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A large body of research has identified peer exposure as a key factor driving adolescent substance use. However, findings on the role of sex partners are less robust and mixed. This study aims to fill this gap by examining the independent contribution of close friends' and sex partners' alcohol and marijuana use on adolescents' use of these substances. A secondary data analysis of social network data collected in 2000-2002 from a household sample of African American youth (14-19 years old) in the Bayview and Hunter's Point neighborhoods of San Francisco was conducted. Index participants and their nominated close friends and romantic sex partners (N = 104 triads) self-reported recent alcohol and marijuana use (defined as any use in the past 3 months). Generalized estimated equations were used to estimate the independent association between adolescent's recent substance use and their friend's and sex partner's use. Adolescents with a marijuana-using romantic sex partner had a nearly six-fold higher odds of using marijuana compared to adolescents with a non-using partner, controlling for close friend's marijuana use and other confounders [OR:5.69, 95%CI: 1.94, 16.7]; no association with close friend's marijuana use was found. A similar pattern was observed for alcohol use. Adolescents with an alcohol-using romantic sex partner had increased odds of using alcohol compared to adolescents with a non-using partner, controlling for close friend's alcohol use and other confounders [OR:2.40, 95%CI: 1.02, 5.63]; no association with close friend's alcohol use was found. Romantic sex partners may play a unique and significant role in adolescent substance use. Peer-focused interventions may be more effective if they consider romantic sex partners. Future research should consider the role of romantic sex partners in changing social context related to substance use from adolescence to young adulthood., (© 2023. Society for Prevention Research.)

Adolescents and young adults (AYA) 13-24 years old make up a disproportionate 21% of new HIV diagnoses. Unfortunately, they are less likely to treat HIV effectively, with only 30% achieving viral suppression, limiting efforts to interrupt HIV transmission. Previous work with mindfulness-based stress reduction (MBSR) has shown promise for improving treatment in AYA living with HIV (AYALH). This randomized controlled trial compared MBSR with general health education (HT). Seventy-four 13-24-year-old AYALH conducted baseline data collection and were randomized to nine sessions of MBSR or HT. Data were collected at baseline, post-program (3 months), 6 and 12 months on mindfulness and HIV management [medication adherence (MA), HIV viral load (HIV VL), and CD4]. Longitudinal analyses were conducted. The MBSR arm reported higher mindfulness at baseline. Participants were average 20.5 years old, 92% non-Hispanic Black, 51% male, 46% female, and 3% transgender. Post-program, MBSR participants had greater increases than HT in MA ( p  = 0.001) and decreased HIV VL ( p  = 0.052). MBSR participants showed decreased mindfulness at follow-up. Given the significant challenges related to HIV treatment in AYALH, these findings suggest that MBSR may play a role in improving HIV MA and decreasing HIV VL. Additional research is merited to investigate MBSR further for this important population.

Purpose: Trust is an essential component of romantic relationships. It is not understood how youth respond to a relationship stressor, which may impact trust, such as perceiving to be at risk for a sexually transmitted infection or their partner has other sex partners. We used a system science approach to examine feedback between trust and prorelationship behaviors within adolescent relationships., Methods: A prospective cohort of clinic-recruited young women (N = 122), aged 16-19 years, completed daily questionnaires on partner-specific feelings and risk perceptions for 18 months. Relationship stressor defined as either perceiving the risk of sexually transmitted infection from a partner or partner had other sex partners. Prorelationship behaviors were more time spent with partner, sex with partner, and/or gift from partner. Time-lagged generalized estimating equation models were used to examine whether a relationship stressor is associated with a decrease in trust and whether prorelationship behaviors changed following the stressor., Results: Experiencing a stressor was associated with threefold increased odds of having a decrease in trust in the same week (odds ratio [OR] = 3.30, 95% confidence interval [CI]: 2.30-4.72). Trust increased significantly the week following the stressor (OR = 2.09, 95% CI: 1.54-2.85). An increase in trust relative to the week of the stressor was associated with a 65% increase in prorelationship behavior in the week following the stressor (OR = 1.65, 95% CI: 1.20-2.26)., Conclusions: Data uniquely show that trust is impacted following a relationship stressor and that youth increase prorelationship behaviors following a drop in trust. The findings suggest that adolescents prioritize maintaining trust, which may impact engagement in protective health behaviors., (Copyright © 2020 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Syphilis and gonorrhea reached an all-time high in 2018. The resurgence of syphilis and gonorrhea requires innovative methods of sexual contact tracing that encourage disclosure of same-sex sexual contacts that might otherwise be suppressed. Over 75% of Grindr mobile phone application users report seeking "friendship," so this study asked people diagnosed with syphilis and gonorrhea to identify their friends., Methods: Patients at the two Baltimore sexually transmitted infection (STI) clinics and the Baltimore City Health Department were asked 12 questions to elicit members of their friendship networks before eliciting sexual networks. The study included 353 index cases and 172 friendship contacts, yielding a friendship network of 331 non-isolates (n = 331) and sexual-only network of 140 non-isolates. The data were plotted and analyzed using exponential family random graph analysis., Results: Eliciting respondents' in-person social contacts yielded 12 syphilis cases and 6 gonorrhea cases in addition to the 16 syphilis cases and 4 gonorrhea cases that would have been found with sexual contacts alone. Syphilis is clustered within sexual (odds ratio = 2.2, 95% confidence interval (1.36, 3.66)) and social contacts (OR = 1.31, 95% CI (1.02, 1.68)). Gonorrhea is clustered within reported social (OR = 1.56, 95% CI (1.22, 2.00)) but not sexual contacts (OR = 0.98, 95% CI (0.62, 1.53))., Conclusions: Eliciting friendship networks of people diagnosed with syphilis and gonorrhea may find members of their sexual networks, drug use networks, or people of similar STI risk. Friendship networks include more diagnosed cases of syphilis and gonorrhea than sexual networks alone, especially among populations with many non-disclosing men who have sex with men (MSM) and women who have sex with women (WSW). Future research should evaluate whether this friendship network method of contact tracing can be implemented by adapting automated mobile phone COVID-19 contact tracing protocols, if these COVID-19 contact tracing methods are able to maintain anonymity and public trust.

In the United States, youth aged 13-24 comprised approximately 21% of new HIV infections in 2017; 13% of these infections occurred among women, the majority of whom (86%) acquired HIV through heterosexual contact (Centers for Disease Control and Prevention. 2019a. HIV and youth . Retrieved from https://www.cdc.gov/hiv/group/age/youth/index.html, Centers for Disease Control and Prevention. 2019b. HIV among women . Retrieved from https://www.cdc.gov/hiv/group/gender/women/index.html). We fit and validated a developmentally appropriate empirical model of Connell's Theory of Gender and Power (Connell, R. W. 1987. Gender and power: Society, the person and sexual politics . Stanford, CA: Stanford University Press, Connell, R. W. 2013. Gender and power: Society, the person and sexual politics . Hoboken, NJ: John Wiley & Sons) in a sample of young women and assessed whether gendered powerlessness reflected a multidimensional higher-order latent factor, as the theory implies. Anonymous computer-assisted interviews were administered to at-risk, sexually active young women ( N  = 1,101). Factor analyses and structural equation modeling were used to determine the dimensionality of gendered powerlessness. Associations with condom use were examined to validate the model. We fit a three-component model of gendered powerlessness, but not a higher-order latent factor. We observed that high scores on two dimensions of gendered powerlessness - cathexis and sexual division of power - were associated with lower likelihood of condom use. Our three-component model helps elucidate the role that components of gendered powerlessness play in young women's health behaviors and underscores the need for measures tailored to young women at high risk of contracting HIV.

Generalized perceived powerlessness is an important psychosocial construct that determines a wide range of health behaviors and outcomes. This study has two aims: (1) examine the structure of the newly developed perceived powerlessness scale using exploratory and confirmatory factor analyses and (2) assess the scale's invariance across key demographic variables using multi-group confirmatory factor analysis among a random household sample of African American and White youth (aged 15-24 years) residing in Baltimore, MD. Our study results demonstrated that the powerlessness scale is valid among a demographically diverse sample of urban youth, showing promise for use in future health behavior and outcome studies.

Purpose: To examine how interpersonal factors are associated with family, peer, and partner social support among urban female adolescents in sexual relationships., Design: Secondary data analysis of cross-sectional data., Setting: Two urban health clinics and community sites in Baltimore, Maryland., Participants: One hundred sixteen female adolescents (ages 16-19) with 131 heterosexual relationships from the Perceived Risk of Sexually Transmitted Diseases cohort., Measures: Interpersonal factors included parental monitoring, friend-partner connectedness, and feelings of intimacy for partner. Social support was measured using the Multidimensional Scale of Perceived Social Support with family, peer, and partner subdomains., Analysis: Multivariable linear regression models using baseline data and accounting for clustering of partners., Results: Adolescents perceived high levels of family, peer, and partner support, with the greatest coming from partners (range: 1-5; family mean: 4.0 [95% confidence interval, CI: 3.83-4.18]; peer mean: 4.2 [95% CI: 4.05-4.33]; partner mean: 4.5 [95% CI: 4.36-4.60]). Parental monitoring and friend-partner connectedness were significantly associated with greater family ( b = 0.11, standard error [SE] = 0.03, P = 0.001; b = 0.15, SE = 0.06, P = .02) and peer support ( b = 0.06, SE = 0.02, P = .01; b = 0.29, SE = 0.07, P < .001). Feelings of intimacy for partner was significantly associated with greater partner support ( b = 0.08, SE = 0.03, P = .02)., Conclusion: Feeling connected to one's social network and having a connected network is an important contribution to social support for urban female adolescents in sexual relationships. Future research targeting interpersonal factors is warranted, as it may result in increased social support and promote positive sexual health behaviors in an urban female adolescent population.

A distal psychosocial factor, perceived powerlessness, has been found to predict various sexual risk behaviors among youth, yet no studies have assessed mediators or moderators in this relationship. Using a demographically diverse, longitudinal sample of urban youth (N = 257), this study assessed whether the need for sexual validation mediates the relationship between perceived powerlessness and sexual risk behaviors and to assess whether this mediated pathway is moderated by socioeconomic status and gender. The mean age of the participants was 21 years old (range: 15-24) and the majority of the sample identified as Black (65%) and female (62%). The results of structural equation modeling showed that the need for sexual validation mediated perceived powerlessness and condomless sex at last sex among Black youth. The need for sexual validation mediated perceived powerlessness and concurrent sexual partnerships among White youth and depended on levels of socioeconomic status. Sexual risk behavior interventions should provide youth with increased opportunities that encourage feelings of validation from other personal achievements in addition to sex while simultaneously addressing the structural conditions that drive young people to feel powerless.

Study Objective: To compare clinician perspectives for the treatment of pelvic inflammatory disease (PID) with those of adolescent patients and parents., Design: Cross-sectional study., Setting: Urban academic pediatric and adolescent medicine practices and school-based health clinics in a large urban community with a high prevalence of sexually transmitted infections and a national sample of adolescent-serving clinicians., Participants: Female patients aged 12-19 years, parents raising an adolescent older than the age of 12 years in the urban community, and clinicians who serve adolescents recruited from regional and national listservs., Interventions: None., Main Outcome Measures: Visual analogue scale scores on a scale of 0-10 corresponding to preferences on patient disposition in 17 clinical scenarios for a hypothetical patient with PID., Results: Compared with adolescents, clinicians were significantly more likely to endorse hospitalizations when patients presented with severe or complicated illness (β = 0.9; standard error [SE], 0.22; P < .001), possible surgical emergency (β = 0.83; SE, 0.2; P < .001), concurrent pregnancy (β = 0.59; SE, 0.3; P = .046), or failure of outpatient treatment (β = 0.58; SE, 0.29; P = .045). Compared with clinicians, adolescents were significantly more likely to endorse hospitalizations when patients presented at a young age (β = 1.36; SE, 0.38; P < .001), were homeless (β = 0.88; SE, 0.32; P = .007), were afraid to inform a partner (β = 1.66; SE, 0.40; P < .001), or had unaware parents (β = 2.86; SE, 0.39; P < .001)., Conclusion: Clinicians were more likely to recommend hospitalization when doing so adhered to national guidelines on PID treatment. Adolescents opted for hospitalization more often than clinicians in scenarios in which patients exhibited social vulnerability. Clinicians should engage with adolescents in shared disposition planning and use a more nuanced approach to PID management for adolescents who might not be able to tolerate an outpatient regimen., (Copyright © 2019 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

This study explored the influence of STI history on childbearing motivations, fertility beliefs, current childbearing desires, and contraception use among urban African-American adolescents and young adults (AYA). Secondary data were from the Neighborhood Influences on Adolescent and Young Adult Health (NIAAH) study, conducted from 2004 to 2007. Sample included 517 AYA ages 15-24 years (male: n = 199, female: n = 318). Linear and logistic regression models examined gender differences in childbearing motivations (CBM) and desires, fertility beliefs, condom, and contraception use. Logistic regression models were constructed to examine age, pregnancy history, and STI fertility knowledge as potential confounders. AYA men (3.29) and AYA women (3.23) had similar CBM mean scores. AYA women had more positive CBM and used condoms less. Condom use was not associated with CBM among AYA men (OR = 0.71, p = 0.069). Low beliefs about fertility (OR = 0.52, p = 0.003) and prior pregnancy (OR = 5.27, p = 0.002) were associated with current childbearing desires among AYA women. AYA men's low fertility beliefs were only associated with current childbearing desires (OR = 0.56, p = 0.044). AYA men reported more contraception use (67.46 vs. 55.04%), especially with no partner pregnancy history (OR = 0.26, p = 0.017). Younger men (15 to 18 years old) reported more contraception or condom use compared to older AYA men (19-25 years old) (OR = 0.40, p = 0.016). Young men reporting a partner's prior pregnancy used fewer condoms or contraception (OR = 0.23, p = 0.028). STI history did not influence CBM in this sample of urban youth. Prior pregnancy experiences and chronological age, however, were important milestones shaping proximal motivations and desires to bear children, beliefs about fertility, and contraception behaviors.

Few studies have examined sexual partnerships and HIV risk in diverse samples of African American/black and Hispanic/Latino adolescent and young adult men who have sex with men (YMSM), a group that have a high burden of HIV in the U.S. A community-venue recruitment approach was used, which identified significant differences in HIV risk by sexual partner type among 1215 YMSM. Those with casual partners had a higher number of sexual partners, had more STIs, and were more likely to engage in transactional sex, to use alcohol, marijuana, or other substances compared with those with main partners only. Among those with female sexual partners, many used condoms "every time" when engaging in vaginal sex with casual partners, but a sizeable proportion "never/rarely" used condoms with their main partners. Our findings demonstrate a need for tailored HIV prevention education and counseling with necessary skills regarding consistent and correct condom use with all sexual partnerships.

Objectives: Feelings of intimacy, perceptions of partner concurrency (PPC) and perceptions of risk for an STD (PRSTD) are meaningful and dynamic attributes of adolescent sexual relationships. Our objective was to examine whether variations in these STI-associated feelings and perceptions predicted incident Chlamydia trachomatis and/or Neisseriagonorrhoeae infection within a prospective cohort of urban adolescent women., Methods: A cohort of clinic-recruited women aged 16-19 completed daily surveys on feelings and risk perceptions about each current sex partner on a smartphone continuously for up to 18 months. Urine was tested for C. trachomatis and N. gonorrhoeae every 3 months. Daily responses were averaged across the week. As overall means for trust, closeness and commitment were high, data were coded to indicate any decrease in feelings from the previous week. PRSTD and PPC were reverse coded to indicate any increase from the previous week. An index was created to examine the cumulative effect of variation in these feelings and perceptions. Generalised linear models were used to account for correlation among repeated measures within relationships., Results: For each week that there was a decrease in trust, there was a 45% increase in the risk of being infected with an STI at follow-up (relative risk (RR) 1.45, 95% CI 1.18 to 1.78, P=0.004). Neither a decrease in closeness or commitment, nor an increase in PRSTD or PPC was associated with an STI outcome. Cumulatively, the index measure indicated that a change in an additional feeling or perception over the week increased the odds of an STI by 14% (RR 1.14, 95% CI 1.02 to 1.29, P=0.026)., Conclusions: A decrease in feelings of trust towards a main partner may be a more sensitive indicator of STI risk than PRSTD, PPC or commitment. The next generation of behavioural interventions for youth will need strategies to address feelings of intimacy within adolescent romantic relationships., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

We proposed a multilevel model of structural influences on HIV-risky sexual partnerships in a diverse sample of 1793 youth residing in 23 states and the District of Columbia. We examined the influence of concentrated disadvantage, HIV stigma, and sexual and gender minority stigma on engagement in HIV risky sexual partnerships and whether youth's participation in opportunity structures, anticipation of HIV stigma, and perceptions of their community as youth-supportive settings mediated structural effects. After controlling for age, HIV status, and race, we found structural HIV stigma had deleterious indirect effects on youth's participation in HIV-risky sexual partnerships. Concentrated disadvantage and structural sexual and gender minority stigma had direct negative effects on youth's perceptions of their communities as supportive and on their participation in prosocial activity. Support perceptions had direct, protective effects on avoidance of HIV-risky sexual partnerships. Structural stigma undermines youth's belief that their communities invest in their safety and well-being.

Youth living with HIV have sub-optimal rates of adherence to antiretroviral therapy (ART). Mindfulness instruction interventions have shown promise for improving medication adherence, but the effects and mechanisms of these interventions are still being explored among people living with HIV, including youth. In the context of a randomized controlled trial of the efficacy of a Mindfulness-Based Stress Reduction (MBSR) program on ART adherence and viral suppression among youth living with HIV, we conducted 44 iterative, semi-structured, in-depth interviews with 20 study participants (13-24 years) recruited from clinics at two academic centers in Baltimore, Maryland. Interviews explored the social context and psychosocial dynamics of ART adherence in the context of the MBSR intervention, compared with those in a control arm. We employed thematic content analysis to systematically code and synthesize textual interview data. Participants' challenges with ART adherence were often situated within an ongoing process of working to manage HIV as a stigmatized, chronic condition in addition to other intersecting social stigmas, inequalities, and stressors. Participation in the MBSR program and related group support allowed participants to non-judgmentally observe and accept difficult thoughts, feelings, and experiences associated with living with HIV and taking ART, which facilitated greater reported adherence. Mindfulness training may stimulate new perspectives and understanding, including greater self- and illness-acceptance among youth living with HIV, leading to improved HIV outcomes.

Background: Despite the large body of extant literature on sexually transmitted infections (STIs) in adolescents and young adults (AYAs), more research on social and environmental contextual factors is needed. Also, further examination of STI indicators by gender remains a critical area of research focus., Methods: Anonymous survey data were collected using audio computer-assisted self-interviews in community venues in urban, low-income, STI prevalent, US neighborhoods to reach AYAs, aged 12 to 24 years. Conventional descriptive statistics, bivariate analysis, and multiple logistical regression models were used to assess indicators of a self-reported lifetime prevalence of STIs., Results: Participants (N = 1540) were on average 20.6 years; 57.2% were women, the majority were racial and ethnic minorities (92%), and almost half (49.2%) identified as sexual minorities. Nearly one third (32.%) had 1 or more STIs. As expected, gender differences were identified. For AYA men, being African American/Black, moving residences more than 4 times since kindergarten, and having a history of human immunodeficiency virus testing were each positively associated with STIs. Also, those who strongly disagreed that many young people in their community exchanged sex for money had a significantly lower likelihood of having an STI. For AYA women, exchanging sex for drugs or money, lacking money, which prevented activities, and using marijuana were each associated with STIs., Conclusions: This research extends our understanding of social and environmental contextual influences on AYAs' risk for STIs. It highlights differences in risk exposures that are distinctly different for AYA women and men, suggesting the need for tailored interventions to address their unique economic needs and social challenges.

Background: Use of methamphetamines (MA) and other stimulants have consistently been associated with HIV/STI risk globally. We evaluated a community mobilization intervention (Connect to Protect, C2P ® ) to prevent MA use among youth and reduce HIV risk behaviors through community structural changes., Design: A community-randomized trial in northern Thailand with matched districts randomized to C2P intervention or a standard voluntary counseling and testing (VCT) control. Intervention districts formed stakeholders' coalitions to plan tailored local prevention programs. Two independent random household samples of youth aged 14-24 were surveyed in 2009 and 2012. Lifetime and recent MA use was modeled with multilevel logistic regression., Results: Intervention initiatives included family-strengthening programs, school-based programs and opening a community drug treatment center. Control communities applied the government-led "war on drugs" approach in addition to youth and family programs. Baseline (N = 1077) and follow-up (N = 1225) samples included 47.5% females and 21.7% aged ≤16. Lifetime MA use in intervention districts reduced from 13.4% to 11.7% compared to reduction from 16.2% to 10.4% in the control districts (non-significant). In models, lifetime MA use was associated with: time (aOR = 0.6, 95%CI: 0.38-0.83), females (aOR = 0.2, 95%CI: 0.15-0.29), increasing age (aOR = 2.4, 95%CI: 1.40-4.20, ages 16-19; aOR = 3.5, 95%CI: 2.00-6.12, ages ≥20), and not being full-time students (aOR = 5.3, 95%CI: 3.77-7.37). Recent MA use showed similar results. Additionally, lifetime MA use was significantly associated with alcohol use, risky sexual behaviors and elevated depressive symptoms., Conclusions: Delay in developing and implementing specific prevention programs in the intervention districts slowed diffusion of the effect into the communities. Secular trends with contentious civil unrest and active drug-enforcement efforts in the control communities also contributed to the null intervention effect. Longer time and intensified efforts stressing a public health approach are needed to demonstrate the effectiveness of community mobilization in reducing substance use and HIV risk in this rural Thai community., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

HIV-infected youth experience many stressors, including stress related to their illness, which can negatively impact their mental and physical health. Therefore, there is a significant need to identify potentially effective interventions to improve stress management, coping, and self-regulation. The object of the study was to assess the effect of a mindfulness-based stress reduction (MBSR) program compared to an active control group on psychological symptoms and HIV disease management in youth utilizing a randomized controlled trial. Seventy-two HIV-infected adolescents, ages 14-22 (mean age 18.71 years), were enrolled from two urban clinics and randomized to MBSR or an active control. Data were collected on mindfulness, stress, self-regulation, psychological symptoms, medication adherence, and cognitive flexibility at baseline, post-program, and 3-month follow-up. CD4+ T lymphocyte and HIV viral load (HIV VL) counts were also pulled from medical records. HIV-infected youth in the MBSR group reported higher levels of mindfulness (P = .03), problem-solving coping (P = .03), and life satisfaction (P = .047), and lower aggression (P = .002) than those in the control group at the 3-month follow-up. At post-program, MBSR participants had higher cognitive accuracy when faced with negative emotion stimuli (P = .02). Also, those in the MBSR study arm were more likely to have or maintain reductions in HIV VL at 3-month follow-up than those in the control group (P = .04). In our sample, MBSR instruction proved beneficial for important psychological and HIV-disease outcomes, even when compared with an active control condition. Lower HIV VL levels suggest improved HIV disease control, possibly due to higher levels of HIV medication adherence, which is of great significance in both HIV treatment and prevention. Additional research is needed to explore further the role of MBSR for improving the psychological and physical health of HIV-positive youth.

Adolescents and young adults living with HIV (YLHIV) face numerous stresses that affect their care and medication adherence. The clinic social environment may play an important supportive role for YLHIV, influencing health outcomes. The aim of this article is to explore how YLHIV in Baltimore, Maryland understand the various forms of social support provided within the social environment of their HIV clinic. We used qualitative research methods including iterative, semi-structured in-depth interviews with 20 YLHIV interviewed up to three times each to explore HIV stressors, support systems, and medication adherence. We employed thematic content analysis to systematically code and synthesize textual interview data. We found that YLHIV experienced social embeddedness with their healthcare teams and through clinic activities. Participants largely perceived these social connections as support, acknowledging that these supports are available to them when needed. Support was enacted through the provision of instrumental support for issues outside of the young person's medical care (i.e., finding a crib for a participant's baby), appraisal (i.e., through respect of the young person's agency and decision making), and information about their HIV care and medication. Support was not always well received, however, as some young people found the support from clinicians demeaning. Limitations of the clinic social support environment included concerns about trust and privacy, and perceiving support as inappropriate or unwanted. Participants identified a number of ways in which the clinic provided meaningful social support. Future research should explore how these supports may improve care and medication adherence of YLHIV.

Background: Young men who have been involved with the criminal justice system are more likely to have concurrent sexual partners, a key driver of sexually transmitted infections. The value men place on having sexual relationships to validate themselves may play an important role in understanding this association., Methods: Data were from a household survey. Young men (N = 132), aged 16 to 24 years, self-reported whether they ever spent time in jail or juvenile detention and if they had sexual partnerships that overlapped in time. A novel scale, "Validation through Sex and Sexual Relationships" (VTSSR) assessed the importance young men place on sex and sexual relationships (α = 0.91). Weighted logistic regression accounted for the sampling design., Results: The mean (SD) VTSSR score was 23.7 (8.8) with no differences by race. Both criminal justice involvement (CJI) (odds ratio [OR], 3.69; 95% confidence interval [CI], 1.12-12.1) and sexual validation (OR, 1.10; 95% CI, 1.04-1.16) were associated with an increased odds of concurrency; however, CJI did not remain associated with concurrency in the fully adjusted model. There was effect modification, CJI was associated with concurrency among those who scored high on sexual validation (OR, 9.18; 95% CI, 1.73-48.6]; however, there was no association among those who scored low on sexual validation. Racial differences were observed between CJI and concurrency, but not between sexual validation and concurrency., Conclusions: Sexual validation may be an important driver of concurrency for men who have been involved with the criminal justice system. Study findings have important implications on how sexual validation may explain racial differences in rates of concurrency.

We assessed the relationships among HIV-related social and behavioral outcomes resulting from an adolescent-focused HIV structural change initiative in eight urban sites operating Connect to Protect (C2P) coalitions. Over a 4-year period, annual cross-sectional panels of adolescents (N = 2,248) completed an audio-computer-assisted interview, providing data on satisfaction with their communities as adolescent-supportive environments, internalized HIV stigma, lifetime HIV-testing, lifetime sexual risk-taking, and number of sexual partners in the prior year. We used structural equation modeling to estimate hypothesized links between time since coalition mobilization to our social and behavioral outcomes. Over the 4 years, adolescents perceived their communities to become more supportive (p < .05). Positive perceptions of community support were associated with lower lifetime HIV sexual risk (p < .05). The effect of time on risk behavior was mediated by perceptions of community support. Stigma was unchanged over time. Stigma had damaging effects on risk behavior, effects which were also mediated by perceptions of community support. Special efforts are needed to address the deleterious effect of HIV stigma on high-risk urban adolescents., Competing Interests: The authors have no financial conflicts of interest to disclose.

Using an ecological perspective, we sought to elucidate the perceived barriers preventing HIV service access among two groups of U.S. youth (ages 12-24) disproportionately affected by HIV, men who have sex with men and high-risk women. We content analyzed interviews with 318 key informants to identify distinct service barriers. The 29 barriers informants named were organized into six categories (service-seeking demands, stigmas, knowledge and awareness, service quality, powerful opposition, and negative emotions). Findings suggest that barriers impacting access to HIV prevention, testing, and linkage-to-care services are remarkably similar and point to the need for comprehensive approaches to improving youth's access services that address both individual-level barriers and extra-individual barriers simultaneously. Findings can be used to guide future research, programming and interventions to reduce the disproportionate spread of HIV among US youth.

Background: Academic health systems and their investigators are challenged to systematically assure clinical research regulatory compliance. This challenge is heightened in the emerging era of centralized single Institutional Review Boards for multicenter studies, which rely on monitoring programs at each participating site., Objective: To describe the development, implementation, and outcome measurement of an institution-wide paired training curriculum and internal monitoring program for clinical research regulatory compliance., Methods: Standard operating procedures (SOPs) were developed to facilitate investigator and research professional adherence to institutional policies, federal guidelines, and international standards. An SOP training curriculum was developed and implemented institution-wide. An internal monitoring program was launched, utilizing risk-based monitoring plans of pre-specified frequency and intensity, assessed upon Institutional Review Boards approval of each prospective study. Monitoring plans were executed according to an additional SOP on internal monitoring, with monitoring findings captured in a REDCap database., Results: We observed few major violations across 3 key domains of clinical research conduct and demonstrated a meaningful decrease in the rates of nonmajor violations in each, over the course of 2 years., Conclusion: The paired training curriculum and monitoring program is a successful institution-wide clinical research regulatory compliance model that will continue to be refined., (© The Association for Clinical and Translational Science 2017.)

Connect to Protect (C2P), a 10-year community mobilization effort, pursued the dual aims of creating communities competent to address youth's HIV-related risks and removing structural barriers to youth health. We used Community Coalition Action Theory (CCAT) to examine the perceived contributions and accomplishments of 14 C2P coalitions. We interviewed 318 key informants, including youth and community leaders, to identify the features of coalitions' context and operation that facilitated and undermined their ability to achieve structural change and build communities' capability to manage their local adolescent HIV epidemic effectively. We coded the interviews using an a priori coding scheme informed by CCAT and scholarship on AIDS-competent communities. We found community mobilization efforts like C2P can contribute to addressing the structural factors that promote HIV-risk among youth and to community development. We describe how coalition leadership, collaborative synergy, capacity building, and local community context influence coalitions' ability to successfully implement HIV-related structural change, demonstrating empirical support for many of CCAT's propositions. We discuss implications for how community mobilization efforts might succeed in laying the foundation for an AIDS-competent community., (© Society for Community Research and Action 2017.)

Importance: Youths aged 13 to 24 years old living with human immunodeficiency virus (HIV) are less likely than adults to receive the health and prevention benefits of HIV treatments, with only a small proportion having achieved sustained viral suppression. These age-related disparities in HIV continuum of care are owing in part to the unique developmental issues of adolescents and young adults as well as the complexity and fragmentation of HIV care and related services. This article summarizes a national, multiagency, and multilevel approach to HIV care for newly diagnosed youths designed to bridge some of these fragmentations by addressing National HIV/AIDS Strategy goals for people living with HIV., Design, Setting, and Participants: Three federal agencies developed memoranda of understanding to sequentially implement 3 protocols addressing key National HIV/AIDS Strategy goals. The goals were addressed in the Adolescent Trials Network, with protocols implemented in 12 to 15 sites across the United States. Outcome data were collected from recently diagnosed youth referred to the program., Main Outcomes and Measures: Cross-agency collaboration, youth-friendly linkage to care services, community mobilization to address structural barriers to care, cooperation among services, proportion of all men who have sex with men who tested, and rates of linkage to prevention services., Results: The program addressed National HIV/AIDS Strategy goals 2 through 4 including steps within each goal. A total of 3986 HIV-positive youths were referred for care, with more than 75% linked to care within 6 weeks of referral, with almost 90% of those youths engaged in subsequent HIV care. Community mobilization efforts implemented and completed structural change objectives to address local barriers to care. Age and racial/ethnic group disparities were addressed through targeted training for culturally competent, youth-friendly care, and intensive motivational interviewing training., Conclusions and Relevance: A national program to address the National HIV/AIDS Strategy specifically for youths can improve coordination of federal resources as well as implement best-practice models that are adapted to decrease service fragmentation and systemic barriers at local jurisdictions.

Baltimore, Maryland ranks among U.S. cities with the highest incidence of HIV infection among men who have sex with men (MSM). HIV screening at sex partner meeting places or venues frequented by MSM with new diagnoses and/or high HIV viral load may reduce transmission by identifying and linking infected individuals to care. We investigated venue-based clustering of newly diagnosed MSM to identify high HIV transmission venues. HIV surveillance data from MSM diagnosed between October 2012-June 2014 and reporting ≥1 sex partner meeting place were examined. Venue viral load was defined according to the geometric mean viral load of the cluster of cases that reported the venue and classified as high (>50,000 copies/mL), moderate (1500-50,000 copies/mL), and low (<1500 copies/mL). 143 MSM provided information on ≥1 sex partner meeting place, accounting for 132 unique venues. Twenty-six venues were reported by > 1 MSM; of these, a tightly connected cluster of six moderate viral load sex partner meeting places emerged, representing 66% of reports. Small, dense networks of moderate to high viral load venues may be important for targeted HIV control among MSM., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

The National HIV/AIDS Strategy emphasizes rapid care linkage and engagement for HIV-infected individuals, though many adolescents are never tested, delay entering care, and frequently drop out. We conducted 183 staff interviews at 15 adolescent medicine clinics (baseline, n = 64; Year 1, n = 60; Year 2, = 59). We used a constant comparative thematic method to examine how providers approached and discussed care linkage/engagement. Qualitative analyses revealed differences in providers' conceptualizations of linkage and engagement. Providers saw linkage as mechanistic and health system driven. It was defined by number of clinic visits and involved relatively little youth agency. In contrast, providers defined engagement by youths' responsibility and participation in their own care. Linkage and engagement are related but distinct aspects of care that require different resources and levels of staff involvement. Integrating an understanding of these differences into future interventions will allow clinic staff to help youth improve long-term health outcomes.

The goal of this research was to examine associations among sociodemographic factors, HIV risk, and community context (e.g., economic insecurity, job training, housing instability, crime victimization, and perceived community norms) in adolescents and young adults who ever exchanged sex for drugs or money. Anonymous survey data were collected using ACASIs at community venues where adolescents and young adults congregate in resource-challenged, STI prevalent, urban, US neighborhoods. Conventional descriptive statistics, Fisher's exact tests, and generalized estimating equations approaches were used to examine associations. Participants (1818, 95.5 % of those screened eligible) were, on average, aged 21.0 years; 42.2 % were males, and 4.6 % were transgender. Almost one-third (32.1 %) identified as gay or lesbian, 18.1 % identified as bisexual; 66.2 % were Black and 21.0 % were Hispanic; 1.3 % was 'living on the street'. A sizeable proportion reported HIV-related risk: 16.3 % exchanged sex, 12.6 % had sex with someone they knew to be HIV-infected, 7.8 % had sex with someone who injected drugs, and 1.3 % injected drugs. Multivariate comparisons identified a number of variables (e.g., being male or transgender, homelessness, sex with a partner who has HIV, STI history, unemployment, job training access, housing instability, crime victimization, perceived community norms) that were significantly associated with exchange of sex (p < 0.05). This research contributes to the knowledge-base regarding exchange of sex among adolescents and young adults, particularly as it relates to community context. Longitudinal studies to describe the trajectory of social, health, and physical risks and consequences are needed for development of effective evidence-based prevention strategies., Competing Interests: The authors declare that they have no conflict of interest.

HIV disproportionately impacts young African American men who have sex with men (MSM). In this study, we sought to understand how previous relationship experiences and expectations for romantic relationships influence condom use among young African American MSM. Twenty African American MSM age 16 to 24 years completed a semi-structured interview and questionnaire on sexual experiences, romantic relationships, and sexual behavior. We identified three major themes characterizing romantic male-male relationships: (1) partner selection, (2) relationship ideals and expectations, and (3) relationship rules for condom use. Our findings indicate that young African American MSM rely on previous relationship experiences and desires for romantic relationships to determine condom use in subsequent relationships. Participants revealed that their previous relationship experiences and desires are often in conflict with their descriptions of their ideal romantic relationships, and subsequently influences their condom use. Our findings fill a gap in the literature describing male-male romantic relationships and condom use among young African American MSM.

Unlabelled: To maximize positive health outcomes for youth with HIV as they transition from youth to adult care, clinical staff need strategies and protocols to help youth maintain clinic engagement and medication adherence. Accordingly, this paper describe transition processes across twelve clinics within the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) to provide lessons learned and inform the development of transition protocols to improve health outcomes as youth shift from adolescent to adult HIV care., Design and Methods: During a large multi-method Care Initiative program evaluation, three annual visits were completed at each site from 2010-2012 and conducted 174 semi-structured interviews with clinical and program staff (baseline n=64, year 1 n=56, year 2=54)., Results: The results underscore the value of adhering to recent American Academy of Pediatrics (AAP) transition recommendations, including: developing formal transition protocols, preparing youth for transition, facilitating youth's connection to the adult clinic, and identifying necessary strategies for transition evaluation., Conclusions: Transitioning youth with HIV involves targeting individual-, provider-, and system-level factors. Acknowledging and addressing key barriers is essential for developing streamlined, comprehensive, and context-specific transition protocols., Practice Implications: Adolescent and adult clinic involvement in transition is essential to reduce service fragmentation, provide coordinated and continuous care, and support individual and community level health., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To examine how the time from HIV testing to care referral and from referral to care linkage influenced time to care engagement for newly diagnosed HIV-infected adolescents., Methods: We evaluated the Care Initiative, a care linkage and engagement program for HIV-infected adolescents in 15 US clinics. We analyzed client-level factors, provider type, and intervals from HIV testing to care referral and from referral to care linkage as predictors of care engagement. Engagement was defined as a second HIV-related medical visit within 16 weeks of initial HIV-related medical visit (linkage)., Results: At 32 months, 2143 youth had been referred. Of these, 866 were linked to care through the Care Initiative within 42 days and thus eligible for study inclusion. Of the linked youth, 90.8% were ultimately engaged in care. Time from HIV testing to referral (eg, ≤7 days versus >365 days) was associated with engagement [adjusted odds ratio = 2.91; 95% confidence interval (CI): 1.43 to 5.94] and shorter time to engagement (adjusted hazard ratio = 1.41; 95% CI: 1.11 to 1.79). Individuals with shorter care referral to linkage intervals (eg, ≤7 days versus 22-42 days) engaged in care faster (adjusted hazard ratio = 2.90; 95% CI: 2.34 to 3.60) and more successfully (adjusted odds ratio = 2.01; 95% CI: 1.04 to 3.89)., Conclusions: These data address a critical piece of the care continuum and can offer suggestions of where and with whom to intervene to best achieve the care engagement goals outlined in the US National HIV/AIDS Strategy. These results may also inform programs and policies that set concrete milestones and strategies for optimal care linkage timing for newly diagnosed adolescents.

Objectives: Qualitative research suggests that young women's relationships with the biological fathers of their children (BFRs), known colloquially as 'baby daddy' relationships, enable risk for pregnancy and STI/HIV. Our study compared partner characteristics and sexual risk within dyads based on BFR, among a sample of young women in Baltimore, Maryland, USA., Methods: We conducted secondary analysis of survey data collected in 2011-2013 from heterosexually experienced youth ages 15-24 in Baltimore, Maryland, USA. Analyses are limited to women with at least one recent (past 6 months) sex partner (n=171 participants, reporting on 271 relationships). Using generalised estimating equations with logit function for correlated binary responses, we evaluate associations of BFR with partner characteristics, sexual risk behaviour and contraceptive non-use., Results: At least one BFR partner was reported by 25.2%. Male partners in BFRs were more likely to have been incarcerated or arrested. BFRs were more often characterised by women as 'main' versus 'casual' partners (adjusted OR (AOR) 3.92, 95% CI 1.19 to 12.9). In adjusted analyses, BFR was associated with condom non-use for vaginal (AOR 12.3, 95% CI 3.92 to 38.7) and anal (AOR 3.32, 95% CI 1.34 to 8.22) intercourse. While BFR was associated with contraceptive non-use (AOR 2.21, 95% CI 1.01 to 4.84), this association attenuated to non-significance after adjusting for partnership type (AOR 2.06, 95% CI 0.91 to 4.67)., Conclusions: While few differences in BFR partner characteristics emerged, significantly greater risk for unprotected intercourse was identified within BFR relationships. Findings suggest that the relationship context of a shared child heightens sexual risk for the young women most affected by STI., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Reducing HIV incidence among adolescents represents an urgent global priority. Structural change approaches to HIV prevention may reduce youth risk by addressing the economic, social, cultural, and political factors that elevate it. We assessed whether achievement of structural changes made by eight Connect-to-Protect (C2P) coalitions were associated with improvements in youth's views of their community over the first 4 years of coalitions' mobilization. We recruited annual cross-sectional samples of targeted youth from each C2P community. We sampled youth in neighborhood venues. We interviewed a total of 2461 youth over 4 years. Males (66 %) and youth of color comprised the majority (52 % Hispanic/Latinos; 41 % African Americans) of those interviewed. By year 4, youth reported greater satisfaction with their community as a youth-supportive setting. They reported their needs were better met by available community resources compared with year 1. However, these findings were moderated by risk population such that those from communities where C2P focused on young men who have sex with men (YMSM) reported no changes over time whereas those from communities focused on other at-risk youth reported significant improvements over time in satisfaction and resource needs being met. Internalized HIV stigma increased over time among those from communities serving other at-risk youth and was unchanged among those from YMSM communities. The very different results we observe over time between communities focused on YMSM versus other at-risk youth may suggest it is unreasonable to assume identical chains of structural causality across youth populations who have such different historical relationships to HIV and who encounter very different kinds of entrenched discrimination within their communities.

In 2011, All Children's Hospital (ACH) joined the Johns Hopkins Health System (JHHS) and in so doing became a member of Johns Hopkins Medicine (JHM). The value proposition for the joining of ACH and JHHS/JHM was to transform ACH into an academic pediatric health system. This case study of the transformation provides evidence for the usefulness of a precision medicine framework to organize investments in programs and practices that further the tripartite mission of academic medical centers and may increase the value of the care they deliver., Competing Interests: Potential Conflicts of Interest: None disclosed.

Background and Objective: Many urban youth experience significant and unremitting negative stressors, including those associated with community violence, multigenerational poverty, failing educational systems, substance use, limited avenues for success, health risks, and trauma. Mindfulness instruction improves psychological functioning in a variety of adult populations; research on mindfulness for youth is promising, but has been conducted in limited populations. Informed by implementation science, we evaluated an adapted mindfulness-based stress reduction (MBSR) program to ameliorate the negative effects of stress and trauma among low-income, minority, middle school public school students., Methods: Participants were students at two Baltimore City Public Schools who were randomly assigned by grade to receive adapted MBSR or health education (Healthy Topics [HT]) programs. Self-report survey data were collected at baseline and postprogram. Deidentified data were analyzed in the aggregate, comparing MBSR and HT classes, by using regression modeling., Results: Three hundred fifth- to eighth-grade students (mean 12.0 years) were in MBSR and HT classes and provided survey data. Participants were 50.7% female, 99.7% African American, and 99% eligible for free lunch. The groups were comparable at baseline. Postprogram, MBSR students had significantly lower levels of somatization, depression, negative affect, negative coping, rumination, self-hostility, and posttraumatic symptom severity (all Ps < .05) than HT., Conclusions: These findings support the hypothesis that mindfulness instruction improves psychological functioning and may ameliorate the negative effects of stress and reduce trauma-associated symptoms among vulnerable urban middle school students. Additional research is needed to explore psychological, social, and behavioral outcomes, and mechanisms of mindfulness instruction., (Copyright © 2016 by the American Academy of Pediatrics.)

Sexual concurrency may increase risk for HIV/STIs among youth. Attitudes about gender roles, including power balances within sexual partnerships, could be a driver. We examined this association among Baltimore youth (N = 352), aged 15-24. Data were collected from February, 2011 to May, 2013. We examined whether index concurrency in male-reported partnerships (N = 221) and sex partner's concurrency in female-reported partnerships (N = 241) were associated with youth's attitudes towards relationship power. Males with more equitable beliefs about power were less likely to report index concurrency. Females with more equitable beliefs were more likely to report sex partner's concurrency. The relationship was significant in main and casual partnerships among females and main partnerships among males. The strongest associations were detected among middle-socioeconomic status (SES) males and low-SES and African American females. Implementing interventions that recognize the complex relationship between socioeconomic context, partner dynamics, gender, and sexual behavior is an important step towards reducing HIV/STI risk among youth.

Purpose: Places are an important determinant of risk for sexually transmitted infection (STI) acquisition and transmission. We sought to identify social places that are critical for targeted STI control activities. The objective of this study was to determine whether sex partner meeting places characterized by drug markets, sex markets, and separately, drug and/or sex markets were more likely to have potential core transmitters as compared with other sex partner meeting places in one urban setting., Methods: In 2008-2009, heterosexual sex partner places or venues were identified in Baltimore, MD using a venue-based study approach., Results: A total of 1334 participants aged 18 to 35 years were enrolled at 85 venues. In those participants, 39 potential core transmitters were identified and 31% of venues had at least one potential core transmitter. In final age-adjusted and gender-adjusted models, core transmitters were significantly more likely to be identified at drug markets (OR = 1.37; 95% CI = 1.23-1.53), sex markets (OR = 1.27; 95% CI = 1.14-1.41), and drug and/or sex markets (OR = 1.49; 95% CI = 1.32-1.68)., Conclusions: This study identified key characteristics of venues, such as drug and sex market activity, that may be important in identifying places for the targeted control of STI transmission., (Copyright © 2015 Elsevier Inc. All rights reserved.)

To address the persistent HIV epidemic in the United States, prevention efforts are focusing on social determinants related to HIV risk by targeting systems and structures, such as organizational and institutional policies, practices and programs, and legislative and regulatory approaches to modify features of the environment that influence HIV risk. With limited evidenced-based examples, communities can benefit from strategic planning resources that help them consider developing structural-level changes that target root causes of HIV risk. In this article, we present the Connect to Protect® project that outlines a process and a tool to move from general ideas to specific structural changes. Examples from 14 coalitions are also provided. Using the process and tools presented here can provide a launching pad for other coalitions seeking to build an HIV prevention agenda and for practitioners seeking to incorporate structural changes for community health promotion., (© 2015 Society for Public Health Education.)

Public health HIV prevention efforts have begun to focus on addressing social and structural factors contributing to HIV risk, such as unstable housing, unemployment, and access to health care. With a limited body of evidence-based structural interventions for HIV, communities tasked with developing structural changes need a defined process to clarify their purpose and goals. This article describes the adaptations made to a coalition development model with the purpose of improving the start-up phase for a second group of coalitions. Modifications focused on preparing coalitions to more efficiently apply structural change concepts to their strategic planning activities, create more objectives that met study goals, and enhance coalition procedures such as building distributed coalition leadership to better support the mobilization process. We report on primary modifications to the process, findings for the coalitions, and recommendations for public health practitioners who are seeking to start a similar coalition.

Despite two recent government-sponsored 'wars on drugs', methamphetamine use continues to be a pervasive problem in Thailand. Out of concern for reported human rights abuses, there has been a call from the international community to take a different approach from the government's 'zero tolerance'. This paper describes the adaptation of the Connect to Protect® coalition formation process from urban U.S. cities to three districts in northern Thailand's Chiang Mai province, aimed to reduce methamphetamine use by altering the risk environment. Project materials, including manuals and materials (e.g. key actor maps and research staff memos), were reviewed to describe partnering procedures and selection criteria. Potential community partners were identified from various government and community sectors with a focus on including representatives from health, police, district and sub-district government officials. Of the 64 potential partners approached, 59 agreed to join one of three district-level coalitions. Partner makeup included 25% from the health sector, 22% who were sub-district government officials and 10% were representatives from the police sector. Key partners necessary for endorsement of and commitment to the coalition work included district-level governors, police chiefs and hospital directors for each district. Initial coalition strategic planning has resulted in policies and programs to address school retention, youth development initiatives and establishment of a new drug treatment and rehabilitation clinic in addition to other developing interventions. Similarities in building coalitions, such as the need to strategically develop buy-in with key constituencies, as well as differences of whom and how partners were identified are explored., (© The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Objective: To examine the HIV risk behaviours of men who have sex with men only (MSMO) and men who have sex with men and women (MSMW), aged 12-24 years, in five US cities and in San Juan, Puerto Rico., Methods: Data were collected through four annual cross-sectional anonymous surveys at community venues and included questions about sexual partnerships, sexual practices including condom use and substance use. Demographic and risk profiles were summarised for both groups., Results: A total of 1198 men were included in this analysis, including 565 MSMO and 633 MSMW. There were statistically significant differences between the two groups for many risk factors examined in multivariable models. MSMW were more likely to identify as bisexual, be in a long-term relationship, have a history of homelessness, have ever used marijuana, have ever been tested for HIV and to have been tested for HIV within the past 6 months. MSMW may be more likely to ever exchange sex for money and ever have a sexually transmitted infection than MSMO., Conclusions: MSMW were more likely to report several markers of socioeconomic vulnerability or behaviours associated with increased risk for HIV than MSMO. MSMW contribute to HIV prevalence in the USA, and better understanding of the risk profile of this group is essential to understand heterosexual HIV transmission. MSMW, particularly those who identify as bisexual or questioning, may feel uncomfortable participating in programmes that are designed for gay-identified men. Therefore, prevention strategies need to target distinct subgroups that compose the population of MSM., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

To inform policy debates surrounding marijuana decriminalization and add to our understanding of social and structural influences on youth drug use, we sought to determine whether there was an independent association between neighborhood drug prevalence and individual-level marijuana use after controlling for peer drug and alcohol norms. We analyzed cross-sectional data from a household survey of 563 youth aged 15-24 in Baltimore, Maryland. The study population was 88 % African-American. Using gender-stratified, weighted, multilevel logistic regression, we tested whether neighborhood drug prevalence was associated with individual-level marijuana use after controlling for peer drug and alcohol norms. Bivariate analyses identified a significant association between high neighborhood drug prevalence and marijuana use among female youth (AOR = 1.76, 95% CI = 1.26, 2.47); the association was in a similar direction but not significant among male youth (AOR = 1.26, 95% CI = 0.85, 1.87). In multivariable regression controlling for peer drug and alcohol norms, high neighborhood drug prevalence remained significantly associated among female youth (AOR = 1.59, 95% CI = 1.12, 2.27). Among male youth, the association was attenuated toward the null (AOR = 0.95, 95% CI = 0.63, 1.45). In the multivariable model, peer drug and alcohol norms were significantly associated with individual-level marijuana use among female youth (AOR = 1.54, 95% CI = 1.17, 2.04) and male youth (AOR = 2.59, 95% CI = 1.65, 4.07). This work suggests that individual-level marijuana use among female youth is associated with neighborhood drug prevalence independent of peer norms. This finding may have important implications as the policy landscape around marijuana use changes.

Purpose: The fear of negative reactions from friends and family members affects many human immunodeficiency virus (HIV)-positive adolescents' decisions regarding disclosure of their HIV status. The complex relationships and interplay among social support, fear of stigma, and disclosure of HIV status need to be better understood among youth living with HIV (YLHIV)., Methods: Social support from friends and family members and HIV status disclosure were examined among 402 youth, aged 12-24 years, living with HIV., Results: In separate analyses, (1) HIV-positive youth who reported more than one close friend and (2) HIV-positive youth who reported that friends and family members continued to socialize with them after disclosure of their HIV diagnosis, had higher levels of perceived social support overall (both p < .05). Furthermore, perceived social support did not differ significantly between those participants for whom no family member knew their HIV status and those for whom at least one family member knew their status (p = .13). Race/ethnicity, sexual orientation, education level, and current living situation were not associated with family's knowledge of the participants' HIV infection status (p > .07)., Conclusion: This investigation adds important information concerning YLHIV, whose early disclosure experiences may influence their resilience and future coping mechanisms regarding experienced stigma, and thus influence the length of time they conceal their HIV status, their decision to disclose their status, and potentially their decisions regarding treatment. Interventions and support systems to assist YLHIV with disclosure, as well as medical care, may improve their overall quality of life., (Published by Elsevier Inc.)

Importance: With the emphasis on structural-level interventions that target social determinants of human immunodeficiency virus (HIV) transmission to curb the HIV epidemic, there is a need to develop evaluation models that can detect changes in individual factors associated with HIV-related structural changes., Objective: To describe whether structural changes developed and achieved by community coalitions are associated with an effect on individual factors associated with the risk of contracting HIV., Design, Setting, and Participants: In this serial cross-sectional survey design, data were collected from 8 cities during 4 rounds of annual surveys from March 13, 2007, through July 29, 2010. Study recruitment took place at venues where the population of focus was known to congregate, such as clubs, bars, community centers, and low-income housing. The convenience sample of at-risk youth (persons aged 12-24 years) included 5337 individuals approached about the survey and 3142 (58.9%) who were screened for eligibility. Of the 2607 eligible participants, 2559 (98.2%) ultimately agreed to participate., Interventions: Achievement of locally identified structural changes that targeted public and private entities (eg, federal agencies, homeless shelters, and school systems) with the goal of fostering changes in policy and practice to ultimately facilitate positive behavioral changes aimed at preventing HIV., Main Outcomes and Measures: Number of sexual partners, partner characteristics, condom use, and history of sexually transmitted infections and HIV testing., Results: Exposure to structural changes was not statistically significantly associated with any of the outcome measures, although some results were in the direction of a positive structural change effect (eg, a 10-unit increase in a structural change score had an odds ratio of 0.88 [95% CI, 0.76-1.03; P = .11] for having an older sexual partner and an odds ratio of 0.91 [95% CI, 0.60-1.39; P = .39] for using a condom half the time or less with a casual partner)., Conclusions and Relevance: This study evaluated a broad representation of at-risk individuals and assessed the effect of numerous structural changes related to various HIV risk factors. No structural changes as measured in this study were associated with a statistically significant reduction in risk behaviors. These null findings underscore the need for a long-term approach in evaluating structural interventions and the development of more nuanced methods of quantifying and comparing structural-change initiatives and determining the appropriate strategies for evaluating effect.

Objectives. We explored gender role strain (GRS) arising from conflict between homosexuality and cultural conceptions of masculinity among young Black men who have sex with men (MSM). Methods. We conducted a categorical analysis (a qualitative, 3-stage, iterative analysis) of data from studies conducted in 2001 to 2006, which interviewed 35 men aged 18 to 24 years in 3 New York cities and Atlanta, Georgia. Results. Participants described rigid, often antihomosexual expectations of masculinity from their families, peers, and communities. Consistent with GRS, this conflict and pressure to conform to these expectations despite their homosexuality led to psychological distress, efforts to camouflage their homosexuality, and strategies to prove their masculinity. Participants believed this conflict and the associated experience of GRS might increase HIV risk through social isolation, poor self-esteem, reduced access to HIV prevention messages, and limited parental-family involvement in sexuality development and early sexual decision-making. Conclusions. Antihomosexual expectations of masculinity isolate young Black MSM during a developmental stage when interpersonal attachments are critical. GRS may influence sexual risk behavior and HIV risk and be an important target for HIV prevention.

Purpose: Hispanic/Latino adolescents and young adults are disproportionately impacted by the HIV/AIDS epidemic; yet little is known about the best strategies to increase HIV testing in this group. Network-based approaches are feasible and acceptable means for screening at-risk adults for HIV infection, but it is unknown whether these approaches are appropriate for at-risk young Hispanics/Latinos. Thus, we compared an alternative venue-based testing (AVT) strategy with a social and sexual network-based interviewing and HIV testing (SSNIT) strategy., Methods: All participants were Hispanics/Latinos aged 13-24 years with self-reported HIV risk; they were recruited from 11 cities in the United States and Puerto Rico and completed an audio computer-assisted self-interview and underwent HIV screening., Results: A total of 1,596 participants (94.5% of those approached) were enrolled: 784 (49.1%) through AVT and 812 (50.9%) through SSNIT. HIV infection was identified in three SSNIT (.37%) and four AVT (.51%) participants (p = .7213)., Conclusions: Despite high levels of HIV risk, a low prevalence of HIV infection was identified with no differences by recruitment strategy. We found overwhelming support for the acceptability and feasibility of AVT and SSNIT for engaging and screening at-risk young Hispanics/Latinos. Further research is needed to better understand how to strategically implement such strategies to improve identification of undiagnosed HIV infection., (Copyright © 2014 Society for Adolescent Health and Medicine. All rights reserved.)