HIV and Hepatitis C Among People Who Inject Drugs in Memphis, Tennessee: an Intersectional Risk Environment Analysis of the Social Determinants of Health.

BACKGROUND: The Southern US is confronting bourgeoning HIV and hepatitis C virus (HCV) epidemics among people who inject drugs (PWID), yet little is known about shared and unique risk factors across the region. We applied an intersectional risk environment framework to understand infectious disease outcomes for sub-groups of PWID that experience multiple axes of social marginalization related to racial and ethnic identity and social and economic vulnerability. METHODS: HIV and HCV prevalence was estimated from the first iteration of the CDC's National HIV Behavioral Surveillance respondent driven sample of PWID in Shelby County, Tennessee in 2018. We ran adjusted multinomial models to test main and interaction effects of race/ethnicity and structural factors on the prevalence of a three-level outcome: HIV-only, HCV-only, and no infection. RESULTS: A total of 564 PWID participated, 558 (99%) completed HIV testing, and 540 (96%) HCV testing. Thirty (5%) were HIV-positive, 224 (40%) HCV-positive, and less than 1% were co-infected. Descriptive differences by race/ethnicity and levels of structural vulnerability for HIV and HCV subpopulations were present; however, there was no evidence for statistical interaction. In the final main effects model, HIV status was positively associated with non-Hispanic Black identity (aRR 4.95, 95% CI 1.19, 20.6), whereas HCV status was associated with non-white identity (aRR 0.11 95% CI 0.07, 0.18). Factors associated with HCV infection were higher scores of structural vulnerability (aRR 2.19 95% CI 1.10, 4.35), and criminal legal involvement (aOR 1.99 95% CI 1.18, 3.37). CONCLUSION: This is the first study to implement local population-based survey data to evaluate distinctive intersections of ethnic/racial and social factors associated with HIV and HCV status among PWID in the Memphis region. Findings come at an opportune time as harm reduction programs are in development in the South and shed light to the need for socially equitable race conscious resource investment.

Patterns of primary healthcare use among female exotic dancers in Baltimore, Maryland.

Female exotic dancers (FEDs) are often exposed to violence-, sex- and drug-related occupational harms and are precluded from employer-based health insurance. We examined access to primary health-care resources, correlates of use, and service needs among a sample of new FEDs (N = 117) working in 22 exotic dance clubs (EDCs) in Baltimore, MD. Self-administered surveys were completed between May and October 2014. Health care measures were aggregated and described, and correlates of use were evaluated using Fisher Exact and Poisson regression with robust variance, adjusting for race/ethnicity. The majority of dancers reported having health insurance (80%), a primary care provider (PCP) (68%), and having visited a PCP (74%). Among dancers with insurance, all were covered by Medicaid. Multivariable regression models demonstrated that having a regular PCP was associated with recent PCP use (adjusted prevalence ratio 1.5; 95% confidence interval: 1.1, 2.1). Despite a high level of health-care coverage and recent visits to PCP, dancers frequently sought services at the emergency department and reported needs for medical care, including mental health support services and drug treatment. Findings highlight that basic access to primary health care is available and used but may not be fully meeting dancers' complex needs.

Evaluating a Dyadic Intervention on Risk Reduction Among People Who Inject Drugs.

Among 100 people who inject drugs enrolled in a peer mentorship intervention aiming to promote injection-related risk reduction behavior change, we evaluated the role of participation in a dyad session on reducing sharing of syringes and cookers in the past 6 months. Dyad participants (n = 69) invited an injection, sex partner, or family member to the study site to reinforce learnt behavior change tools by practicing communication skills and risk reduction lessons. In all, 31 participants did not participate in the dyad session. We descriptively assessed changes in sharing injection equipment between the 2 time points of pre- and postintervention using the tests of proportions by dyad participation. Multivariable logistic regression adjusted for sex was used with an interaction term (time points × dyad participation) to evaluate the dyad effect. Dyad participants reported reduced syringe and cooker sharing at postintervention (sharing syringe: 17% versus 39%, P < .05 and cooker: 32% versus 59%, P < .01). There was no difference between the dyad group's sharing injection equipment behavior after the intervention (sharing syringes: adjusted odds ratio [aOR] 0.76; 95% confidence interval [CI] 0.1-3.9 and cookers: aOR 0.72; 95% CI 0.1-3.5). The role of the dyad session alone on risk taking was not effective. With a small sample size, it is important to continue to evaluate the nature of peer-based dyadic experiences in future studies.

HIV and Viral Hepatitis Among Imprisoned Key Populations.

Prisons and other closed facilities create opportunities for transmission of human immunodeficiency virus (HIV) and viral hepatitis during detention and after release. We conducted a systematic review and meta-analysis of peer-reviewed publications (2005-2015) to describe the prevalence of HIV, hepatitis C virus, and hepatitis B virus among key populations in prisons worldwide and to compare estimates of infection with those of other prison populations. Most data were reported for people who inject drugs (PWID; n = 72) and for men who have sex with men (MSM; n = 21); few data were reported on sex workers (SW; n = 6), or transgender women (n = 2). Publications were identified from 29 countries, predominantly middle- and high-income countries. Globally, PWID had 6 times the prevalence of HIV (pooled prevalence ratio (PPR) = 6.0, 95% CI: 3.8, 9.4), 8 times the prevalence of hepatitis C virus (PPR = 8.1, 95% CI: 6.4, 10.4), and 2 times the prevalence of hepatitis B virus (PPR = 2.0, 95% CI: 1.5, 2.7) compared with noninjecting prisoner populations. Among these articles, only those from Iran, Scotland, Spain, and Italy included the availability of methadone therapy; 2 articles included information on access to needle exchange programs by PWID detainees. HIV prevalence was more than 2 times higher among SW (PPR = 2.6, 95% CI: 2.2, 3.1) and 5 times higher among MSM (PPR = 5.3, 95% CI: 3.5, 7.9) compared with other prisoners. None of these articles reported HIV prevention coverage among SW or transgender women; 1 described HIV and sexually transmitted infection screening for MSM in prison. Prevention programs specific to key populations are important, particularly for populations that are criminalized and/or may cycle in and out of prison.

Acceptability and feasibility of a Peer Mentor program to train young Black men who have sex with men to promote HIV and STI home-testing to their social network members.

Young Black men who have sex with men (YBMSM) experience persistently high rates of undiagnosed HIV and other sexually transmitted infections (STIs) and testing rates remain sub-optimal. Home-based testing (HBT) has been found to be acceptable among MSM and while awareness about HBT is relatively high, uptake has been low. Peer-based approaches have been shown to be effective in reducing HIV risk behavior, yet have not been used to increase utilization of HBT. The purpose of this study was to assess acceptability and feasibility of a program to train YBMSM as Peer Mentors to use and promote HIV and STI home-based testing and specimen collection to their social network members. Fifteen YBMSM ages 18-30 completed in-depth structured interviews and were asked to talk with their social network members about home-based testing. Participants reported acceptability of the Peer Mentor role and two-thirds had conversations with diverse social network members (e.g., male and female, sex partners, friends, family). Facilitators of peer outreach included the novelty of home-based testing, confidence about accuracy of the tests, and resources for linkage to care. Barriers included concerns about negative responses and disclosure of sexual identity/behavior. Results of this study suggest that YBMSM are willing and able to promote HBT to their social networks. This is a promising approach to increasing dissemination of HBT kits for both HIV and STI testing.

Enduring Consequences From the War on Drugs: How Policing Practices Impact HIV Risk Among People Who Inject Drugs in Baltimore City.

BACKGROUND: Neighborhood-level characteristics, including police activity, are associated with HIV and Hepatitis C injection risk-behaviors among people who inject drugs (PWID). However, the pathways through which these neighborhood perceptions shape individual-level HIV risk behaviors are unclear. This study helps to explain perceived behaviors between perceived neighborhood police activity and HIV injection risk behavior (i.e., injection syringe/tool sharing in the previous 6 months). METHODS: A sample of (n = 366) PWIDs who self-reported recent use were recruited using community-based outreach methods in Baltimore, Maryland. Neighborhood police perceptions were assessed by asking participants whether they would (1) be more likely to ask others to share injection tools in the context of heightened police activity and (2) be less likely to carry syringes with them due to fear of arrest. Poisson regression with robust variance was used to identify statistical relationships. Recent police encounters, frequency of heroin injection, and sociodemographic characteristics were controlled for in the model. RESULTS: Neighborhood police perceptions shaped injection-risk behavior. Half of the sample (49%) reported an aversion of carrying personal syringes, due to fear of arrest. Those who agreed they would be more likely to ask others to share injection equipment in the context of heightened police activity were more likely to share syringes (21% vs. 3%, p <.01). Adjusted models showed that syringe sharing was independently associated with asking to borrow equipment in neighborhoods with perceived heightened police activity (aPR: 2.22, 95% confidence interval (CI): 1.7, 3.0). CONCLUSION: This study sheds light on how police perceptions may influence injection risk behavior. While these relationships require further elucidation, this study suggests that public health interventions aiming to reduce HIV risk would benefit from improving community-police relationships.