Correction to: Development of the Experiences of Sex Work Stigma Scale Using Item Response Theory: Implications for Research on the Social Determinants of HIV

While HIV stigma has received significant attention, limited work has been conducted on the measurement of intersecting stigmas. We developed the Experiences of Sex Work Stigma (ESWS) scale in the Dominican Republic (DR) and Tanzania. We conducted in-depth interviews with 20 female sex workers (FSW) per country to identify scale domains followed by cognitive debriefing interviews to assess content validity. Items were administered in a survey to FSW in DR (n = 211) and Tanzania (n = 205). Factor analysis established four sex work stigma domains including: shame (internalized), dignity (resisted), silence (anticipated) and treatment (enacted). Reliability across domains ranged from 0.81 to 0.93. Using item response theory (IRT) we created context-specific domain scores accounting for differential item functioning between countries. ESWS domains were associated with internalized HIV stigma, depression, anxiety, sexual partner violence and social cohesion across contexts. The ESWS is the first reliable and valid scale to assess multiple domains of sex work stigma and can be used to examine the effects of this form of intersectional stigma on HIV-related outcomes across settings.

     

Construction of the Pediatric Asthma Impact Scale (PAIS) for the Patient-Reported Outcomes Measurement Information System (PROMIS)

Background. Recently, the National Institutes of Health Roadmap for Medical Research initiative led a large-scale effort to develop the Patient-Reported Outcomes Measurement Information System (PROMIS). PROMIS's main goal was to develop a set of item banks and computerized adaptive tests for the clinical research community. Asthma, as the most common chronic childhood disease, was chosen for a disease-specific pediatric item bank. Objectives. The primary objective of this research is to present the details of the psychometric analyses of the asthma domain items. Methods. Item response theory (IRT) analyses were conducted on a 34–asthma item bank. Test forms containing PROMIS Pediatric Asthma domain items were completed by 622 children ages 8 to 12. Items were subsequently evaluated for local dependence, scale dimensionality, and differential item functioning. Results. A 17-item pool and an 8-item short form for the new PROMIS Pediatric Asthma Impact Scale (PAIS) were generated using IRT. The recommended 8-item short form contains the item set that provides the maximum test information at the mean (50) on the T-score metric. If more score precision is required, the complete 17-item pool is recommended and may be used in toto or as the basis of a computerized adaptive test (CAT). A shorter test form can also be created and scored on the same scale. Conclusions. The present study presents the PROMIS Pediatric Asthma Impact Scale (PAIS) developed with IRT, and provides the initial calibration data for the items.     

NIDA’s Clinical Trials Network: An Opportunity for HIV Research in Community Substance Abuse Treatment Programs

Background/Objectives: HIV continues to be a significant problem among substance users and their sexual partners in the United States. The National Drug Abuse Treatment Clinical Trials Network (CTN) offers a national platform for effectiveness trials of HIV interventions in community substance abuse treatment programs. This article presents the HIV activities of the CTN during its first 10 years. Results: While emphasizing CTN HIV protocols, this article reviews the (1) HIV context for this work; (2) the collaborative process among providers, researchers, and National Institute on Drug Abuse CTN staff, on which CTN HIV work was based; (3) results of CTN HIV protocols and HIV secondary analyses in CTN non-HIV protocols; and (4) implications for future HIV intervention effectiveness research in community substance abuse treatment programs. Conclusion/Significance: While the feasibility of engaging frontline providers in this research is highlighted, the limitations of small to medium effect sizes and weak adoption and sustainability in everyday practice are also discussed.     

Substance Use and High Risk Sexual Behaviors among Women in Psychosocial Outpatient and Methadone Maintenance Treatment Programs

Objectives: The purpose of the present study was to assess the association between substance use/diagnosis and sexual risk behaviors among women enrolled in both psychosocial outpatient (PS) and methadone maintenance (MM) treatment and involved in a HIV prevention intervention study within the National Institute for Drug Abuse Clinical Trials Network. Methods: 515 sexually active women reported on unprotected sexual occasions (USO), anal sex, sex trading, sex with drug occasions, and multiple male sex partners at the baseline assessment. Results: Within the PS sample, cocaine use diagnosis was associated with more than twice the risk of having multiple partners, trading sex for drugs, having anal sex, or having sex with drugs; alcohol or opioid use diagnosis was associated with fewer risk behaviors. Within the MM sample, cocaine use, alcohol use and opiate use diagnoses were each associated with one to two risk behaviors. Associations between sexual risk and substance using days were less frequent in both samples. Conclusions: These findings highlight the need for integration of HIV sexual prevention interventions that address the relationship between sexual risk behavior and substance use diagnoses into substance abuse treatment programs.     

Promoting the Sexual Health of MSM in the Context of Comorbid Mental Health Problems

This study of 632 drug injectors enrolled in eight residential detoxification centers within the National Drug Abuse Treatment Clinical Trials Network tested three interventions to reduce drug and sex risk behaviors. Participants were randomized to: (a) a two-session, HIV/HCV counseling and education (C&E) model added to treatment as usual (TAU), (b) a one-session, therapeutic alliance (TA) intervention conducted by outpatient counselors to facilitate treatment entry plus TAU, or (c) TAU. Significant reductions in drug and sex risk behaviors occurred for all three conditions over a 6-month follow-up period. C&E participants reported significantly greater rates of attending an HIV testing appointment, but this was not associated with better risk reduction outcomes. Reporting treatment participation within 2 months after detoxification and self-efficacy to practice safer injection behavior predicted reductions in injection risk behaviors. Findings indicate that participation in detoxification was followed by significant decreases in drug injection and risk behaviors for up to 6-months; interventions added to standard treatment offered no improvement in risk behavior outcomes.     

The validity of DSM-IV cannabis abuse and dependence criteria in adolescents and the value of additional cannabis use indicators

Aims This study assessed the validity of DSM‐IV cannabis abuse and dependence criteria in an adolescent general population sample and evaluated the usefulness of additional cannabis use indicators. Design and setting Data came from the 2008 Survey on Health and Consumption during the Day of Defense Preparation (ESCAPAD), a cross‐sectional self‐administered survey conducted in France. Participants The analytical sample comprised 3641 adolescents aged 17–19 years who reported cannabis use in the past 12 months. Measurements To assess DSM‐IV criteria of cannabis abuse and dependence, the Munich Composite International Diagnostic Interview (M‐CIDI) was used. As additional cannabis use indicators, daily use, use when alone and use before midday were assessed. Confirmatory factor analyses and two‐parameter logistic item response theory (IRT) models were run. Differential item functioning was assessed using the IRT log‐likelihood ratio approach. Results A one‐factor model comprising both abuse and dependence criteria showed the best fit to the data. Abuse item legal problems showed the greatest severity, whereas dependence items larger/longer and tolerance were found least severe. Discriminatory power was lowest for impaired control and legal problems. Additional cannabis use indicators increased the precision of the overall DSM‐IV criterion set. Gender‐based differential item functioning was observed for items tolerance, withdrawal and use before midday. Conclusion The current DSM conceptualization with two distinct and graded diagnostic classes has limited validity among adolescents. In forthcoming revisions of the classification system, several existing criteria should be revised or dropped, new indicators of substance use disorders should be included and gender should be considered.     

RhinAsthma patient perspective: A Rasch validation study

Objective: In daily practice, Health-Related Quality of Life (HRQoL) tools are useful for supplementing clinical data with the patient's perspective. To encourage their use by clinicians, the availability of tools that can quickly provide valid results is crucial. A new HRQoL tool has been proposed for patients with asthma and rhinitis: the RhinAsthma Patient Perspective—RAPP. The aim of this study was to evaluate the psychometric robustness of the RAPP using the Item Response Theory (IRT) approach, to evaluate the scalability of items and test whether or not patients use the items response scale correctly. Methods: 155 patients (53.5% women, mean age 39.1, range 16–76) were recruited during a multicenter study. RAPP metric properties were investigated using IRT models. Differential item functioning (DIF) was used for gender, age, and asthma control test (ACT). Results: The RAPP adequately fitted the Rating Scale model, demonstrating the equality of the rating scale structure for all items. All statistics on items were satisfactory. The RAPP had adequate internal reliability and showed good ability to discriminate among different groups of participants. DIF analysis indicated that there were no differential item functioning issues for gender. One item showed a DIF by age and four items by ACT. Conclusions: The psychometric evaluation performed using IRT models demonstrated that the RAPP met all the criteria to be considered a reliable and valid method of measurement. From a clinical perspective, this will allow physicians to confidently interpret scores as good indicators of Quality of Life of patients with asthma.     

Patterns of substance use and correlates of lifetime and active injection drug use among women in Malaysia

ABSTRACT

Background: While drug use is associated with HIV risk in Southeast Asia, little is known about substance use behaviors among women, including drug injection. Objectives: To describe patterns of substance use among women using alcohol and drugs in Malaysia and identify correlates of lifetime and active drug injection, a risk factor for HIV transmission. Methods: A survey of 103 women who used drugs in the last 12 months assessed drug use history and frequency, including drug injection and drug use during pregnancy, self-reported HIV-status, childhood and adulthood physical and sexual abuse, and access to and utilization of harm reduction services, including needle-syringe exchange programs (NSEP) and opioid agonist maintenance therapy (OAT). Principal component analyses (PCA) were conducted to assess drug use grouping. Results: Amphetamine-type substances (ATS; 82.5%), alcohol (75.7%) and heroin (71.8%) were the most commonly used drugs across the lifetime. Drug injection was reported by 32.0% (n = 33) of participants with 21.4% (n = 22) having injected in the last 30 days. PCA identified two groups of drug users: opioids/benzodiazepines and club drugs. Lifetime drug injection was significantly associated with lower education, homelessness, prior criminal justice involvement, opioid use, polysubstance use, childhood physical and sexual abuse, and being HIV-infected, but not with prior OAT. Conclusion: Women who use drugs in Malaysia report high levels of polysubstance use and injection-related risk behaviors, including sharing of injection equipment and being injected by others. Low OAT utilization suggests the need for improved access to OAT services and other harm reduction measures that prioritize women.     

The impact of needle exchange-based health services on emergency department use

OBJECTIVE: To examine the impact of the New Haven Community Health Care Van (CHCV), a mobile needle exchange-based health care delivery system, in reducing emergency department (ED) use among out-of-treatment injection drug users (IDUs) between January 1, 1996 and December 31, 1998. DESIGN: A pre-post comparison of ED utilization was performed using linked medical records from New Haven’s only two emergency departments. Fixed-effect negative binomial regression analysis was used to explore the impact of the CHCV on ED use within a longitudinal cohort. SETTING: Mobile health clinic in New Haven, Conn. PARTICIPANTS: Out-of-treatment IDUs. INTERVENTION: Acute care, linkages to medical, drug treatment, and social services. MEASUREMENTS AND MAIN RESULTS: Among 373 IDUs, 117 (31%) were CHCV clients, and 256 had not used CHCV services. At baseline, CHCV users were more frequent users of ED services (P<.001). After full-scale implementation, mean ED utilization declined among CHCV clients and increased within the non-CHCV group. CHCV use is associated with statistically significant reductions in ED use, with an incidence rate ratio (IRR) of 0.79 (95% confidence interval [95% CI], 0.66 to 0.95). Subgroup analyses demonstrated significant IRR reductions, notably among Hispanics (0.65; 95% CI, 0.47 to 0.90), men (0.79; 95% CI, 0.64 to 0.98), HIV-negative IDUs (0.79; 95% CI, 0.63 to 0.98), and those with mental illness (0.75; 95% CI, 0.60 to 0.94). CONCLUSION: Needle exchange-based health care services can reduce ED utilization among high-risk injection drug users. Such services may have an important role within communities with high rates of drug use and HIV/AIDS. This research was funded by the National Institute on Drug Abuse (R01-DA10186, Principal Investigator Frederick L. Altice).     

Evaluation of a Japanese version of the Mini‐Mental State Examination in elderly persons

Aim: This study aimed to examine the validity and item‐response characteristics of the Mini‐Mental State Examination (MMSE), which is used for assessing cognitive function, in Japanese older adults. Methods: Factor analysis and item response analysis were carried out for MMSE responses (n = 1971) from older adults living in the community (n = 1339) or in a nursing home (n = 632), including Alzheimer‐type dementia (n = 330), vascular dementia (n = 36), frontotemporal dementia (n = 7), mixed Alzheimer‐type and frontotemporal type dementia (n = 27), and age‐related cognitive decline (n = 29). When choosing the cut‐off score of 23 points for the MMSE, sensitivity and specificity for each item were calculated. Results: A three‐factor solution was found to be most appropriate by factor analysis: complex processing, simple processing and working memory. The item characteristics curves showed unidimensionality with high reproducibility. We identified a simplified scale comprising 10 items in all participants: “naming”, “three‐step command”, “registration”, “repeat a sentence”, “write a complete sentence”, “copies drawing of two polygons”, “orientation to place”, “delayed recall”, “orientation to time” and “serial sevens” tasks. Sensitivity and specificity for both “year” task and “day” task were more than 90% (“year”: sensitivity 92.5%, specificity 96.3%; “day”: sensitivity 92.4%, specificity 91.7%). For the Alzheimer‐type dementia patients, the five‐factor solution was suggested by factor analysis and the MMSE also had unidimensionality in terms of level of difficulty. Conclusions: We found that the MMSE had multiple cognitive areas. We showed that the MMSE could be used as an essentially unidimensional measure of cognitive ability and the question about orientation to time might be useful in the simplest assessment to identify cognitive dysfunction. Geriatr Gerontol Int 2012; 12: 310–316.     

Conducting Research with Racial/Ethnic Minorities: Methodological Lessons from the NIDA Clinical Trials Network

Background: Multiple studies in the National Institute on Drug Abuse Clinical Trials Network (CTN) demonstrate strategies for conducting effective substance abuse treatment research with racial/ethnic minorities (REMs). Objectives: The objectives of this article are to describe lessons learned within the CTN to (1) enhance recruitment, retention, and other outcomes; (2) assess measurement equivalence; and (3) use data analytic plans that yield more information. Method: This article includes background information and examples from multiple CTN studies on inclusion, measurement, and data analysis. Results and Conclusions: Seven recommendations are included for conducting more effective research on REMs.     

Is Monogamy or Committed Relationship Status a Marker for Low Sexual Risk among Men in Substance Abuse Treatment? Clinical and Methodological Considerations

Background: HIV prevention interventions often promote monogamy to reduce sexual risk. However, there is little consensus about how to define monogamy. Objective: To determine the extent to which recent monogamy and/or being in a committed relationship serve as markers for low sexual risk among men in substance abuse treatment. Methods: Participants were 360 men enrolled in the National Institute on Drug Abuse Clinical Trials Network “Real Men Are Safe” protocol who completed all assessments (baseline, 3 months, and 6 months). Self-reported behaviors included number of sexual partners, type of relationships, frequency of vaginal/anal intercourse, and percentage of condom use. Results: The rate of self-reported monogamy in the prior 90 days was stable across assessments (54.2%, 53.1%, 58.3%). However, at each assessment 7.5–10% of monogamous men identified their partner as a casual partner, and only 123 (34.2%) reported being monogamous at every assessment. Of these, 20 (5.6%) reported being monogamous with different partners across assessments. Men with both committed relationship and casual partners reported more condom use with their committed relationship partners than men with only a committed relationship partner. Conclusion: Clinicians and researchers should consider individual relationship context and behavior and avoid assuming that recent monogamy or being in a committed relationship denotes low risk. Scientific Significance: This study provides evidence that, in male drug users, monogamy does not necessarily reflect low sexual risk. Rather, “monogamous” men actually encompass various combinations of partner types and levels of risk behavior that are unstable, even over brief time periods. Clinicians and researchers must take these variations into account.

Trial registration: ClinicalTrials.gov identifier: NCT00084175.     

Using Behavioral Research to Address Drug Abuse and AIDS

Drug abuse and the spread of HIV/AIDS are intertwined public health problems that require many and multifaceted solutions. Behavioral and social science research plays an important role in helping us to understand and develop solutions to these related epidemics. Behavioral research supported by the National Institute on Drug Abuse (NIDA) has demonstrated that drug users are amenable to behavior change strategies. Drug abuse treatment, prevention and community-based outreach programs have all been found to be effective in reducing drug use, needle-sharing practices, unsafe sex behaviors, as well as risk for HIV infection.     

HIV Sex-Risk Behaviors among In- versus Out-of-Treatment Heroin-Addicted Adults

Background: Relatively limited empirical evidence exists comparing the impact on HIV sex risk behavior for patients admitted to methadone treatment programs (MTPs) as compared with nontreatment seekers. Methods: This longitudinal cohort study examined HIV sex-risk behavior among 164 out-of-treatment heroin-dependent adults recruited from the street and 351 newly admitted MTP patients. The AIDS Risk Assessment was administered at baseline, 6 months, and 12 months. Generalized linear mixed model and generalized estimating equation analyses were used to examine the changes in sex risk behavior over time. Results: The participants mean age was 41.5 years, 74.8% were African-American, 24.3% were White, and 54.4% were men. There were no significant differences between the groups in age, race, or gender. At baseline, the out-of-treatment group compared with the in-treatment group reported more sex partners (p < .001) and higher frequency of sex (p = .001). There was a group x time interaction for three of the sex-risk items and the out-of-treatment group reported having significantly more sex partners at both follow-up time points and having significantly more frequent unprotected sex while high at 6 months (all values of p < .01). Conclusions: Nontreatment seekers are at higher HIV risk than those entering MTPs and should be a focus of sex-risk reduction interventions, even if they are not interested in treatment at that time.     

Heterosexual Anal Sex Among Female Drug Users: U.S. National Compared to Local Long Beach, California Data

Receptive anal sex is a well-studied Human Immunodeficiency Virus (HIV) high-risk behavior among gay and bisexual men, yet previous research indicates that more women than men may be at risk from heterosexual anal sex (HAS). 1991-1996 data from the National Institute on Drug Abuse (NIDA) Cooperative Agreement (CA) were analyzed to model risk for women who reported having had HAS in the 30 days prior to interview. This model was then tested on recent data (2001-2006) collected on women in Long Beach, California. The multivariate model predicting anal sex in the NIDA CA dataset included sex trading; risk perception for HIV; ever had gonorrhea; sex while high; and drugs used in the last 30 days. African American race/ethnicity and older age were inversely associated with HAS. Risk factors common to both samples of women were number of days used amphetamine in the last month and risk perception for HIV.     

Rasch analysis provides new insights into the measurement properties of the neck disability index

Objective

The most widely used neck‐specific measure in intervention trials is the 10‐item Neck Disability Index (NDI), which is assumed to be a unidimensional interval scale, as shown by how NDI data are scored, analyzed, and interpreted. Our objective was to use modern measurement methods to test this assumption (and thereby to also test the validity of calculating summed scores and parametric statistics on NDI data) through Rasch analysis.

Methods

NDI data from 521 trial subjects with neck pain were fit to the Rasch model. We examined threshold ordering of NDI items, fit of data to model expectations, presence of differential item functioning, and whether or not the set of NDI items collectively measure a single construct, which is a requirement for calculating summative scores.

Results

There was a lack of fit of data to the Rasch model (χ² = 140.35, 70 df; P < 0.001). Five items (personal care, lifting, headaches, work, and recreation) had disordered response thresholds. Differential item functioning was detected for age and sex. The NDI items did not contribute to a single construct. Unidimensionality and interval scaling were achieved by removing 2 of the 10 items (resulting in the NDI‐8), and converting NDI‐8 ordinal (paper) summative scores to NDI‐8 interval (Rasch‐weighted) scores.

Conclusion

As originally proposed and conventionally used, the NDI is not a unidimensional scale, and has only ordinal scaling. This raises fundamental doubts about the practice of calculating change scores and other parametric statistics on NDI data. A revised 8‐item version provides unidimensional interval‐level measurement of neck pain disability.     

Possible age-associated bias in reporting of clinical features of drug dependence: epidemiological evidence on adolescent-onset marijuana use

Aims To probe recent evidence on apparent excess occurrence of marijuana dependence when marijuana smoking starts in adolescence. Design and participants A national sample of recent‐onset marijuana users was identified within public data files of the National Household Survey on Drug Abuse (NHSDA), 1995–98 (1866 adolescents and 762 adults). Measurements Marijuana dependence was assessed via seven standardized questions about its clinical features, such as being unable to cut down. Multivariate response models (GLM/GEE and MIMIC) were used to evaluate adolescent excess risk and possible item biases. Findings Among people who had just started to use marijuana, clinical features of marijuana dependence occurred twice as often among adolescents compared to adults, even with statistical adjustment for other covariates (P < 0.01 from GLM/GEE). MIMIC analyses suggest that adolescent‐onset users have somewhat higher levels of marijuana dependence, and they also provide evidence of age‐associated response bias for some but not all clinical features of marijuana dependence. That is, even with level of marijuana dependence held constant, adolescent recent‐onset users were more likely than adults to report being unable to cut down (P = 0.01) and tolerance (P = 0.029). Conclusion Nosologic, methodological and substantive reasons for observed age‐related excess in occurrence of marijuana dependence problems among early onset users deserve more attention in future research.     

Psychometric Evaluation of the HIV Disclosure Belief Scale: A Rasch Model Approach

This study provides psychometric assessment of an HIV disclosure belief scale (DBS) among men who have sex with men (MSM). This study used baseline data from a clinical trial evaluating the effectiveness of an HIV serostatus disclosure intervention of 338 HIV-positive MSM. The Rasch model was used after unidimensionality and local independence assumptions were tested for application of the model. Results suggest that there was only one item that did not fit the model well. After removing the item, the DBS showed good model-data fit and high item and person reliabilities. This instrument showed measurement invariance across two different age groups, but some items showed differential item functioning between Caucasian and other minority groups. The findings suggest that the DBS is suitable for measuring the HIV disclosure beliefs, but it should be cautioned when the DBS is used to compare the disclosure beliefs between different racial/ethnic groups.     

Factors Associated with Public Injecting Among Users of Vancouver's Supervised Injection Facility

Background: We evaluated factors associated with public drug injection among a cohort of injection drug users (SEOSI) originally recruited from within Vancouver's supervised injecting facility (SIF). Methods: We used univariate statistics and logistic regression to examine factors associated with public drug injection among SEOSI participants. Findings: Between June 2004 and July 2005, 714 IDU were followed up as part of SEOSI. In multivariate analyses, factors associated with public drug injection included homelessness (adjusted odds ratio (aOR) = 3.10; p < .001), syringe lending (aOR = 5.39; p < .001), requiring help injecting (aOR = 1.60; p = .05), and reporting that wait times affected frequency of SIF use (aOR = 3.26; p < .001). Interpretation: Persistent public injection was independently associated with elevated HIV risk behaviors, as well as programmatic factors that limit SIF use. SIF program expansion may further help to reduce persistent risk behaviors and the community concerns related to public injection drug use.     

Factors associated with incarceration and incident human immunodeficiency virus (HIV) infection among injection drug users participating in an HIV vaccine trial in Bangkok, Thailand, 1999–2003

Aims To determine if incarceration was associated with human immunodeficiency virus (HIV) infection and identify risk factors for incarceration among injection drug users (IDUs) participating in an HIV vaccine trial in Bangkok. Design The AIDSVAX B/E HIV vaccine trial was a randomized, double‐blind, placebo‐controlled study. A proportional hazards model was used to evaluate demographic characteristics, risk behavior and incarceration as predictors of HIV infection and generalized estimation equation logistic regression analysis to investigate demographic characteristics and risk behaviors for predictors of incarceration. Setting The trial was conducted in Bangkok Metropolitan Administration drug‐treatment clinics, 1999–2003. Participants A total of 2546 HIV‐uninfected IDUs enrolled in the trial. Measurements HIV testing was performed and an interviewer‐administered questionnaire was used to assess risk behavior and incarceration at baseline and every 6 months for a total of 36 months. Findings HIV incidence was 3.4 per 100 person‐years [95% confidence interval (CI), 3.0–3.9] and did not differ among vaccine and placebo recipients. In multivariable analysis, being in jail (P < 0.04), injecting (P < 0.0001), injecting daily (P < 0.0001) and sharing needles (P = 0.02) were associated with HIV infection and methadone maintenance was protective (P = 0.0006). Predictors of incarceration in multivariable analysis included: male sex (P = 0.04), younger age (P < 0.0001), less education (P = 0.001) and being in jail (P < 0.0001) or prison (P < 0.0001) before enrollment. Conclusions Among IDUs in the AIDSVAX B/E trial, incarceration in jail was associated with incident HIV infection. IDUs in Thailand remain at high risk of HIV infection and additional prevention tools are needed urgently. HIV prevention services, including methadone, should be made available to IDUs.