent sexual risk behavior. Twenty-five percent of participants reported engaging in unprotected anal sex (UAS) during their last sexual contact with a man. Men who were married to a woman were more likely to have engaged in UAS during their last sexual contact with a man (35% vs. 17%, p=0.018). In multivariable models, significant predictors of engaging in UAS were current major depression (adjusted odds ratio [AOR]=2.61; 95% confidence interval [CI] 1.07, 6.39) and number of stressful life events (AOR=0.91; 95% CI 0.83, 0.99). Alcohol dependence, anxiety, and self-esteem were not associated with engaging in UAS. Indian MSM with depression are at higher odds of engaging in UAS compared to MSM without depression. HIV prevention programs for Indian MSM may benefit from incorporating treatment or triage for mental health problems.

Psychosocial Predictors of Non-Adherence and Treatment Failure in a Large Scale Multi-National Trial of Antiretroviral Therapy for HIV: Data from the ACTG A5175/PEARLS Trial

Background PEARLS, a large scale trial of antiretroviral therapy (ART) for HIV (n = 1,571, 9 countries, 4 continents), found that a once-daily protease inhibitor (PI) based regimen (ATV+DDI+FTC), but not a once-daily non-nucleoside reverse transcriptase inhibitor/nucleoside reverse transcriptase inhibitor (NNRTI/NRTI) regimen (EFV+FTC/TDF), had inferior efficacy compared to a standard of care twice-daily NNRTI/NRTI regimen (EFV+3TC/ZDV). The present study examined non-adherence in PEARLS. Methods Outcomes: non-adherence assessed by pill count and by self-report, and time to treatment failure. Longitudinal predictors: regimen, quality of life (general health perceptions  =  QOL-health, mental health  =  QOL-mental health), social support, substance use, binge drinking, and sexual behaviors. “Life-Steps” adherence counseling was provided. Results In both pill-count and self-report multivariable models, both once-a-day regimens had lower levels of non-adherence than the twice-a-day standard of care regimen; although these associations attenuated with time in the self-report model. In both multivariable models, hard-drug use was associated with non-adherence, living in Africa and better QOL-health were associated with less non-adherence. According to pill-count, unprotected sex was associated with non-adherence. According to self-report, soft-drug use was associated with non-adherence and living in Asia was associated with less non-adherence. Both pill-count (HR = 1.55, 95% CI: 1.15, 2.09, p<.01) and self-report (HR = 1.13, 95% CI: 1.08, 1.13, p<.01) non-adherence were significant predictors of treatment failure over 72 weeks. In multivariable models (including pill-count or self-report nonadherence), worse QOL-health, age group (younger), and region were also significant predictors of treatment failure. Conclusion In the context of a large, multi-national, multi-continent, clinical trial there were variations in adherence over time, with more simplified regimens generally being associated with better adherence. Additionally, variables such as QOL-health, regimen, drug-use, and region play a role. Self-report and pill-count adherence, as well as additional psychosocial variables, such QOL-health, age, and region, were, in turn, associated with treatment failure.

Racial Residential Segregation and Rates of Gonorrhea in the United States, 2003–2007

OBJECTIVES In the United States, Black persons are disproportionately affected by sexually transmitted infections (STIs), including gonorrhea. Individual behaviors do not fully explain these racial disparities. We explored the association of racial residential segregation with gonorrhea rates among Black persons and hypothesized that specific dimensions of segregation would be associated with gonorrhea rates. METHODS We used 2003 to 2007 national STI surveillance data and 2000 US Census Bureau data to examine associations of 5 dimensions of racial residential segregation and a composite measure of hypersegregation with gonorrhea rates among Black persons in 257 metropolitan statistical areas, overall and by sex and age. We calculated adjusted rate ratios with generalized estimating equations. RESULTS Isolation and unevenness were significantly associated with gonorrhea rates. Centralization was marginally associated with gonorrhea. Isolation was more strongly associated with gonorrhea among the younger age groups. Concentration, clustering, and hypersegregation were not associated with gonorrhea. CONCLUSIONS Certain dimensions of segregation are important in understanding STI risk among US Black persons. Interventions to reduce sexual risk may need to account for racial residential segregation to maximize effectiveness and reduce existent racial disparities.

Racial Disparities in Age at Preventable Hospitalization Among U.S. Adults

BACKGROUND Similar to the well-documented racial inequities in health status, disease burden, healthcare access, and hospitalization, studies have generally found higher rates of hospitalization resulting from ambulatory care-sensitive conditions for blacks compared to whites. Beyond identifying disparity in rates of disease or risks of hospitalization, identifying disparity in age at hospitalization may provide deeper insight into the social and economic effects of disparities on individuals, families, and communities. PURPOSE The objective of this paper is to evaluate potential racial disparities in age of preventable hospitalizations as measured by ambulatory care-sensitive conditions. METHODS Differences in mean age at hospitalization for ambulatory care-sensitive conditions were evaluated in a nationally representative sample of 6815 hospital discharges using the 2005 National Hospital Discharge Survey. Linear regression using robust SE procedures was used to evaluate differences among nine chronic and three acute conditions. Analyses were conducted in 2008. RESULTS After adjustment for sociodemographic characteristics, blacks were hospitalized > or =5 years earlier than whites across all conditions combined and for chronic and acute conditions separately. The largest differences were seen for uncontrolled diabetes (adjusted difference= -12.0 years) and bacterial pneumonia (adjusted difference= -7.5 years). CONCLUSIONS Racial disparities in age at preventable hospitalization exist across a spectrum of conditions. This difference in age at hospitalization places an undue burden on individuals, families, and society with long-term health and financial sequelae. Promoting equity in disease prevention, management, and treatment should be a priority of any healthcare reform efforts.

Psychiatric Diagnoses and Comorbidities in a Diverse, Multicity Cohort of Young Transgender Women: Baseline Findings From Project LifeSkills

IMPORTANCE Transgender youth, including adolescent and young adult transgender women assigned a male sex at birth who identify as girls, women, transgender women, transfemale, male-to-female, or another diverse transfeminine gender identity, represent a vulnerable population at risk for negative mental health and substance use outcomes. Diagnostic clinical interviews to assess prevalence of mental health, substance dependence, and comorbid psychiatric disorders in young transgender women remain scarce. OBJECTIVE To report the prevalence of mental health, substance dependence, and comorbid psychiatric disorders assessed via clinical diagnostic interview in a high-risk community-recruited sample of young transgender women. DESIGN, SETTING, AND PARTICIPANTS Observational study reporting baseline finding from a diverse sample of 298 sexually active, young transgender women aged 16 through 29 years (mean age, 23.4 years; 49.0% black, 12.4% Latina, 25.5% white, and 13.1% other minority race/ethnicity) and enrolled in Project LifeSkills, an ongoing randomized controlled HIV prevention intervention efficacy trial in Chicago and Boston, between 2012 and 2015. EXPOSURE Transfeminine gender identity. MAIN OUTCOMES AND MEASURES Age- and site-adjusted prevalence and comorbidities of mental health and substance dependence disorders assessed via the Mini-International Neuropsychiatric Interview, including 1 or more diagnoses, 2 or more comorbid diagnoses, major depressive episode (current and lifetime), past 30-day suicidal risk (no/low risk vs moderate/high risk), past 6-month generalized anxiety disorder and posttraumatic stress disorder, and past 12-month alcohol dependence and nonalcohol psychoactive substance use dependence. RESULTS Of the 298 transgender women, 41.5% of participants had 1 or more mental health or substance dependence diagnoses; 1 in 5 (20.1%) had 2 or more comorbid psychiatric diagnoses. Prevalence of specific disorders was as follows: lifetime and current major depressive episode, 35.4% and 14.7%, respectively; suicidality, 20.2%; generalized anxiety disorder, 7.9%; posttraumatic stress disorder, 9.8%; alcohol dependence, 11.2%; and nonalcohol psychoactive substance use dependence, 15.2%. CONCLUSIONS AND RELEVANCE Prevalence of psychiatric diagnoses was high in this community-recruited sample of young transgender women. Improving access to routine primary care, diagnostic screening, psychotherapy, and pharmacologic treatments, and retention in care in clinical community-based, pediatric, and adolescent medicine settings are urgently needed to address mental health and substance dependence disorders in this population. Further research will be critical, particularly longitudinal studies across development, to understand risk factors and identify optimal timing and targets for psychosocial interventions.

A compensatory model of risk and resilience applied to adolescent sexual orientation disparities in nonsuicidal self-injury and suicide attempts.

This study investigated and applied a compensatory model of risk and resilience to differences in past-year nonsuicidal self-injury (NSSI) and suicide attempts by sexual orientation using representative data from the 2007 Massachusetts Youth Risk Behavior Survey (n = 3,131). Self-identified lesbian, gay, bisexual, and questioning (LGBQ) adolescents comprised 7% of the sample, but accounted for 67% of NSSI and 80% of suicide attempts. Compared with heterosexuals, LGBQ adolescents had an increased odds of NSSI (adjusted Odds Ratio (aOR) = 2.76; 95% Confidence Interval (CI) [2.00, 3.81] and suicide attempts (aOR = 2.73; 95% CI [1.47, 5.08]. NSSI was highly associated with suicidality (aOR = 10.87; 95% CI [6.17, 19.18]. Family support was independently associated with a decreased odds of both NSSI (aOR = 0.56; 95% CI [0.35, 0.89] and suicidality (aOR = 0.48; 95% CI [0.29, 0.79] supporting a compensatory model of resilience. Screening and preventive interventions for LGBQ adolescents are warranted, including at the family level. Sexual orientation should be included as a standard demographic to monitor health disparities.

Economic dependence and unprotected sex: the role of sexual assertiveness among young urban mothers.

In the USA, sexual intercourse is the leading route of human immunodeficiency virus transmission among women, primarily through their main partner. Because male condom use is not directly under a womans control, gender inequalities may help shape this sexual risk behavior. To examine this association, data came from follow-up interviews of young, primarily minority, pregnant women enrolled in a prospective, randomized controlled trial. Specifically, we aimed to determine the relationship between economic dependence on a male partner and condom use, and to establish whether this relationship was mediated by sexual assertiveness. Overall, 28% of women reported being economically dependent on a male partner. Young women dependent on a male partner were 1.6 times more likely to report not using a condom at last sex than women not dependent on their partner (95% confidence interval = 1.11–2.32; p = 0.01). Sexual assertiveness mediated the relationship between economic dependence and condom use (Sobel = 2.05, p = 0.04). Coupled with past research, this study supports the premise that sexual behaviors may be rooted in a complex web of social determinants. Addressing gender inequalities in contextual factors may promote healthier decisions within sexual relationships.