Kristen Clements-Nolle

Incidence of human immunodeficiency virus among male-to-female transgendered persons in San Francisco.

Objective: To estimate HIV incidence among male‐to‐female transgendered persons (MtF transgendered persons) who repeatedly tested for HIV antibodies at public San Francisco counseling and testing sites between July 1997 and June 2000. Methods: HIV seroconversions were identified and person‐time of observation were estimated using the date and result of the current test and the self‐reported date and result of the previous test. Factors independently associated with HIV seroconversion were determined using multivariable proportional hazard analysis. Results: HIV incidence was 7.8 per 100 person‐years (95% confidence intervals [CI], 4.6‐12.3) based on 13 seroconversions among 155 repeat testers with 167.7 person‐years of observation. African‐American race/ethnicity (adjusted relative hazard ratio [HR], 5.0; 95% CI, 1.5‐16.2) and unprotected receptive anal intercourse (HR, 3.9; 95% CI, 1.2‐13.1) were independent predictors of HIV seroconversion. Conclusions: HIV is currently spreading at an extremely high rate among MtF transgendered persons in San Francisco, especially those who are African Americans.

Health Promotion for Older Americans in the 21st Century

Objectives. To provide a broad overview of the role of the individual, the physical environment, and the social environment on health and functioning in older adults (65 and older), and to highlight interventions and recommendations for action on each of these levels. Data Sources. Published studies and government reports on health and functioning in older Americans and on the individual, social, and physical environmental contributors to health were identified through journal and government documents review and computer library searches of medical and social science data bases for 1980–1999. Study Selection. Preference was given to published studies and government reports that focused specifically on behavioral and environmental contributors and barriers to health promotion in Americans 65 and older and/or that highlighted creative interventions with relevance to this population. Both review articles and presentations of original research were included, with the latter selected based on soundness of design and execution and/or creativity of intervention described. Data Extraction. Studies were examined and their findings organized under three major headings: (1) behavioral risk factors and risk reduction, including current government standards for prevention and screening; (2) the role of the physical environment; and (3) the role of the social environment in relation to health promotion of older adults. Data Synthesis. Although most attention has been paid to the role of behavioral factors in health promotion for older adults, a substantial body of evidence suggests that physical and social environmental factors also play a key role. Similarly, interventions that promote individual behavioral risk reduction and interventions targeting the broader social or physical environment all may contribute to health in the later years. Conclusions. With the rapid aging of Americas population, increased attention must be focused on health promotion for those who are or will soon be older adults. Promising intervention strategies addressing the individual, the physical environment, and the social environment should be identified and tested, and their potential for replication explored, as we work toward a more comprehensive approach to improving the health of older Americans in the 21st century.

Intimate Partner Violence and Depression in a Population-Based Sample of Women: Can Social Support Help?

Data from the 2006 Behavioral Risk Factor Surveillance System in Nevada was analyzed to determine whether social support is independently associated with depression in a population-based sample of women with a history of intimate partner violence (IPV). More than a quarter (27%) of the women who were randomly chosen to participate in the survey reported lifetime IPV (n = 472). Twenty-four percent of abused women were categorized as currently depressed according to the eight-item Patient Health Questionnaire (PHQ). Abused women who reported low social support, adjusted odds ratio (AOR) = 4.95, 95% CI (1.69-14.49), or moderate social support, AOR = 2.71, 95% CI (1.00-7.33), were more likely to be depressed than women who reported high levels of social support. Other independent risk factors for depression included younger age, AOR = 5.36, 95% CI (1.36-25.39); low education (less than high school), AOR = 12.55, 95% CI (2.78-56.72); fair or poor perceived health status, AOR = 3.72, 95% CI (1.39-9.87); being overweight or obese, AOR = 3.21, 95% CI (1.26-8.19); having experienced sexual IPV, AOR = 4.95, 95% CI (1.08-22.74); and having experienced both physical and sexual IPV, AOR = 4.54, 95% CI (2.07-9.99). There is an urgent need for routine screening for IPV and depression in clinic and community settings. Interventions that target younger women who experience IPV and aim to decrease depression in this vulnerable population are likely to be most effective if they promote social support, increase education opportunities, and support healthy weight loss behaviors.

Highly active antiretroviral therapy use and HIV transmission risk behaviors among individuals who are HIV infected and were recently released from jail.

We evaluated highly active anti-retroviral therapy (HAART) use and risk behaviors among 177 inmates who were HIV infected and were released and reincarcerated in San Francisco, Calif, jails over a 12-month period. During the month preceding reincarceration, HIV transmission risk behaviors were common among respondents, and 59% of those with a history of antiretroviral use were not taking HAART. HAART discontinuation was independently associated with homelessness, marijuana use, injection drug use, and not receiving community medical care. Postrelease interventions for inmates who are HIV infected are needed.

Childhood Trauma and Risk for Past and Future Suicide Attempts among Women in Prison

PURPOSE We sought to determine whether childhood trauma is an independent risk factor for past suicide attempts and the future likelihood of attempts among women in prison. METHODS A random sample of 247 women incarcerated in a state prison in Las Vegas, Nevada, completed a confidential interview that included the Childhood Trauma Questionnaire, the 18-item Brief Symptom Inventory, standard measures of illicit drug use, and the revised Suicidal Behaviors Questionnaire. Multiple logistic regression models were developed to evaluate the independent influence of cumulative childhood trauma on past suicide attempts with intent to die and the future likelihood of suicide attempts. RESULTS Childhood trauma was frequently reported by female prisoners: emotional abuse (58%), physical abuse (54%), sexual abuse (51%), emotional neglect (53%), and physical neglect (41%). Factors independently associated with past suicide attempts included having a higher childhood trauma score (p < .001), a higher psychological distress score (p=.005), and longer duration of current incarceration (> or =5 years; p=.003). Childhood trauma (p=.05), psychological distress (p < .001), and lack of legal employment before incarceration (p=.05) were independent risk factors for future likelihood of attempting suicide. CONCLUSIONS Childhood trauma is an independent risk factor for attempted suicide among women in prison that persists into adulthood and cannot fully be attributed to psychological distress, illicit drug use, or incarceration duration. Addressing the emotional impact of childhood trauma among female prisoners may increase the effectiveness of correctional suicide prevention efforts.

Sex trade in a male-to-female transgender population: psychosocial correlates of inconsistent condom use

BACKGROUND Research suggests that because of economic necessity, many male-to-female (MTF) transgender individuals trade sex for money, drugs, housing, and other things they may need. To date, no studies have quantitatively assessed psychosocial correlates of condom use with this population. METHODS We conducted a cross sectional study with 190 MTF transgender individuals involved in sex trade in San Francisco, California. Multivariate logistic regression was used to determine factors independently associated with inconsistent condom use during receptive anal sex with exchange partners. RESULTS About one fifth of our participants reported inconsistent condom use during receptive anal sex in the past 6 months. In the multivariate model, low self-esteem [adjusted odds ratio (AOR)=3.09; 95% confidence interval (CI) (1.28, 7.47)], a history of forced sex or rape [AOR=2.91; 95% CI (1.06, 8.01)], and use of crack-cocaine [AOR=2.59; 95% CI (1.09, 6.13)] were independently associated with inconsistent condom use. CONCLUSIONS Our findings highlight an urgent need for multilevel risk reduction interventions for MTF transgender individuals involved in sex trade. Such interventions will be most effective if they address the psychosocial context of sexual risk taking by focusing on issues such as low self-esteem, sexual violence, and illicit drug use.

Nevada's academic-practice collaboration: public health preparedness possibilities outside an academic center.

The Nevada State Health Division developed a local academic-practice partnership with the University of Nevada Renos Master of Public Health Program to assess the bioterrorism risk communication, information, response, and training needs of professional and public stakeholder groups throughout Nevada. Between October 16, 2002, and April 13, 2004, 22 needs assessment focus groups and 125 key informant interviews were conducted to gather information on the diverse needs of the stakeholders. The themes that emerged from these activities included the need for effective pre-event education and training; a coordinated and responsive public health preparedness infrastructure; honest, accurate, and timely communication in the event of a bioterrorism situation; and appropriate information dissemination methods and technology. The data collected through this needs assessment gave the Nevada State Health Division vital information to plan public health preparedness initiatives. The establishment of local academic-practice partnerships for states without a Centers for Disease Control and Prevention-funded Academic Center for Public Health Preparedness is an effective way for health departments to develop their public health preparedness infrastructure while simultaneously training the future public health workforce.

Dating Violence, Psychological Distress, and Attempted Suicide Among Female Adolescents in the Juvenile Justice System

The prevalence of mental illness and suicide among female adolescents involved with the juvenile justice system is alarmingly high and there is a need to identify risk factors that may be amenable to intervention. This study examined the independent association between dating violence and poor mental health (psychological distress and attempted suicide) among 305 female adolescents involved with the juvenile justice system in Nevada. Overall, 28% of the sample met the criteria for clinically significant psychological distress and 18% had attempted suicide with intent to die. After controlling for well-established risk factors such as sexual orientation, childhood abuse, and substance abuse, dating violence remained independently associated with psychological distress and attempted suicide. These findings suggest that mental health programming for this population may be more effective if it includes a focus on dating violence.

The Association between Adverse Childhood Experiences and Alcohol Use during Pregnancy in a Representative Sample of Adult Women.

BACKGROUND The impact of adverse childhood experiences (ACEs) on adult alcohol consumption is well-established, but little is known about the association with alcohol use during pregnancy. METHODS Using data from the 2010 Nevada Behavioral Risk Factor Surveillance System, we assessed the relationship between ACEs and alcohol use during pregnancy in a representative sample of 1,987 adult women. An established ACEs scale was used to assess a range of childhood physical, emotional, and sexual abuse and household dysfunction (range, 0-8). Weighted logistic regression was used to assess the relationship between ACE scores and alcohol use during pregnancy after controlling for drinking before pregnancy and other covariates. RESULTS Six percent of participants reported drinking alcohol during pregnancy. After controlling for race/ethnicity, age, employment status, smoking status, and prepregnancy alcohol use, increasing ACEs were positively associated with higher odds of alcohol use during pregnancy (1 ACE: adjusted odds ratio [AOR], 2.92; 95% CI, 1.08-7.87), (2-3 ACEs: AOR, 3.52; 95% CI, 1.46-8.48), and (≥4 ACEs: AOR, 4.79; 95% CI, 2.14-10.72). Prepregnancy drinking was also strongly associated with alcohol use during pregnancy (AOR, 11.95; 95% CI, 5.02-28.43). CONCLUSIONS We found evidence of a dose-response relationship between ACEs and alcohol use during pregnancy that remained even after controlling for prepregnancy drinking and other covariates. Screening women of childbearing age as well as pregnant women for ACEs may be an effective way to identify and address many of the emotional, behavioral, and physical sequelae of childhood adversity.

Sexual Identity, Adverse Childhood Experiences, and Suicidal Behaviors

PURPOSE The objective of this study was to examine the influence of sexual identity and adverse childhood experiences (ACEs) on suicidal behaviors in a population-based sample of high school students. METHODS A two-stage cluster random sampling design was used to recruit 5,108 students from 97 high schools. A total of 4,955 students (97%) provided information that allowed for classification of sexual identity into three groups: (1) lesbian, gay, or bisexual (LGB) (10%); (2) not sure (4.6%); and (3) heterosexual (85.4%). Five measures of childhood abuse and household dysfunction were summed, and the ACE score was categorized as 0, 1, 2, and 3-5 ACEs. Weighted logistic regression was used to assess the influence of sexual identity, ACEs, and their interaction on suicide ideation and attempts in the past 12 months. RESULTS Compared with heterosexual students, those who were LGB and were not sure had higher odds of suicide ideation and attempts. There was also a graded relationship between cumulative ACE exposure and suicidal behaviors. Although sexual identity/ACE interaction was not observed, LGB/not sure students who experienced a high number of ACEs were disproportionately affected. Compared with heterosexual students with 0 ACE, LGB/not sure students with 0 ACE (adjusted odds ratio [AOR] = 3.32, 95% confidence interval [CI] = 1.96-5.61), 1 ACE (AOR = 6.58, 95% CI = 4.05-10.71), 2 ACEs (AOR 13.50, 95% CI = 8.45-21.58), and 3-5 ACEs (AOR = 14.04, 95% CI = 8.72, 22.62) had higher odds of suicide ideation. A similar pattern was observed for suicide attempts. CONCLUSIONS LGB and students not sure of their sexual identity with greater exposure to ACEs have disproportionately high levels of suicide ideation and attempts. Trauma-informed interventions for these populations are warranted.