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Low perception of HIV risk is a challenge to PrEP implementation. We analyzed associations between perceptions of PrEP candidacy, behavioral indications for PrEP, and sexual behaviors. We recruited a sample of 580 MSM from a geosocial-networking smartphone application in Paris, France. A modified Poisson regression model was conducted to examine associations between perceived candidacy for PrEP and behavioral indications for PrEP, and relationships among engagement in group sex, transactional sex, HIV test history, and indications for PrEP. Adjusted risk ratios (aRR) and 95% confidence intervals (CIs) were calculated. For the outcome of perceived candidacy for PrEP, a multinomial logistic regression was performed, and adjusted relative risk ratios (aRRR) were calculated. Multivariate analyses were adjusted for socio-demographics. Respondents who considered themselves PrEP candidates were more likely to meet PrEP eligibility criteria compared to those who did not consider themselves candidates (aRR 1.65; 95% CI 1.34–2.03). Those who had engaged in group or transactional sex were more likely to have behavioral indications for PrEP (aRR 1.27; 95% CI 1.07–1.50, aRR 1.32; 95% CI 1.13–1.56, respectively), whereas HIV test history was not significantly associated with behavioral indications for PrEP. Respondents who had engaged in group sex or transactional sex were more likely to perceive themselves as candidates for PrEP (aRRR 2.24; 95% CI 1.21–4.16, aRRR 2.58; 95% CI 1.09–6.13, respectively), although those never tested for HIV were less likely to perceive themselves as candidates for PrEP (aRRR 0.18; 95% CI 0.03–0.91). The elucidation of candidacy perceptions and risk behaviors is key to furthering the effective implementation of PrEP engagement interventions. [ABSTRACT FROM AUTHOR]

Pre-exposure prophylaxis (PrEP) is an important biomedical human immunodeficiency virus (HIV) prevention tool gaining more popularity among Parisian men who have sex with men (MSM) who engage in transactional sex. This study examines the knowledge of, and willingness to use, different modalities of PrEP among this subgroup. Broadcast advertisements were placed on a geosocial-networking smartphone application with a link to a Web-based survey during three 24-hour periods in October 2016. Modified Poisson regression models were used to assess the association between engagement in transactional sex and preferences for each of these PrEP modalities. A total of 444 respondents were included. About 14% reported engagement in transactional sex. In all, 90% of MSM who engaged in transactional sex were knowledgeable of daily oral PrEP, while 13.3% were knowledgeable about long-acting injectable PrEP or penile or rectal microbicides. They were more likely to be aware of long-acting injectable PrEP (aRR = 2.52, 95% CI = 1.16 to 5.47) and willing to use daily oral PrEP (aRR = 1.48; 95% CI = 1.11 to 1.98) or long-acting injectable PrEP (aRR = 1.40; 95% CI = 1.09 to 1.81) than MSM who had not engaged in transactional sex. Long-acting injectable PrEP may be an important HIV-prevention option for MSM who engage in transactional sex if this modality is proven effective. [ABSTRACT FROM AUTHOR]

Men who have sex with men (MSM) who use smartphone applications (apps) to meet sexual partners represent a high-risk subset of MSM. As such, the use of pre-exposure prophylaxis (PrEP) may be highly suitable. The purpose of the study was to evaluate awareness of and willingness to use PrEP among 179 HIV-uninfected MSM recruited in London who use these apps. Regression models were fit to assess the associations between perceived barriers and willingness to use PrEP in the future. Most (84.9%) had heard of PrEP and more than half (57.1%) were willing to use PrEP in the future if it were to become available. Low perceived risk for acquiring HIV (prevalence ratio (PR): 0.11; 95% confidence interval (CI): 0.04, 0.33) and concerns about PrEP-related side effects (PR: 0.01; 95% CI: 0.00, 0.04) were associated with being unwilling to use PrEP. Efforts to make PrEP widely available should be continued. Uptake interventions should focus on correcting self-perceptions of HIV risk and educate MSM about the potential side effects of PrEP use so that MSM can make more informed decisions about prevention options. [ABSTRACT FROM AUTHOR]

Geosocial-networking smartphone applications (“apps”) are widely used by gay, bisexual, and other men who have sex with men (MSM) and facilitate connections between users based on proximity and attraction. MSM have sexual encounters and relationships of varying degrees of emotional and physical intimacy with app-met individuals, potentially placing them at risk for intimate partner violence (IPV). The purpose of the current study was to utilize a geosocial-networking application to investigate relationships between experiences of IPV victimization as it relates to substance use and sexual risk behaviors in a sample of MSM. Participants (n = 175) were recruited by means of broadcast advertisements on an application widely used by MSM (Grindr) to seek sexual partners. Multivariable regression models were fit to examine associations between IPV, substance abuse, and sexual risk behaviors. Lifetime experiences of IPV victimization were common, where 37.7% of respondents reported having experienced at least one form of IPV. While a marginally significant positive association between IPV and substance abuse was detected in multivariable models (p = .095), individual forms of IPV were strongly associated with substance abuse. For example, sexual IPV victimization was associated with an increase in substance abuse in the preceding month (p = .004). Experiences of IPV victimization were associated with higher numbers of partners for both condomless receptive and insertive anal intercourse (p < .05). Given the relatively high prevalence of IPV victimization and its associations with substance abuse and sexual risk behaviors, these findings suggest that IPV screening and prevention programs may reduce substance abuse and sexual risk behaviors in this population. [ABSTRACT FROM AUTHOR]

Men who have sex with men (MSM) who attend group sex events (GSEs) tend to also engage in high-risk sexual behaviors and substance use that may place them at additional increased risk for becoming infected with HIV. These sorts of events may be facilitated by the use of geosocial-networking smartphone applications, where MSM may have access to a large virtual pool of potential partners. The purpose of the current study was to examine the prevalence of recent engagement in GSEs and its demographic and behavioral correlates among a sample of MSM ( n = 202). Log-binomial models were fit to assess correlates of engagement in GSEs in the preceding three months. Overall, 42.6% had engaged in a GSE in the preceding three months. In multivariable models, the use of inhalant nitrites (PR: 2.239; 95% CI: 1.119, 4.848; p = .024) and methamphetamine (PR: 7.601; 95% CI: 2.340, 24.691; p = .001) were associated with recent engagement in GSEs. Given the high prevalence of these potentially high-risk behaviors, future research should be conducted to examine the concurrent use of substance use and condom use at the GSEs to develop appropriate risk reduction interventions. [ABSTRACT FROM AUTHOR]

The association between recent release from incarceration and dramatically increased risk of fatal overdose is well-established at the individual level. Fatal overdose and. arrest/release are spatially clustered, suggesting that this association may persist at the neighborhood level. We analyzed multicomponent data from Rhode Island, 2016–2020, and observed a modest association at the census tract level between rates of release per 1000 population and fatal overdose per 100,000 person-years, adjusting for spatial autocorrelation in both the exposure and outcome. Our results suggest that for each additional person released to a given census tract per 1000 population, there is a corresponding increase in the rate of fatal overdose by 2 per 100,000 person years. This association is more pronounced in suburban tracts, where each additional release awaiting trial is associated with an increase in the rate of fatal overdose of 4 per 100,000 person-years and 6 per 100,000 person-years for each additional release following sentence expiration. This association is not modified by the presence or absence of a licensed medication for opioid use disorder (MOUD) treatment provider in the same or surrounding tracts. Our results suggest that neighborhood-level release rates are moderately informative as to tract-level rates of fatal overdose and underscore the importance of expanding pre-release MOUD access in correctional settings. Future research should explore risk and resource environments particularly in suburban and rural areas and their impacts on overdose risk among individuals returning to the community. • Release from incarceration is associated with fatal overdose at the individual level. • This association is also apparent at the neighborhood level. • Release is more strongly associated with fatal overdose in suburban neighborhoods. • Treatment provider presence does not modify the neighborhood-level association. [ABSTRACT FROM AUTHOR]

The number of new HIV infections continues to be on the rise in many high-income countries, most notably among men who have sex with men (MSM). Despite recent attention to the use of antiretroviral medications as pre-exposure prophylaxis (PrEP) among MSM, considerably less research has been devoted to examining the awareness and use of post-exposure prophylaxis (PEP). Based on a convenience sample of 179 self-reported HIV-uninfected MSM using a geosocial-networking smartphone application, this study is among the first to examine the awareness and use of PEP and their demographic and behavioral correlates among MSM in London. Most respondents (88.3%) had heard of PEP, where 27.4% reported having used it. In multivariable models, the disclosure of one’s sexual orientation to their general practitioner (Prevalence ratio [PR]: 3.49; 95% confidence interval (CI): 1.14, 10.70;p = .029) and reporting one’s HIV status as negative (rather than unknown) (PR: 11.49; 95% CI: 1.68, 76.92;p = .013) were associated with having heard of PEP; while the recent use of club drugs (PR: 3.02; 95% CI: 1.42, 6.43;p = .004) was associated with having ever used PEP. High awareness and use in this sample suggest that PEP is a valuable risk-reduction strategy that should be capitalized on, be it in addition to or in the absence of PrEP. [ABSTRACT FROM PUBLISHER]

Serodiscussion-the mutual discussion of HIV statuses between sexual partners-can be viewed as an essential prerequisite for risk-reduction behaviors among men who have sex with men (MSM). The current study aimed to assess the prevalence of serodiscussion with one's most recent sexual partner and its association with sexual behaviors with these partners. Broadcast advertisements were placed on a geosocial-networking smartphone application, encouraging users to complete an online survey. A total of 200 MSM completed the survey. Serodiscussion occurred in 43.5% of dyads, and it was most common in dyads where both partners were reported to be HIV positive, χ2(5) = 60.3, P < .001. Serodiscussion was associated with engagement in both condomless insertive, χ2(1) = 3.847, P = .046, and receptive anal intercourse, χ2(1) = 6.5, P = .011. However, there were no significant differences in how recently a respondent was tested for HIV, representing potentially high-risk scenarios. [ABSTRACT FROM AUTHOR]

To date, various dimensions of body image and their associations with condom use have not been studied among men who have sex with men (MSM) who use geosocial-networking smartphone applications (“apps”) to meet new sexual partners. The purpose of the current study was to evaluate associations between weight perception, body dissatisfaction, and self-objectification with sexual behaviors among a sample of MSM (N = 92) recruited from Grindr, an app popular among MSM, to complete an online survey. Obese participants scored significantly higher on measures of body dissatisfaction and lower on measures of sexual sensation seeking. Decreased propensities to seek sexual sensations were associated with fewer sexual partners. By assessing associations between dimensions of body dissatisfaction and sexual risk behaviors, this study adds support to a theory of syndemics among MSM, which suggests that synergistically related biological, psychological, social, and behavioral factors disproportionately affect health and health-related behaviors in this population. [ABSTRACT FROM PUBLISHER]

Background: The endocannabinoid system has been implicated in physiological processes fundamental to pain, giving plausibility to the hypothesis that cannabis may be used as a substitute or complement to prescription opioids in the management of chronic pain. We examined the association of medical cannabis licensure with likelihood of prescription opioid receipt using administrative records.Methods: This study linked registry information for medical cannabis licensure with records from the prescription drug monitoring program from April 1, 2016 to March 31, 2019 to create a population-based, retrospective cohort in Rhode Island. We examined within-person changes in receipt of any opioid prescription and receipt of an opioid prescription with a morphine equivalent dose of 50 mg or more, and of 90 mg or more.Results: The sample included 5,296 participants with medical cannabis license. Medical cannabis licensure was not associated with the odds of filling any opioid prescription (OR: 0.99; 95% CI: 0.94-0.1.05) or the odds of filling a prescription with a morphine equivalent dose of 50 mg or more (OR: 0.93; 95% CI: 0.84-1.04) and 90 mg or more (OR: 0.99; 95% CI: 0.86-1.15).Conclusion: Medical cannabis licensure was not associated with subsequent cessation and reduction in prescription opioid use. Re-scheduling of cannabis will allow for the conduct of randomized controlled trials to determine the efficacy of medical cannabis as an alternative to prescription opioid use or a complement to the use of lower doses of prescription opioids in patients with chronic pain. [ABSTRACT FROM AUTHOR]

Black sexually minoritized men (SMM) and transgender women (TW) are subgroups with lower rates of substance use and comparable rates of condom use relative to White SMM and TW yet experience heightened vulnerability to HIV. This study sought to explore associations of substance use, including sex-drug use (i.e., drug or alcohol use during sex to enhance sex), and condomless sex among Black SMM and TW. Data were collected from Black SMM and TW living in Chicago, Illinois, enrolled in the Neighborhoods and Networks (N2) cohort study, from November 2018 to April 2019. We used bivariate analyses followed by a multilevel egocentric network analysis to identify factors associated with condomless sex. We conducted Spearman correlation coefficients to examine correlations between pairs of sex-drugs to enhance sex. We used a bipartite network analysis to identify correlates of sex-drug use and condomless sex. A total of 352 Black SMM and TW (egos) provided information about 933 sexual partners (alters). Of respondents, 45% reported condomless sex and 61% reported sex-drug use. In unadjusted analyses, marijuana (34%) and cocaine/crack (5%) sex-drug use were associated with condomless sex (p < 0.05). Condomless sex was positively associated with sex-polydrug use, or the use of 2+ drugs or 1 drug and alcohol (OR = 1.48; 95% CI: 1.02–2.14; p = 0.039), and negatively associated with sharing an HIV-negative serostatus with a sexual partner (OR = 0.57; 95% CI: 0.33–0.98; p = 0.041), having a different HIV serostatus with a sexual partner (OR = 0.37; 95% CI: 0.21–0.64; p < 0.001) or not knowing the HIV serostatus of a sexual partner (OR = 0.47; 95% CI: 0.26–0.84; p = 0.011). The following pairs of sex-polydrug use had Spearman correlation coefficients higher than 0.3: marijuana and alcohol, ecstasy and alcohol, cocaine/crack and ecstasy, and methamphetamine and poppers (p < 0.05). HIV prevention interventions for Black SMM and TW designed to reduce HIV transmission through egocentric sexual networks could address sex-drug use through sex-positive and pleasure-centered harm reduction strategies and provide and promote biomedical prevention and care options at supraoptimal levels. [ABSTRACT FROM AUTHOR]

Individual-level behavior can be influenced by injunctive and descriptive social network norms surrounding that behavior. There is a need to understand how the influence of social norms within an individual's social networks may influence individual-level sexual behavior. We aimed to typologize the network-level norms of sexual behaviors within the social networks of Black sexual and gender minoritized groups (SGM) assigned male at birth. Survey data were collected in Chicago, Illinois, USA, between 2018 and 2019 from Black SGM. A total of 371 participants provided individual-level information about sociodemographic characteristics and HIV vulnerability from sex (i.e., condomless sex, group sex, use of alcohol/drugs to enhance sex) and completed an egocentric network inventory assessing perceptions of their social network members' (alters') injunctive and descriptive norms surrounding sexual behaviors with increased HIV vulnerability. We used Latent Profile Analysis (LPA) to identify network-level norms based on the proportion of alters' approval of the participant engaging in condomless sex, group sex, and use of drugs to enhance sex (i.e., injunctive norms) and alters' engagement in these behaviors (i.e., descriptive norms). We then used binomial regression analyses to examine associations between network-level norm profiles and individual-level HIV vulnerability from sex. The results of our LPA indicated that our sample experienced five distinct latent profiles of network-level norms: (1) low HIV vulnerability network norm, (2) moderately high HIV vulnerability network norm, (3) high HIV vulnerability network norm, (4) condomless sex dominant network norm, and (5) approval of drug use during sex dominant network norm. Condomless anal sex, group sex, and using drugs to enhance sex were positively and significantly associated with higher HIV vulnerability social network norm profiles, relative to low HIV vulnerability norm profiles. To mitigate Black SGM's HIV vulnerability, future HIV risk reduction strategies can consider using network-level intervention approaches such as opinion leaders, segmentation, induction, or alteration, through an intersectionality framework. [ABSTRACT FROM AUTHOR]

Background: Little is known about how best to reach people with social marketing messages promoting use of clinical HIV and sexually transmitted infection (STI) services., Objective: We evaluated a multiplatform, digital social marketing campaign intended to increase use of HIV/STI testing, treatment, and prevention services among gay, bisexual, and other men who have sex with men (MSM) at an LGBTQ+ (lesbian, gay, bisexual, transgender, queer, and/or questioning) community health center., Methods: We evaluated engagement with a social marketing campaign launched by Open Door Health, the only LGBTQ+ community health center in Rhode Island, during the first 8 months of implementation (April to November 2021). Three types of advertisements encouraging use of HIV/STI services were developed and implemented on Google Search, Google Display, Grindr, and Facebook. Platforms tracked the number of times that an advertisement was displayed to a user (impressions), that a user clicked through to a landing page that facilitated scheduling (clicks), and that a user requested a call to schedule an appointment from the landing page (conversions). We calculated the click-through rate (clicks per impression), conversion rate (conversions per click), and the dollar amount spent per 1000 impressions and per click and conversion., Results: Overall, Google Search yielded the highest click-through rate (7.1%) and conversion rate (7.0%) compared to Google Display, Grindr, and Facebook (click-through rates=0.4%-3.3%; conversion rates=0%-0.03%). Although the spend per 1000 impressions and per click was higher for Google Search compared to other platforms, the spend per conversion-which measures the number of people intending to attend the clinic for services-was substantially lower for Google Search (US $48.19 vs US $3120.42-US $3436.03)., Conclusions: Campaigns using the Google Search platform may yield the greatest return on investment for engaging MSM in HIV/STI services at community health clinics. Future studies are needed to measure clinical outcomes among those who present to the clinic for services after viewing campaign advertisements and to compare the return on investment with use of social marketing campaigns relative to other approaches., (© Laura C Chambers, Yelena Malyuta, William C Goedel, Philip A Chan, Cassandra Sutten Coats, Ken Allen, Amy S Nunn. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org).)

Importance: Clinicians are a key component of preexposure prophylaxis (PrEP) care. Yet, no prior studies have quantitatively investigated how PrEP adherence differs by clinician specialty., Objective: To understand the association between prescribing clinician specialty and patients not picking up (reversal/abandonment) their initial PrEP prescription., Design, Setting, and Participants: This cross-sectional study of patients who were 18 years or older used pharmacy claims data from 2015 to 2019 on new insurer-approved PrEP prescriptions that were matched with clinician data from the US National Plan and Provider Enumeration System. Data were analyzed from January to May 2022., Main Outcomes and Measures: Clinician specialties included primary care practitioners (PCPs), infectious disease (ID), or other specialties. Reversal was defined as a patient not picking up their insurer-approved initial PrEP prescription. Abandonment was defined as a patient who reversed and still did not pick their prescription within 365 days., Results: Of the 37 003 patients, 4439 (12%) were female and 32 564 (88%) were male, and 77% were aged 25 to 54 years. A total of 24 604 (67%) received prescriptions from PCPs, 3571 (10%) from ID specialists, and 8828 (24%) from other specialty clinicians. The prevalence of reversals for patients of PCPs, ID specialists, and other specialty clinicians was 18%, 18%, and 25%, respectively, and for abandonments was 12%, 12%, and 20%, respectively. After adjusting for confounding, logistic regression models showed that, compared with patients who were prescribed PrEP by a PCP, patients prescribed PrEP by ID specialists had 10% lower odds of reversals (odds ratio [OR], 0.90; 95% CI, 0.81-0.99) and 12% lower odds of abandonment (OR, 0.88; 95% CI, 0.78-0.98), while patients prescribed by other clinicians had 33% higher odds of reversals (OR, 1.33; 95% CI, 1.25-1.41) and 54% higher odds of abandonment (OR, 1.54; 95% CI, 1.44-1.65)., Conclusion: The results of this cross-sectional study suggest that PCPs do most of the new PrEP prescribing and are a critical entry point for patients. PrEP adherence differs by clinician specialties, likely due to the populations served by them. Future studies to test interventions that provide adherence support and education are needed.

Background: Delays in hospital presentation limit access to acute stroke treatments. While prior research has focused on patient-level factors, broader ecological and social determinants have not been well studied. We aimed to create a geospatial map of prehospital delay and examine the role of community-level social vulnerability., Methods: We studied patients with ischemic stroke who arrived by emergency medical services in 2015 to 2017 from the American Heart Association Get With The Guidelines-Stroke registry. The primary outcome was time to hospital arrival after stroke (in minutes), beginning at last known well in most cases. Using Geographic Information System mapping, we displayed the geography of delay. We then used Cox proportional hazard models to study the relationship between community-level factors and arrival time (adjusted hazard ratios [aHR] <1.0 indicate delay). The primary exposure was the social vulnerability index (SVI), a metric of social vulnerability for every ZIP Code Tabulation Area ranging from 0.0 to 1.0., Results: Of 750 336 patients, 149 145 met inclusion criteria. The mean age was 73 years, and 51% were female. The median time to hospital arrival was 140 minutes (Q1: 60 minutes, Q3: 458 minutes). The geospatial map revealed that many zones of delay overlapped with socially vulnerable areas (https://harvard-cga.maps.arcgis.com/apps/webappviewer/index.html?id=08f6e885c71b457f83cefc71013bcaa7). Cox models (aHR, 95% CI) confirmed that higher SVI, including quartiles 3 (aHR, 0.96 [95% CI, 0.93-0.98]) and 4 (aHR, 0.93 [95% CI, 0.91-0.95]), was associated with delay. Patients from SVI quartile 4 neighborhoods arrived 15.6 minutes [15-16.2] slower than patients from SVI quartile 1. Specific SVI themes associated with delay were a community's socioeconomic status (aHR, 0.80 [95% CI, 0.74-0.85]) and housing type and transportation (aHR, 0.89 [95% CI, 0.84-0.94])., Conclusions: This map of acute stroke presentation times shows areas with a high incidence of delay. Increased social vulnerability characterizes these areas. Such places should be systematically targeted to improve population-level stroke presentation times., Competing Interests: Disclosures Dr Dhand is Co-Founder and has stock options in ECHAS (Emergency Call for Heart Attack and Stroke). He is also a consultant for Availity and participates in expert witness activities. Dr Bergmark a consultant for Analysis Group and received grant funding from I-Mab Biopharma, and reports grants from Brigham and Women’s Hospital. Dr Fonarow is a consultant for Abbott Pharmaceuticals, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Cytokinetics, Eli Lilly and Company, Janssen Pharmaceuticals, Medtronic, Merck, Novartis, and Pfizer. Dr Saver is a consultant for Abbott Laboratories, Aeromics, Biogen, Boehringer Ingelheim, BrainQ, BrainGate, CSL Behring, Johnson & Johnson Health Care Systems Inc, Medtronic, MindRhythm, Neuronics Medical, Rapid Medical, Roche, and Stream Medical. He is on the data and safety monitoring board for MIVI Neuroscience. Dr Schwamm is a consultant for Genentech and Medtronic. Dr Sheth is President for Advanced Innovation in Medicine. He has stock options in BrainQ and receives grant support from BARD and Hyperfine. He is a consultant for Astrocyte, Cerevasc, CSL Behring, and Rhaeos. He is on the data and safety monitoring board for Sense. He reports a patent pending for Stroke wearables licensed to Alva Health

Objective: In the United States, one in five newly insurer-approved pre-exposure prophylaxis (PrEP) prescriptions are reversed with over 70% of those reversed, being abandoned. Given the Ending the HIV Epidemic (EHE) initiative's goals, we assessed geographic variations of PrEP reversal and abandonment across EHE and non-EHE counties in the United States., Design: This was a cross-sectional analysis of secondary data., Methods: Data were collected from Symphony Analytics for adults 18 years and older, with a newly prescribed PrEP claim. Using the proportion of PrEP prescriptions by county, hotspot analysis was conducted utilizing Getis Ord Gi∗ statistics stratified by EHE and non EHE counties. Multivariable logistic regression was used to identify factors associated with residing in hotspots of PrEP reversal or PrEP abandonments., Results: Across 516 counties representing 36,204 patients, the overall PrEP reversal rate was 19.4%, whereas the PrEP abandonment rate was 13.7%. Reversals and abandonments were higher for non-EHE (22.7 and 17.1%) than EHE (15.6 and 10.5%) counties. In both EHE and non-EHE counties, younger age, less education, females, and an out-of-pocket cost of greater than $100, were significantly associated with greater likelihood of residing in hotspots of PrEP reversal or abandonment, while Hispanics, Medicaid recipients, and an out-of-pocket cost of $10 or less had lower likelihood of residing in hotspots of reversal and abandonment., Conclusion: Findings indicate the need for implementation of focused interventions to address disparities observed in PrEP reversal and abandonment. Moreover, to improve primary PrEP adherence, national PrEP access programs should streamline and improve PrEP accessibility across different geographic jurisdictions., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Examine differences in neighborhood characteristics and services between overdose hotspot and non-hotspot neighborhoods and identify neighborhood-level population factors associated with increased overdose incidence., Methods: We conducted a population-based retrospective analysis of Rhode Island, USA residents who had a fatal or non-fatal overdose from 2016 to 2020 using an environmental scan and data from Rhode Island emergency medical services, State Unintentional Drug Overdose Reporting System, and the American Community Survey. We conducted a spatial scan via SaTScan to identify non-fatal and fatal overdose hotspots and compared the characteristics of hotspot and non-hotspot neighborhoods. We identified associations between census block group-level characteristics using a Besag-York-Mollié model specification with a conditional autoregressive spatial random effect., Results: We identified 7 non-fatal and 3 fatal overdose hotspots in Rhode Island during the study period. Hotspot neighborhoods had higher proportions of Black and Latino/a residents, renter-occupied housing, vacant housing, unemployment, and cost-burdened households. A higher proportion of hotspot neighborhoods had a religious organization, a health center, or a police station. Non-fatal overdose risk increased in a dose responsive manner with increasing proportions of residents living in poverty. There was increased relative risk of non-fatal and fatal overdoses in neighborhoods with crowded housing above the mean (RR 1.19 [95 % CI 1.05, 1.34]; RR 1.21 [95 % CI 1.18, 1.38], respectively)., Conclusion: Neighborhoods with increased prevalence of housing instability and poverty are at highest risk of overdose. The high availability of social services in overdose hotspots presents an opportunity to work with established organizations to prevent overdose deaths., Competing Interests: Declaration of competing interest None., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Drug overdose persists as a leading cause of death in the United States, but resources to address it remain limited. As a result, health authorities must consider where to allocate scarce resources within their jurisdictions. Machine learning offers a strategy to identify areas with increased future overdose risk to proactively allocate overdose prevention resources. This modeling study is embedded in a randomized trial to measure the effect of proactive resource allocation on statewide overdose rates in Rhode Island (RI)., Methods: We used statewide data from RI from 2016 to 2020 to develop an ensemble machine learning model predicting neighborhood-level fatal overdose risk. Our ensemble model integrated gradient boosting machine and super learner base models in a moving window framework to make predictions in 6-month intervals. Our performance target, developed a priori with the RI Department of Health, was to identify the 20% of RI neighborhoods containing at least 40% of statewide overdose deaths, including at least one neighborhood per municipality. The model was validated after trial launch., Results: Our model selected priority neighborhoods capturing 40.2% of statewide overdose deaths during the test periods and 44.1% of statewide overdose deaths during validation periods. Our ensemble outperformed the base models during the test periods and performed comparably to the best-performing base model during the validation periods., Conclusions: We demonstrated the capacity for machine learning models to predict neighborhood-level fatal overdose risk to a degree of accuracy suitable for practitioners. Jurisdictions may consider predictive modeling as a tool to guide allocation of scarce resources., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

As the field of public health rises to the demands of real-time surveillance and rapid data-sharing needs in a postpandemic world, it is time to examine our approaches to the dissemination and accessibility of such data. Distinct challenges exist when working to develop a shared public health language and narratives based on data. It requires that we assess our understanding of public health data literacy, revisit our approach to communication and engagement, and continuously evaluate our impact and relevance. Key stakeholders and cocreators are critical to this process and include people with lived experience, community organizations, governmental partners, and research institutions. In this viewpoint paper, we offer an instructive approach to the tools we used, assessed, and adapted across 3 unique overdose data dashboard projects in Rhode Island, United States. We are calling this model the "Rhode Island Approach to Public Health Data Literacy, Partnerships, and Action." This approach reflects the iterative lessons learned about the improvement of data dashboards through collaboration and strong partnerships across community members, state agencies, and an academic research team. We will highlight key tools and approaches that are accessible and engaging and allow developers and stakeholders to self-assess their goals for their data dashboards and evaluate engagement with these tools by their desired audiences and users., (©Jesse Yedinak, Maxwell S Krieger, Raynald Joseph, Stacey Levin, Sarah Edwards, Dennis A Bailer, Jonathan Goyer, Colleen Daley Ndoye, Cathy Schultz, Jennifer Koziol, Rachael Elmaleh, Benjamin D Hallowell, Todd Hampson, Ellen Duong, Abdullah Shihipar, William C Goedel, Brandon DL Marshall. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 12.02.2024.)

Oral HIV pre-exposure prophylaxis (PrEP) is highly effective for preventing HIV. Several different developments in the US either threaten to increase or promise to decrease PrEP out-of-pocket costs and access in the coming years. In a sample of 58,529 people with a new insurer-approved PrEP prescription, we estimated risk-adjusted percentages of patients who abandoned (did not fill) their initial prescription across six out-of-pocket cost categories. We then simulated the percentage of patients who would abandon PrEP under hypothetical changes to out-of-pocket costs, ranging from $0 to more than $500. PrEP abandonment rates of 5.5 percent at $0 rose to 42.6 percent at more than $500; even a small increase from $0 to $10 doubled the rate of abandonment. Conversely, abandonment rates that were 48.0 percent with out-of-pocket costs of more than $500 dropped to 7.3 percent when those costs were cut to $0. HIV diagnoses were two to three times higher among patients who abandoned PrEP prescriptions than among those who filled them. These results imply that recent legal challenges to the provision of PrEP with no cost sharing could substantially increase PrEP abandonment and HIV rates, upending progress on the HIV/AIDS epidemic.

Background: The US Ending the HIV Epidemic (EHE) initiative aims to reduce national HIV incidence 90% by 2030 and to address the disproportionate burden of HIV among different racial/ethnic populations. Florida's state-wide 2022-2026 Integrated HIV Prevention and Care Plan outlines objectives for reaching EHE goals. In Miami-Dade County, we determined the epidemiological impact of achieving the integrated plan's objectives individually and jointly., Methods: We adapted an HIV transmission model calibrated to Miami-Dade County adjusting access to HIV testing, pre-exposure prophylaxis (PrEP) and antiretroviral treatment to model the effects of each objective between 2022 and 2030. We compared two service scale-up approaches: (a) scale-up proportionally to existing racial/ethnic group access levels, and (b) scale-up according to new diagnoses across racial/ethnic groups (equity-oriented). We estimated reductions in new HIV infections by each objective and approach, compared to the EHE's incidence reduction target., Findings: The single most influential strategy was reducing new HIV diagnoses in Hispanic/Latinx men who have sex with men through increased PrEP uptake, resulting in 907/2444 (37.1%) fewer annual new HIV infections in 2030. Achieving all objectives jointly would result in 1537/2444 (62.9%) and 1553/2444 (63.5%) fewer annual new HIV infections with the proportional and equity-oriented approaches, respectively., Interpretation: Achieving the goals of Florida's integrated care plan would significantly reduce HIV incidence in Miami-Dade County; however, further efforts are required to achieve EHE targets. Structural changes in service delivery and a focus on effective implementation of available interventions to address racial/ethnic disparities will be crucial to ending the HIV epidemic., Funding: This work was supported by the National Institutes of Health/National Institute on Drug Abuse grant no. R01-DA041747., Competing Interests: XZ reports subaward funding from the National Institute on Drug Abuse (R01DA041747) as Co-Investigator. DJF reports consultant payments from R01DA041747. PSS reports grant funding from NIH, CDC, Gilead Sciences, Merck and Viiv Healthcare. BN reports NIDA R01DA041747 funding paid to institution as Principal Investigator. HET reports grant funding from Gilead Sciences and Viiv Healthcare, participation in Data Safety Monitoring Board/Advisory Board for 4UH3DA047720-03, and leadership or fiduciary roles involving HIVMA, PACHA, SAFE project and Florida Harm Reduction Collection., (© 2023 Published by Elsevier Ltd.)

Black sexual minority men (SMM) in the Deep South are heavily impacted by HIV; yet studies fail to consider discordance across aspects of sexual orientation (i.e., identity, attraction, behavior) or how a lack of concordance enhances vulnerability to HIV. We sought to explore the overlap across aspects of sexual orientation and examine associations between each aspect and the number of sexual partners who engaged in HIV vulnerability-enhancing behaviors, and HIV prevention and care outcomes. A total of 204 Black SMM completed surveys, reporting their sexual identity, attraction, and behavior (i.e., sex with men only vs. sex with men and women), number of condomless sex or transactional sex (e.g., buyers vs. sellers) partners in the past 6 months, and adherence to pre-exposure prophylaxis (PrEP) or antiretroviral therapy (ART) among users. Less than one in four participants (22.5%) reported overlap in same-sex sexual orientations, while 17.1% of bisexual men reported overlap across aspects. In multivariable models, differences were found in how aspects of sexual orientation were associated with the number of partners who bought or sold sex; as well as how often participants tested for HIV in the past 12 months. Results suggest different aspects of sexual orientation have implications for addressing HIV among Black SMM in the Deep South., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The coronavirus disease 2019 (COVID-19) pandemic continues to put strain on health systems in the United States, leading to significant shifts in the delivery of routine clinical services, including those offering HIV pre-exposure prophylaxis (PrEP). We aimed to assess whether individuals discontinued PrEP use at higher rates during the COVID-19 pandemic and the extent to which disruptions to usual clinical care were mitigated through telehealth., Methods: Using data from an ongoing prospective cohort of men who have sex with men (MSM) newly initiating PrEP in 3 mid-sized cities (n = 195), we calculated the rate of first-time discontinuation of PrEP use in the period before the COVID-19 pandemic and during the COVID-19 pandemic and compared these rates using incidence rate ratios (IRRs). Furthermore, we compared the characteristics of patients who discontinued PrEP use during these periods with those who continued to use PrEP during both periods., Results: Rates of PrEP discontinuation before the COVID pandemic and during the COVID-19 pandemic were comparable [4.29 vs. 5.20 discontinuations per 100 person-months; IRR: 1.95; 95% confidence interval (CI): 0.83 to 1.77]. Although no significant differences in the PrEP discontinuation rate were observed in the overall population, the rate of PrEP discontinuation increased by almost 3-fold among participants aged 18-24 year old (IRR: 2.78; 95% CI: 1.48 to 5.23) and by 29% among participants covered by public insurance plans at enrollment (IRR: 1.29; 95% CI: 1.03 to 5.09). Those who continued to use PrEP were more likely to have had a follow-up clinical visit by telehealth in the early months of the pandemic (45% vs. 17%)., Conclusions: In this study, rates of PrEP discontinuation were largely unchanged with the onset of the COVID-19 pandemic. The use of telehealth likely helped retain patients in PrEP care and should continue to be offered in the future., Competing Interests: Supported by a grant from the National Institute of Mental Health (R01MH114657; MPI: P.A.C. and A.S.N.). B.G.R. has received research project funds from Gilead Sciences, Inc. L.A.M. has received consulting fees and speaker fees from Gilead Sciences, Inc.; GlaxoSmithKline, LLC; Merck Sharp & Dohme Corporation; Roche Molecular Systems, Inc.; Theratechnologies, Inc.; and ViiV Health Healthcare Company. R.R.P. has received consulting fees from Gilead Sciences, Inc. and ViiV Healthcare Company. The remaining authors have no conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Suboptimal HIV pre-exposure prophylaxis (PrEP) care outcomes among Black/African American men who have sex with men (MSM) limits its population-level effects on HIV incidence. We conducted a pilot study of a brief patient navigation intervention aimed at improving PrEP initiation and persistence among Black/African American MSM in the Southern United States., Setting: Community health center in Jackson, MS., Methods: We recruited 60 Black/African American MSM aged 18-34 years who were newly prescribed PrEP. Participants were randomized to receive the clinic's current standard of care or an intervention condition including a single patient navigation session to discuss and address perceived barriers to initiating and maintaining access to PrEP and biweekly check-ins. Participants were followed over 6 months using survey assessments, medical chart review, and pharmacy purchase records to ascertain PrEP initiation and persistence., Results: Participants in the intervention condition were more likely to pick up their initial PrEP prescription [RR: 1.47; 95% confidence interval (CI): 1.10 to 1.97], be retained in PrEP care at 3 months (RR: 1.62; 95% CI: 1.01 to 2.59) and 6 months (RR: 1.38; 95% CI: 0.64 to 2.93), and have access to PrEP medications greater than 80% of all study days based on pharmacy fill records (RR: 3.00; 95% CI: 1.50 to 5.98)., Conclusion: A brief patient navigation intervention demonstrated proof-of-concept in improving PrEP initiation and persistence among Black/African American MSM in the Southern United States., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Standard equations for estimating glomerular filtration rate (eGFR) employ race multipliers, systematically inflating eGFR for Black patients. Such inflation is clinically significant because eGFR thresholds of 60, 30, and 20 ml/min/1.73m 2 guide kidney disease management. Racialized adjustment of eGFR in Black Americans may thereby affect their clinical care. In this study, we analyze and extrapolate national data to assess potential impacts of the eGFR race adjustment on qualification for kidney disease diagnosis, nephrologist referral, and transplantation listing., Methods: Using population-representative cross-sectional data from the United States National Health and Nutrition Examination Survey (NHANES) from 2015-2018, eGFR values for Black Americans were calculated using the Modification of Diet in Renal Disease (MDRD) equation with and without the 1.21 race-specific coefficient using cohort data on age, sex, race, and serum creatinine., Findings: Without the MDRD eGFR race adjustment, 3.3 million (10.4%) more Black Americans would reach a diagnostic threshold for Stage 3 Chronic Kidney Disease, 300,000 (0.7%) more would qualify for beneficial nephrologist referral, and 31,000 (0.1%) more would become eligible for transplant evaluation and waitlist inclusion., Interpretation: These findings suggest eGFR race coefficients may contribute to racial differences in the management of kidney. We provide recommendations for addressing this issue at institutional and individual levels., Funding: No external funding was received for this study., Competing Interests: Author JPC acknowledges support from the National Institutes of Health Medical Scientist Training Program Grant T32GM136651 and the Robert Wood Johnson Health Policy Research Scholars Program. Author WSA has previously acted as a site principal investigator, with fees paid to the institution, for Novartis, Medeor Therapeutics, Amplyx Therapeutics, and InRegen. WSA also serves on the education committee for the American Society of Transplantation. Author MLM previously consulted for BayerAG in 2020. Author VG has previously received payment for educational work for Akebia Pharmaceuticals, the University of New Mexico, Alameda Health System, and the University of Illinois Chicago., (© 2021 The Author(s).)

This study investigated sexual identity and behavior and their potential associations with PrEP use and attitudes in cisgender Black gay and bisexual men. A total of N = 173 (mean age 25.2) participants from the Neighborhoods and Networks (N2) Study in Chicago were included. Of these, 104 were gay-identified and reported sex with men only (GSMO), 26 were gay-identified and reported sex with men and women (GSMW), 8 were bisexual-identified and reported sex with men only (BSMO), and 35 were bisexual-identified and reported sex with men and women (BSMW). Reporting sex with men and women in the past 6 months, RR = 0.39, 95% CI [0.17, 0.89], identifying as bisexual, RR = 0.52, 95% CI [0.29, 0.92], and the combination of the two, RR = 0.24, 95% CI [0.07, 0.76] were significantly associated with lower rates of current oral PrEP use. Black bisexual-identifying men who reported sex with men and women were significantly more likely to have discontinued oral PrEP, RR = 2.50, 95% CI [1.14, 5.50], than Black gay-identified men who reported sex with men only. Participants who had not used oral PrEP before reported lower levels of interest in long-acting injectable PrEP than those who were currently using oral PrEP, RR = 0.56, 95% CI [0.40, 0.79]. No other significant differences were found. Overlooking the combination of sexual identity and behavior may mischaracterize PrEP rates and miss uniquely vulnerable subgroups. Black gay and bisexual men who had not used oral PrEP may be particularly disinterested in long-acting injectable PrEP., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: In the USA, Black and Hispanic or Latinx individuals continue to be disproportionately affected by HIV. Applying a distributional cost-effectiveness framework, we estimated the cost-effectiveness and epidemiological impact of two combination implementation approaches to identify the approach that best meets the dual objectives of improving population health and reducing racial or ethnic health disparities., Methods: We adapted a dynamic, compartmental HIV transmission model to characterise HIV micro-epidemics in six US cities: Atlanta, Baltimore, Los Angeles, Miami, New York, and Seattle. We considered combinations of 16 evidence-based interventions to diagnose, treat, and prevent HIV transmission according to previously documented levels of scale-up. We then identified optimal combination strategies for each city, with the distribution of each intervention implemented according to existing service levels (proportional services approach) and the racial or ethnic distribution of new diagnoses (between Black, Hispanic or Latinx, and White or other ethnicity individuals; equity approach). We estimated total costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios of strategies implemented from 2020 to 2030 (health-care perspective; 20-year time horizon; 3% annual discount rate). We estimated three measures of health inequality (between-group variance, index of disparity, Theil index), incidence rate ratios, and rate differences for the selected strategies under each approach., Findings: In all cities, optimal combination strategies under the equity approach generated more QALYs than those with proportional services, ranging from a 3·1% increase (95% credible interval [CrI] 1·4-5·3) in New York to more than double (101·9% [75·4-134·6]) in Atlanta. Compared with proportional services, the equity approach delivered lower costs over 20 years in all cities except Los Angeles; cost reductions ranged from $22·9 million (95% CrI 5·3-55·7 million) in Seattle to $579·8 million (255·4-940·5 million) in Atlanta. The equity approach also reduced incidence disparities and health inequality measures in all cities except Los Angeles., Interpretation: Equity-focused HIV combination implementation strategies that reduce disparities for Black and Hispanic or Latinx individuals can significantly improve population health, reduce costs, and drive progress towards Ending the HIV Epidemic goals in the USA., Funding: National Institute on Drug Abuse., Competing Interests: Declaration of interests KA reports grants from the US National Institutes of Health (NIH), personal fees from The All of Us Research Program (NIH), personal fees from TrioHealth, and non-financial support from Cumming School of Medicine, University of Calgary, outside the submitted work. CNB reports grants from the National Institute on Drug Abuse, during the conduct of the study. EE reports personal fees from ViiV Healthcare, outside the submitted work. KAG reports personal fees from Simon Fraser University, during the conduct of the study. SHM reports personal fees from Gilead Sciences, outside the submitted work. MG reports research support from Hologic, outside the submitted work. SAS reports grants from NIH, outside the submitted work. HT reports grants from Gilead Sciences, outside the submitted work. BN reports grants from NIH, during the conduct of the study. All other authors declare no competing interests., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Preexposure prophylaxis (PrEP) for prevention of human immunodeficiency virus (HIV) infection may benefit not only the person who uses it but also their uninfected sexual risk contacts. We developed an agent-based model using a novel trial emulation approach to quantify disseminated effects of PrEP use among men who have sex with men in Atlanta, Georgia, from 2015 to 2017. Model components (subsets of agents connected through partnerships in a sexual network but not sharing partnerships with any other agents) were first randomized to an intervention coverage level or the control group; then, within intervention components, eligible agents were randomized to receive or not receive PrEP. We calculated direct and disseminated (indirect) effects using randomization-based estimators and report corresponding 95% simulation intervals across scenarios ranging from 10% coverage in the intervention components to 90% coverage. A population of 11,245 agents was simulated, with an average of 1,551 components identified. When comparing agents randomized to no PrEP in 70% coverage components with control agents, there was a 15% disseminated risk reduction in HIV incidence (risk ratio = 0.85, 95% simulation interval: 0.65, 1.05). Persons not on PrEP may receive a protective benefit by being in a sexual network with higher PrEP coverage. Agent-based models are useful for evaluating possible direct and disseminated effects of HIV prevention modalities in sexual networks., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: We assessed if young transgender women (YTW) with parents who are supportive of their transgender identity had lower odds of having suicidal ideation compared with YTW with unsupportive parents. Methods: This study analyzed baseline findings from a diverse sample of 297 sexually active, YTW 16-29 years of age who were enrolled in Project LifeSkills, a randomized controlled HIV prevention intervention efficacy trial in Chicago and Boston, between 2012 and 2015. Bivariate and multivariable logistic regression were used to assess if parental support was associated with a decreased odds of suicidal ideation. Results: Nearly one-fifth (18.9%) of YTW reported suicidal ideation at baseline. In our adjusted multivariable model, YTW with supportive mothers had 0.37 (95% confidence interval = 0.15-0.90) times the odds of having suicidal ideation compared with YTW with unsupportive mothers. Conclusion: This study found that the odds of suicidal ideation were lower among YTW who had mothers who were supportive of their transgender identity. Our results suggest that parent-focused interventions to improve the relationships between YTW and their parents may lower the odds of YTW having suicidal ideation. Clinical Trial Registration Identifier: NCT01575938.

Background: Male sex workers (MSWs) are at increased risk of HIV infection in the United States. Research is limited on sexual and drug use network characteristics of MSWs., Setting: Community-based organization and health center in 2 US Northeast cities., Methods: One hundred MSWs completed a behavioral assessment and sexual and drug network inventory. Using dyadic analyses, we assessed whether network characteristics, including sex worker-male client age, race, and HIV status homophily and risk multiplexity (ie, overlap in drug-use and sex networks), were associated with condom use., Results: MSW participants' mean age was 33.6. Two-thirds identified as Black or Latino, 12% identified as heterosexual, and 90% reported recent drug use. Participants reported an average of 5.3 male clients in the past month (SD = 3.4), and having anal sex with 74% of these clients, at a rate of 2.2 times per month (SD = 4.6). Participants reported inconsistent condom use during anal sex with 53% of clients. In multivariable models, inconsistent condom use was more common in relationships with presumed HIV status homophily [odds ratio (OR): 1.25; 95% confidence interval (CI): 1.07 to 1.46] and sexual and drug network multiplexity (OR: 1.19; 95% CI: 1.09 to 1.30); and less common within relationships where the client is older than the MSW participant (OR: 0.83; 95% CI: 0.74 to 0.93). Number of multiplex relationships was positively associated with number of condomless anal sex acts with male clients (incidence rate ratio: 1.35; 95% CI: 1.19 to 1.54)., Conclusions: Network characteristics may contribute to disproportionate HIV risk among MSWs. Modeling studies should include network characteristics when simulating HIV transmission, and future HIV interventions should address the role of networks.

Pre-exposure prophylaxis (PrEP) is an effective tool for preventing HIV infection among men who have sex with men (MSM), but its cost-effectiveness has varied across settings. Using an agent-based model, we projected the cost-effectiveness of a statewide PrEP program for MSM in Rhode Island over the next decade. In the absence of PrEP, the model predicted an average of 830 new HIV infections over ten years. Scaling up the existing PrEP program to cover 15% of MSM with ten or more partners each year could reduce the number of new HIV infections by 33.1% at a cost of $184,234 per quality-adjusted life-year (QALY) gained. Expanded PrEP use among MSM at high risk for HIV infection has the potential to prevent a large number of new HIV infections but the high drug-related costs may limit the cost-effectiveness of this intervention.