Viraj V. Patel

Bangladeshi Immigrants in New York City: A Community Based Health Needs Assessment of a Hard to Reach Population

South Asians, particularly Bangladeshis, are one of the fastest growing immigrant groups in the U.S. Limited data exist regarding the health needs of Bangladeshis in the U.S. More data are needed to guide health intervention efforts for this community. To help address this gap, we conducted a community-based health needs assessment survey among women in a Bangladeshi population living in Bronx, NY. Community health promoters conducted a door-to-door household survey and collected data from 167 women, an approach that yielded a participation rate over 90%. Over half reported fair or poor health and 36.5% screened positive for risk of depression. Only 35% had engaged in physical activity over the past month. 60% reported never having received a pap smear. Using WHO guidelines for BMI, 74% were either overweight or obese. Age-standardized prevalence of type 2 diabetes and hypertension were 15.4 and 36.5% respectively. In a multivariable logistic regression model, age and percent lifetime in the U.S. were independently associated with having diabetes. Poor health behaviors and high prevalence of cardiovascular risk factors observed in this group suggest the need for early health promotion and prevention interventions.

Injections through skin colonized with Staphylococcus aureus biofilm introduce contamination despite standard antimicrobial preparation procedures

While surgical site preparation has been extensively studied, there is little information about resistance of skin microbiota in the biofilm form to antimicrobial decontamination, and there are no quantitative models to study how biofilm might be transferred into sterile tissue/implant materials during injections for joint spine and tendon, aspiration biopsies and dermal fillers (DF). In this work, we develop two in vitro models to simulate the process of skin preparation and DF injection using pig skin and SimSkin (silicone) materials, respectively. Using the pig skin model, we tested three of the most common skin preparation wipes (alcohol, chlorhexidine and povidone iodine) and found that during wiping they reduced the biofilm bacterial burden of S. aureus (CFU cm−2) by three logs with no statistically significant differences between wipes. Using the SimSkin model, we found that transfer of viable bacteria increased with needle diameter for 30G, 25G and 18G needles. Transfer incidence decreased as injection depth was increased from 1 mm to 3 mm. Serial puncture and linear threading injection styles had similar transfer incidence, whereas fanning significantly increased transfer incidence. The results show that contamination of DF during injection is a risk that can be reduced by modifying skin prep and injection practices.

Tension in South Asian Women: Developing a Measure of Common Mental Disorder Using Participatory Methods

Background: Although common mental disorder (CMD) is highly prevalent among South Asian immigrant women, they rarely seek mental treatment. This may be owing in part to the lack of conceptual synchrony between medical models of mental disorder and the social models of distress common in South Asian communities. Furthermore, common mental health screening and diagnostic measures may not adequately capture distress in this group. Community-based participatory research (CBPR) is ideally suited to help address measurement issues in CMD as well as to develop culturally appropriate treatment models. Objectives: To use participatory methods to identify an appropriate, culturally specific mental health syndrome and develop an instrument to measure this syndrome. Methods: We formed a partnership between researchers, clinicians, and community members. The partnership selected a culturally specific model of emotional distress/illness, “tension,” as a focus for further study. Partners developed a scale to measure Tension and tested the new scale on 162 Bangladeshi immigrant women living in the Bronx. Results: The 24-item “Tension Scale” had high internal consistency (α = 0.83). On bivariate analysis, the scale significantly correlated in the expected direction with depressed as measured by the Patient Health Questionnaire (PHQ-2), age, education, self-rated health, having seen a physician in the past year, and other variables. Conclusions: Using participatory techniques, we created a new measure designed to assess CMD in an isolated immigrant group. The new measure shows excellent psychometric properties and will be helpful in the implementation of a community-based, culturally synchronous intervention for depression. We describe a useful strategy for the rapid development and field testing of culturally appropriate measures of mental distress and disorder.

Low Awareness and Use of Preexposure Prophylaxis in a Diverse Online Sample of Men Who Have Sex With Men in New York City

Sanchit Gupta, MD, MS, is an Internal Medicine resident, Mount Sinai Health System, New York, New York, USA. David W. Lounsbury, PhD, is an Assistant Professor of Epidemiology, Division of Community Collaboration & Implementation Science, Albert Einstein College of Medicine, Bronx, New York, USA. Viraj V. Patel, MD, MPH, is an Assistant Professor of Medicine, Division of General Internal Medicine, Montefiore Health System/Albert Einstein College of Medicine, Bronx, New York, USA. (*Correspondence to: vpatel@montefiore.org).

Pre-exposure prophylaxis prescribing and retention in care among heterosexual women at a community-based comprehensive sexual health clinic

ABSTRACT In the United States, heterosexual women account for 20% of new HIV infections. As a user-controlled HIV prevention method, pre-exposure prophylaxis (PrEP) has substantial potential to reduce new infections among women. However, among women, PrEP is vastly underutilized. To guide efforts to increase women-at-risk’s PrEP use, we sought to describe the characteristics of women prescribed PrEP as well as their retention in PrEP care. We conducted a chart review of women who received care at a comprehensive sexual health clinic within a large urban health care system. Referral sources included the health care system’s clinics and HIV testing program, as well as local community-based organizations. From 1 December 2014 to 5 August 2016, 554 women received care at the clinic. During this period, 21 heterosexual women (3.8%) received at least one prescription for daily oral PrEP. For women prescribed PrEP, median age was 35 years old (range: 20–52). The majority (66.7%) were either Latina or non-Latina Black and most (81.2%) had public health insurance. The most common PrEP indication was being in a known sero-discordant partnership (85.7%). Of women in such partnerships, 83.3% reported their male partner was currently taking antiretroviral medications (ARVs) and 16.7% reported trying to conceive with their partner (not mutually exclusive). Of women with ARV-using partners, 66.7% reported that their partners were virally suppressed. Retention in PrEP care at three months was 61.1% and, at six months, 37.5%. Further study is necessary to expand PrEP to women whose risk factors extend beyond being in a known sero-discordant partnership, and to understand the reasons for the observed drop-off in PrEP care visits in real-world settings.

Leveraging Social Media to Explore Black Women's Perspectives on HIV Pre-exposure Prophylaxis

Bianca S. Hill, MPH, is a medical student, Meharry Medical College, Nashville, Tennessee, USA. Viraj V. Patel, MD, MPH, is an Assistant Professor of Medicine, Division of General Internal Medicine, Montefiore Medical Center/ Albert Einstein College of Medicine, Bronx, New York, USA. Lorlette J. Haughton, MPH, is a research study coordinator, Division of General Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA. Oni J. Blackstock, MD, MHS, is an Assistant Professor of Medicine, Division of General Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA. (*Correspondence to: oblackst@montefiore.org).

Empowering With PrEP (E-PrEP), a Peer-Led Social Media–Based Intervention to Facilitate HIV Preexposure Prophylaxis Adoption Among Young Black and Latinx Gay and Bisexual Men: Protocol for a Cluster Randomized Controlled Trial

Background Young black and Latinx, gay, bisexual, and other men who have sex with men (YBLGBM, aged 18-29 years) have among the highest rates of new HIV infections in the United States and are not consistently reached by existing prevention interventions. Preexposure prophylaxis (PrEP), an oral antiretroviral regimen taken daily by HIV-uninfected individuals to prevent HIV acquisition, is highly efficacious in reducing HIV acquisition and could help stop the HIV epidemic in YBLGBM. Use of social media (eg, Facebook, Twitter, online dating sites) is ubiquitous among young people, providing an efficient avenue to engage YBLGBM to facilitate PrEP adoption. Objective Our overall goal was to develop and pilot test a theoretically grounded, social media–based, peer-led intervention to increase PrEP uptake in YBLGBM. We used diffusion of innovation and information-motivation-behavioral skills frameworks to (1) identify potential factors associated with interest in and adoption of PrEP among YBLGBM; (2) develop Empowering with PrEP (E-PrEP), a social media–based, peer-led intervention to increase PrEP uptake in YBLGBM; and (3) pilot test the feasibility and acceptability of E-PrEP, and determine its preliminary efficacy for increasing adoption of PrEP by YBLGBM. We describe the development and protocol for E-PrEP. Methods Using a participatory research approach, we partnered with YBLGBM intervention development partners to develop a social media–based behavioral intervention to facilitate PrEP uptake, which involved an online messaging campaign disseminated by YBLGBM peer leaders to their existing online networks. We designed the 6-week campaign to provide education about PrEP, increase motivation to use PrEP, and facilitate access to PrEP. We then conducted a cluster-randomized trial of E-PrEP compared with an attention-matched general health control condition (E-Health) among YBLGBM aged 18 to 29 years to assess E-PrEP’s feasibility, acceptability, preliminary efficacy for increasing self-reported intention to use PrEP, PrEP uptake, and impact on knowledge and attitudes about PrEP at 12-week follow-up (6 weeks after the end of the online campaign). Results From October 2016 to March 2017, we developed, pretested, and refined E-PrEP with 6 YBLGBM intervention development partners. From May to June 2017, we recruited, enrolled, and randomly assigned 10 peer leaders (n=5 for each condition). The 10 peer leaders then recruited and enrolled 152 participants from their existing online networks (range 3-33 per peer leader), during June and July 2017. Intervention follow-up was completed after 12 weeks, in November 2017, with analyses underway. Conclusions We hypothesize that, compared with E-Health, participants randomly assigned to E-PrEP will be more likely to express intention to use PrEP and greater PrEP uptake, and will also show changes in potential mediators of PrEP uptake (knowledge, attitudes, stigma, and access). A Web-based biobehavioral intervention model such as E-PrEP could be rapidly scaled even with limited resources and have significant population-level impact. Trial Registration ClinicalTrials.gov NCT03213366; https://clinicaltrials.gov/ct2/show/NCT03213366 (Archived by WebCite at http://www.webcitation.org/71onSdcXY) Registered Report Identifier RR1-10.2196/11375

Prevalence of and Factors Associated with the Use of HIV Serosorting and Other Biomedical Prevention Strategies Among Men Who Have Sex with Men in a US Nationwide Survey

PrEP and treatment-as-prevention (TasP) are biomedical strategies to reduce HIV transmission. Some men who have sex with men (MSM) are combining biomedical strategies with HIV serosorting—termed “biomed matching” when both partners are either on PrEP or TasP, or “biomed sorting” when one partner is using PrEP and the other TasP. Nevertheless, there is limited data on the extent of biomed matching/sorting in large geographically diverse samples. In 2016–2017, 5021 MSM from across the US were surveyed about their HIV status and HIV viral load/PrEP use, as well as that of their recent casual male partners. For each participant, we calculated the proportion of his partners who were (1) HIV-positive and undetectable, (2) HIV-positive and detectable/unknown, (3) HIV unknown/undiscussed, (4) HIV-negative on PrEP, (5) HIV-negative, not on PrEP. In total, 66.6% (n = 3346) of participants were HIV-negative and not on PrEP, 11.9% (n = 599) on PrEP, 14.1% (n = 707) HIV-positive and undetectable, 1.1% (n = 55) HIV-positive and viral load detectable/unknown, and 6.2% (n = 313) HIV unsure/unknown. A participant’s own HIV and PrEP status/was significantly associated with that of his partners (all p < 0.001), evincing evidence of both serosorting and biomed matching. Among men on PrEP and those who were HIV-undetectable, there was also some evidence to suggest these participants dually engaged in biomed matching as well as biomed sorting. We found evidence of biomed matching and sorting, which may compound its effectiveness for those using it (i.e., both partners bring biomedical protection). Unintended consequences of biomed matching/sorting include that men not using a biomedical strategy may be less likely to benefit from a partner’s use of the strategy—potentially further driving disparities in HIV infections. Public health campaigns might be well served to highlight not only the benefits that biomedical HIV prevention strategies provide for their users (e.g., “being on PrEP protects me from getting HIV”), but also the benefits that a user brings to his partners (e.g., “my use of PrEP means my partners won’t get HIV”), and the benefits of being with a partner who is using a biomedical strategy (e.g., “my partner’s use of PrEP/TasP protects me from HIV”).ResumenLa PrEP y el tratamiento-como-prevención (TasP, por sus siglas en inglés) son estrategias biomédicas para reducir la transmisión del VIH. Algunos hombres que tienen sexo con hombres (HSH) combinan estrategias biomédicas con la sero-clasificación de VIH—denominado “Pareo biomédico” cuando ambas parejas están en PrEP o TasP, o “clasificación biomédica” cuando una pareja usa PrEP y la otra TasP. Sin embargo, la data sobre el grado de pareo/clasificación biomédica en grandes muestras geográficamente diversas es limitada. En 2016–2017, 5021 HSH de todo EEUU fueron encuestados sobre su estado de VIH, su carga viral/uso de PrEP, así como la de sus recientes parejas masculinas casuales. Para cada participante, calculamos la proporción de parejas que eran (1) VIH-positivos e indetectables, (2) VIH-positivos y detectables/desconocidos, (3) VIH-desconocidos/No-discutidos, (4) VIH-negativos tomando PrEP, (5) VIH-negativos, sin tomar PrEP. En total, 66.6% (n = 3346) de los participantes eran VIH-negativos y sin tomar PrEP, 11.9% (n = 599) tomaban PrEP, 14.1% (n = 707) VIH-positivos e indetectables, 1.1% (n = 55) VIH-positivos con carga viral detectable/desconocida, y 6.2% (n = 313) desconocían o estaban inseguros de su estado de VIH. El estado de VIH y de PrEP de un participante estaba significativamente asociado al estado de sus parejas (todos p < 0.001), evidencia evidente de pareo y clasificación biomédica. Entre los hombres tomando PrEP y los que eran VIH-indetectables también hubo evidencia para sugerir que estos participantes dualmente utilizaban pareo biomédico tanto como clasificación biomédica. Encontramos evidencia de pareo y clasificación biomédica, los cuales pueden aumentar su efectividad para los que los utilizan (Por ejemplo, ambas parejas trayendo protección biomédica). Las consecuencias imprevistas del pareo/clasificación biomédica incluyen que los hombres quienes no utilizan una estrategia biomédica podrían ser menos probables a beneficiarse del uso de la estrategia por parte de una pareja—potencialmente impactando disparidades en infecciones de VIH. Las campañas para la salud pública pueden ser bien servidas resaltando no solo los beneficios que las estrategias biomédicas para la prevención del VIH proveen para sus usuarios (por ejemplo, “estando en PrEP me protege del VIH”), pero también los beneficios que un usuario provee a sus parejas (por ejemplo, “Mi uso de la PrEP significa que mis parejas no se contagiarán con el VIH”), y los beneficios de estar con una pareja que utiliza una estrategia biomédica (por ejemplo, “El uso de PrEP/TasP por parte de mi pareja me protege del VIH”).

ASHA: Using Participatory Methods to Develop an Asset-building Mental Health Intervention for Bangladeshi Immigrant Women

Background. Common mental disorder (CMD) is highly prevalent among low-income immigrant women, yet few receive effective treatment. This underutilization is partly owing to a lack of conceptual synchrony between biopsychiatric theories underlying conventional mental treatments and explanatory models in community settings. The Action to Improve Self-esteem and Health through Asset building (ASHA) program is a depression intervention designed by and for South Asian women immigrants. ASHA helps women to build psychological, social, and financial assets.Objectives. This paper describes the development and a preliminary pilot evaluation of the ASHA intervention.Methods. Researchers, clinicians, activists, and women from the Bronx Bangladeshi community collaboratively designed a depression intervention that would synchronize with local concepts of distress. In addition to providing mental health treatment, ASHA addresses social isolation and financial dependence. ASHA was evaluated in a pilot study described in this paper. Participants were assigned to intervention or delayed intervention (control) groups. Data collection at baseline and time 2 (6 months) included the Patient Health Questionnaire–9 (PHQ–9) and an indigenous measure of psychological and somatic distress.Results. Eighty percent of intervention participants completed the 6-month program. After treatment, mean PHQ–9 scores in the intervention group decreased from 9.90 to 4.26 (p < .001). Participants saved an average of

A Cross-Sectional Online Survey of HIV Pre-Exposure Prophylaxis Adoption Among Primary Care Physicians

10 per week. To date, participants have applied their skills and savings toward such activities as starting small businesses and enrolling in community college.Conclusions.ASHA was effective in improving depression and increasing financial independence. Using a culturally synchronous approach to psychological treatment may be effective in ameliorating distress in immigrant populations.