Comparing Sexual Network Mean Active Degree Measurement Metrics Among Men Who Have Sex With Men.

BACKGROUND: Mean active degree is an important proxy measure of cross-sectional network connectivity commonly used in HIV/sexually transmitted infection epidemiology research. No current studies have compared measurement methods of mean degree using a cross-sectional study design for men who have sex with men (MSM) in the United States. We compared mean degree estimates based on reported ongoing main and casual sexual partnerships (current method) against dates of first and last sex (retrospective method). METHODS: We used data from ARTnet, a cross-sectional survey of MSM in the United States (2017-2019). ARTnet collected data on the number and types of sexual partners in the past year, limited to the 5 most recent partners (data truncation). We quantified partnerships for months 0 to 12 before the survey date (retrospective method) and compared that with ongoing partnerships on the day of survey (current method). We used linear regression to understand the impact of truncated partnership data on mean degree estimation. RESULTS: The retrospective method yielded similar degree estimates to the current for months proximate to the day of survey. The retrospective method mean degree systematically decreased as the month increased from 0 to 12 months before survey date. This was driven by data truncation: among participants with >5 partners in the past year compared with those with ≤5, the average change in main partnership degree between 12 and 0 months before survey date was -0.05 (95% confidence interval, -0.08 to -0.03) after adjusting for race/ethnicity, age, and education. The adjusted average change in casual partnership degree was -0.40 (95% confidence interval, -0.45 to -0.35). CONCLUSIONS: The retrospective method underestimates mean degree for MSM in surveys with truncated partnership data, especially for casual partnerships. The current method is less prone to bias from partner truncation when the target population has high rate of partners per year.

Buprenorphine dispensing in an epicenter of the U.S. opioid epidemic: A case study of the rural risk environment in Appalachian Kentucky.

BACKGROUND: Buprenorphine is a cornerstone to curbing opioid epidemics, but emerging data suggest that rural pharmacists in the US sometimes refuse to dispense this medication. We conducted a case study to explore buprenorphine dispensing practices in 12 rural Appalachian Kentucky counties, and analyze whether and how they were shaped by features of the rural risk environment. METHODS: In this case study, we conducted one-on-one semi-structured interviews with 14 pharmacists operating 15 pharmacies in these counties to explore buprenorphine dispensing practices and perceived influences on these practices. Thematic analyses of the resulting transcripts revealed three features of the rural risk environment that shaped dispensing. To explore these three risk environment features, we analyzed policy documents (e.g., Attorney General lawsuits) and administrative databases (e.g., incarceration data). Textual documents were analyzed using thematic analyses and administrative data were analyzed using descriptive statistics; memoes explored relationships among risk environment features and dispensing practices. RESULTS: Twelve of the 15 pharmacies limited dispensing, by refusing to serve new patients; limiting dispensing to known patients or prescribers; or refusing to dispense buprenorphine altogether. Concerns about exceeding a "Drug Enforcement Administration (DEA) cap" on opioid dispensing stifled dispensing. A legacy of aggressive and fraudulent marketing of opioid analgesics (OAs) by pharmaceutical companies and physician OA overprescribing undermined pharmacist trust in buprenorphine and in its prescribers. The escalating local war on drugs may have undermined dispensing by reinforcing stigma against people who use drugs. CONCLUSIONS: Initiatives to increase buprenorphine prescribing must be accompanied by policy changes to increase dispensing. Specifically, buprenorphine should be removed from opioid monitoring systems; efforts to de-escalate the war on drugs should be extended to encompass rural areas; initiatives to dismantle aggressive OA marketing should be strengthened; and efforts to re-build pharmacist trust in physicians are needed.