Syringe Disposal Among Injection Drug Users in San Francisco

To assess the prevalence of improperly discarded syringes and to examine syringe disposal practices of injection drug users (IDUs) in San Francisco, we visually inspected 1000 random city blocks and conducted a survey of 602 IDUs. We found 20 syringes on the streets we inspected. IDUs reported disposing of 13% of syringes improperly. In multivariate analysis, obtaining syringes from syringe exchange programs was found to be protective against improper disposal, and injecting in public places was predictive of improper disposal. Few syringes posed a public health threat.Needlestick injuries resulting from injection drug users (IDUs) improperly disposing of syringes present a potential risk of transmission of viral infections such as hepatitis and HIV to community members, sanitation workers, law enforcement officers, and hospital workers.^1–8 There have been no reports of HIV, HBV, or HCV seroconversion among children who incurred accidental needlesticks.^6,7,9–11 Among IDUs, syringe exchange program (SEP) utilization is associated with proper disposal of used syringes.^12–16 In 2007, the San Francisco Chronicle published a series of articles containing anecdotal reports of widespread improper disposal of syringes on city streets and in Golden Gate Park. The reports implied that SEPs were responsible for improper disposal of syringes.^17–19 Concerned about public safety, the San Francisco Department of Public Health worked with other researchers to (1) determine the prevalence of improperly discarded syringes in San Francisco, and (2) examine syringe disposal practices of IDUs.     

Associations between herpes simplex virus type 2 and HCV With HIV among injecting drug users in New York City: the current importance of sexual transmission of HIV

Objectives. We examined relationships between herpes simplex virus type 2 (HSV-2), a biomarker for sexual risk, and HCV, a biomarker for injecting risk, with HIV among injecting drug users (IDUs) who began injecting after large-scale expansion of syringe exchange programs in New York City.Methods. We recruited 337 heroin and cocaine users who began injecting in 1995 or later from persons entering drug detoxification. We administered a structured interview covering drug use and HIV risk behavior and collected serum samples for HIV, HCV, and HSV-2 testing.Results. HIV prevalence was 8%, HSV-2 39%, and HCV 55%. We found a significant association between HSV-2 and HIV (odds ratio [OR] = 7.9; 95% confidence interval [CI] = 2.9, 21.4) and no association between HCV and HIV (OR = 1.14; 95% CI = 0.5, 2.6). Black IDUs had the highest prevalence of HSV-2 (76%) and HIV (24%) but the lowest prevalence of HCV (34%).Conclusions. Most HIV infections among these IDUs occurred through sexual transmission. The relative importance of injecting versus sexual transmission of HIV may be critical for understanding racial/ethnic disparities in HIV infection.Persons who inject drugs, or injecting drug users (IDUs), are at risk for HIV infection through both multiperson use (sharing) of needles and syringes and unprotected sex. Sharing needles and syringes is a considerably more efficient mode of HIV transmission than is heterosexual intercourse,^1,2 so in most epidemiological situations, injecting-related transmission is much more important than is sexual transmission. This relative efficiency of transmission is reflected in the current Centers for Disease Control and Prevention transmission classification system, in which persons with both injecting drug risk and heterosexual risk behavior are placed in the injecting drug use transmission category only.³However, several factors may change the relative importance of injecting versus sexual transmission of HIV among IDUs. First, programs to prevent injecting-related transmission can be quite effective. In areas where combined HIV prevention programs (including syringe exchange, drug abuse treatment, community outreach, and voluntary HIV counseling and testing)⁴ have been implemented, injecting-related transmission has been substantially reduced and sexual transmission can be more important among IDUs. This effect appears to have occurred in Amsterdam^5,6 and Chicago.⁷Second, use of certain drugs may be associated with unsafe sexual behaviors and thus increase the importance of sexual transmission of HIV in populations of injecting and noninjecting drug users. Crack cocaine^8,9 and, more recently, methamphetamine^10,11 are probably the 2 most important examples of this phenomenon.Third, some sexually transmitted diseases, such as syphilis and herpes simplex virus type 2 (HSV-2), may increase HIV transmission among both injecting and noninjecting drug users. There is considerable biological and epidemiological evidence that HSV-2 infection facilitates both acquiring and transmitting HIV. Two meta-analyses and a recent qualitative review have concluded that prevalent HSV-2 infection is associated with a two- to threefold increased likelihood of acquiring HIV.^12–14 Although most research on HSV-2 and HIV has been conducted in Africa, several studies indicate positive associations between HSV-2 and HIV among injecting and noninjecting drug users in the United States.¹⁵ Because HSV-2 is transmitted sexually but not through sharing drug injection equipment, it can be used as a biomarker for sexual risk among IDUs.¹⁶Assessing the relative importance of injecting versus sexual transmission of HIV among IDUs may also have great importance for understanding racial/ethnic differences in HIV infection among injecting and noninjecting drug users.We examined relationships between HSV-2 and HIV among IDUs who began injecting after arge-scale implementation of syringe exchange programs from 1992 to 1998 in New York City. The expanded programs included not only a much greater volume of syringes exchanged but also increases in services such as voluntary HIV counseling and testing and referrals to drug abuse treatment. Thus, the large-scale expansion of the syringe exchange programs can be seen as the beginning of combined HIV prevention programs for IDUs^17–19 in New York City. The expansion of the syringe exchange programs was followed by a reduction in HIV incidence from approximately 4/100 person-years to 1/100 person-years among IDUs in New York City.²⁰We chose the term “persons who inject drugs,” which emphasizes that these individuals should be considered persons first and that they are much more than the behavior of injecting drug use. However, we address official classification of HIV transmission routes, so we use the current standard terms “injecting drug use” and “injecting drug users” and the abbreviation “IDU.” We want to emphasize that HIV prevention for persons who inject drugs should fully consider their human rights.     

Integrated behavioral intervention to improve HIV/AIDS treatment adherence and reduce HIV transmission

Objectives. We conducted a randomized clinical trial to test an integrated behavioral intervention designed to enhance using HIV treatment as prevention by improving medication adherence, reducing risks for other sexually transmitted infections, and minimizing risk compensation beliefs.Methods. Individuals living with HIV/AIDS (n = 436) participated in a randomized clinical trial testing an intensive behavioral intervention aimed at reducing HIV transmission risks compared with an attention control condition. We used unannounced pill counts to monitor antiretroviral therapy adherence and computerized interviews to measure risk behaviors.Results. The integrated transmission risk reduction intervention demonstrated increased antiretroviral therapy adherence and less unprotected intercourse with nonseroconcordant partners at 3- and 6-month follow-ups as well as fewer new sexually transmitted infections diagnosed over the 9-month follow-up period (adjusted odds ratio = 3.0; P < .05; 95% confidence interval = 1.01, 9.04). The integrated intervention also reduced behavioral risk compensation beliefs.Conclusions. A theory-based integrated behavioral intervention can improve HIV treatment adherence and reduce HIV transmission risks. HIV treatment as prevention should be bundled with behavioral interventions to maximize effectiveness.Antiretroviral therapy (ART) improves the health and increases the longevity of people infected with HIV.¹ Growing evidence indicates that ART can also reduce HIV infectiousness, raising the possibility of using HIV treatment as prevention.^2–3 Mathematical models suggest that HIV testing with immediate treatment may have a substantial preventative effect in high HIV prevalence populations.^4–6 The potential preventative benefits of treating HIV infection are shifting prevention policies. Most notably, the Swiss Federal AIDS Commission has stated that repeated undetectable HIV RNA (viral load) tests can render individuals noninfectious.^7–9 Although biologically and epidemiologically plausible,^10,11 using HIV treatment as prevention will fail when medication adherence is poor and when there are co-occurring sexually transmitted infections (STIs).Most ART regimens demonstrate suppressive effects in the genital tract that are similar to those in blood plasma,¹² and the genital tract suffers similar detrimental ramifications of ART nonadherence.¹³ The most forgiving ART regimens require at least 85% adherence to suppress HIV replication, avoid treatment-resistant variants of the virus, and reduce infectiousness.^14–16 Evidence also shows that individuals who experience difficulty adhering to ART engage in higher-risk sexual behaviors.¹⁷ Even under optimal adherence, persons with undetectable peripheral blood viral loads will be highly infectious in their genital secretions when they have co-occurring STIs.¹⁸Co-occurring STIs are prevalent among people living with HIV/AIDS^19,20 and cause HIV shedding in genital fluids.²¹ Individuals who are coinfected with HIV and other STIs are therefore far more infectious than their blood plasma viral load indicates. The poor concordance between blood plasma and semen HIV RNA is at least in part the result of inflammatory processes caused by co-occurring STIs.²² The interplay between treatment, viral load, and sexual transmission is further complicated by risk compensation; individuals who believe they are less infectious take fewer precautions against infecting partners.^23–26To succeed, the use of HIV treatment as prevention, or so-called test and treat strategies, will require a comprehensive approach that encompasses adherence support, sexual risk reduction, and the amelioration of risk compensation.²⁷ HIV transmission risk reduction interventions for people infected with HIV have thus far focused exclusively on reducing unprotected sex with non-HIV–positive partners.²⁸ Similarly, ART adherence interventions have not directly addressed HIV transmission risks. One example of an intervention that addressed treatment adherence and transmission risk reduction was the Healthy Living Project.^29–30 In a multisite trial, the Healthy Living Project targeted mental health, treatment adherence, and risk behaviors in separate intervention modules delivered several weeks apart. The investigators of the Healthy Living Project examined the 3 modules independently in separate analyses. The Healthy Living Project medication module demonstrated significant increased treatment adherence,²⁸ and the prevention module resulted in significant reductions in HIV transmission risk behaviors.²⁹ Unfortunately, the Healthy Living Project did not test the synergistic effects of the adherence and risk reduction modules. We are not aware of any unified behavioral intervention that has attempted to simultaneously reduce HIV infectiousness by improving treatment adherence and reducing HIV exposures. We sought to fill this gap by testing an integrated adherence and risk-reduction intervention designed for use in conjunction with HIV treatment as prevention.The aim of this clinical trial was to test the effects of a theory-based integrated behavioral intervention for reducing HIV transmission risks in individuals living with HIV/AIDS. Our primary hypothesis was that an integrated intervention approach would improve treatment adherence and reduce risk behaviors relative to a matched-contact control intervention. The secondary hypothesis was that the integrated intervention would reduce risk compensation beliefs concerning undetectable HIV RNA.     

Using Pharmacies in a Structural Intervention to Distribute Low Dead Space Syringes to Reduce HIV and HCV Transmission in People Who Inject Drugs

Ongoing injection drug use contributes to the HIV and HCV epidemics in people who inject drugs. In many places, pharmacies are the primary source of sterile syringes for people who inject drugs; thus, pharmacies provide a viable public health service that reduces blood-borne disease transmission.Replacing the supply of high dead space syringes with low dead space syringes could have far-reaching benefits that include further prevention of disease transmission in people who inject drugs and reductions in dosing inaccuracies, medication errors, and medication waste in patients who use syringes.We explored using pharmacies in a structural intervention to increase the uptake of low dead space syringes as part of a comprehensive strategy to reverse these epidemics.There are approximately 1.1 million people living with HIV in the United States.1 Over the past decade, the HIV incidence rate among people who inject drugs (PWID) has decreased; however, PWID remain disproportionately affected by HIV. It is estimated that 8% of new HIV cases in 2010 were among PWID.1 Co-occurring is the HCV epidemic; approximately 2.7 million people are chronically infected with HCV.2 Studies estimate that the prevalence of HCV among PWID ranges from 40% to 90%.3,4 Ongoing injection drug use and injection risk behaviors contribute to both epidemics.Although effective therapies exist, ultimately, preventing the transmission of HIV and HCV is essential to ending these epidemics, particularly in high-risk populations. PWID constitute a vulnerable population that faces numerous economic and personal barriers (e.g., comorbidities) that prevent them from receiving appropriate medical care.5,6 Public health resources and interventions that focus on the prevention of HIV and HCV in PWID are needed.Multiperson use of needles and syringes (i.e., direct sharing) and multiperson use of drug preparation materials (i.e., indirect sharing) are important risk factors for infection acquisition and transmission among PWID.7 An estimated 50% to 80% of PWID acquire HCV infection within the first year of injection drug use.8 Recommended interventions to discourage injection drug use include risk-reduction programs and substance abuse treatment.9 However, because of limited awareness of available programs, lack of access to treatment facilities, need for program referral, and cost of treatment, many PWID are unable to stop injecting drugs.7 A well-known public health measure to reduce the spread of infection is to promote the use of sterile syringes.10 We explored using pharmacies in a structural intervention to help prevent the transmission of HIV and HCV through syringes.     

Childbearing Intentions of HIV-Positive Women of Reproductive Age in Soweto,South Africa: The Influence of Expanding Access to HAART in an HIV Hyperendemic Setting

Objectives. We investigated whether the intention to have children varied according to HIV status and use of highly active antiretroviral therapy (HAART) among women in Soweto, South Africa.Methods. We used survey data from 674 women aged 18 to 44 years recruited from the Perinatal HIV Research Unit in Soweto (May through December 2007); 217 were HIV-positive HAART users (median duration of use = 31 months; interquartile range = 28, 33), 215 were HIV-positive and HAART–naive, and 242 were HIV negative. Logistic regression models examined associations between HIV status, HAART use, and intention to have children.Results. Overall, 44% of women reported intent to have children, with significant variation by HIV status: 31% of HAART users, 29% of HAART-naive women, and 68% of HIV-negative women (P < .001). In adjusted models, HIV-positive women were nearly 60% less likely to report childbearing intentions compared with HIV-negative women (for HAART users, adjusted odds ratio [AOR] = 0.40; 95% confidence interval [CI] = 0.23, 0.69; for HAART-naive women, AOR = 0.35; 95% CI = 0.21, 0.60), with minimal differences according to use or duration of HAART.Conclusions. Integrated HIV, HAART, and reproductive health services must be provided to support the rights of all women to safely achieve their fertility goals.In sub-Saharan Africa, women of childbearing age comprise 61% of people living with HIV, accounting for over 12 million women.¹ In many regions, HIV incidence is increasing most dramatically among young women aged 18 to 30 years,^1,2 which coincides with their peak reproductive years.³ Globally, a plethora of evidence indicates that many women living with HIV continue to desire children,^4–8 become pregnant,^5,6,9 and give birth^5,6,10 after knowing their HIV-positive status.Childbearing decision making can be complex regardless of HIV seropositivity¹¹; among HIV-infected women, however, reproduction introduces additional personal, public health, and clinical care issues.¹² The vast majority of conceptions occur without the use of reproductive technologies such as sperm washing and artificial insemination.¹³ Thus, the unprotected sexual activity required for conception carries a risk of HIV transmission to uninfected sexual partners.¹⁴ Reproduction among HIV-positive women also carries a risk of vertical transmission during pregnancy and labor and through breastfeeding.^15,16 Moreover, HIV-positive women have a lower life expectancy than HIV-negative women,¹⁷ increasing the risk of maternal orphanhood.¹⁸ In light of these concerns, early reproductive guidelines for people living with HIV were dissuasive,¹⁹ and HIV-positive women who express a desire to have children continue to encounter the disapproval of the community and of health care workers.^4,20Nonetheless, although the potential health risks may have dampened the fertility intentions of some HIV-positive women, stigma associated with childlessness in many societies²¹ and the strong personal desires for biological parenthood⁴ remain potent drivers of childbearing intentions, despite an HIV-positive status. Indeed, in some cultural contexts, remaining childless can be a violation of societal norms more stigmatizing than the HIV infection itself.^4,22Expanding access to highly active antiretroviral therapy (HAART) is changing the landscape of childbearing decision making for people living with HIV.²³ HAART increases life expectancy,^24–26 decreases morbidity,^25,27 and dramatically reduces the risks of vertical²⁸ and horizontal^29,30 transmission. In this era of expanding access to HAART, the significant reduction in health risks and barriers to reproduction among people living with HIV has coincided with increased calls for a rights- and evidenced-based approach to reproduction.^31,32 Since childbearing intentions are among the strongest predictors of eventual childbearing,³³ creating effective and responsive sexual and reproductive health services for HIV-positive women in the context of expanding access to HAART requires a clear understanding of expressed childbearing intentions.Existing evidence concerning the influence of expanding access to HAART on childbearing intentions is largely incomplete. Although recent regional studies have shown that HAART use is associated with higher childbearing intentions, these studies neglected to consider the duration of HAART use^6,7 and tended only to compare the childbearing intentions of HIV-positive women without conducting a comparison with HIV-negative women from the same community.^6–8 Moreover, the lack of an HIV-negative control group precludes the opportunity to assess whether HAART users begin to resemble HIV-negative women in their childbearing intentions, particularly as HIV is increasingly recognized as a manageable chronic disease.Given the high HIV prevalence among women of reproductive age in Soweto, South Africa,¹ we aimed to assess the prevalence of childbearing intentions and to determine whether they varied according to HIV status and HAART use among women. We hypothesized that HIV-positive women would have lower childbearing intentions than would HIV-negative women. In addition, we hypothesized that HIV-positive women receiving HAART would have higher childbearing intentions than would HIV-positive HAART-naive women, with increasing duration of HAART treatment associated with incrementally higher childbearing intentions. Overall, we hypothesized that HAART use would narrow the measurable differences in childbearing intentions between HIV-positive and HIV-negative women.²³     

Improving the health and mental health of people living with HIV/AIDS: 12-month assessment of a behavioral intervention in Thailand

Objectives. We examined findings from a randomized controlled intervention trial designed to improve the quality of life of people living with HIV in Thailand.Methods. A total of 507 people living with HIV were recruited from 4 district hospitals in northern and northeastern Thailand and were randomized to an intervention group (n = 260) or a standard care group (n = 247). Computer-assisted personal interviews were administered at baseline and at 6 and 12 months.Results. At baseline, the characteristics of participants in the intervention and standard care conditions were comparable. The mixed-effects models used to assess the impact of the intervention revealed significant improvements in general health (B = 2.51; P = .001) and mental health (B = 1.57; P = .02) among participants in the intervention condition over 12 months and declines among those in the standard care condition.Conclusions. Our results demonstrate that a behavioral intervention was successful in improving the quality of life of people living with HIV. Such interventions must be performed in a systematic, collaborative manner to ensure their cultural relevance, sustainability, and overall success.People living with HIV/AIDS in Thailand face multiple challenges, including coping with HIV-related disclosure and stigma and maintaining positive family relationships. HIV disclosure has been identified as a key stressor for people living with HIV in Thailand^1–3; when patients do not disclose their serostatus, their odds of becoming depressed increase 3-fold.⁴ Disclosure is also a key issue among Thai HIV support groups.⁵ Once individuals disclose their serostatus to their partners and family members, treatment becomes a challenge for the entire family.In addition to disclosure, it is necessary to address stigma as an HIV-related stressor. We have documented a high level of perceived stigma in Thailand and associations with other conditions, including a significant association between stigma and depression.⁶ People living with HIV in Thailand also face challenges with respect to maintaining general health routines,⁷ including medical visits, prophylactic treatment of symptoms (e.g., hepatitis C virus, pneumonia, tuberculosis),⁸ adherence to antiretroviral therapy (ART),⁹ knowledge of the course of their disease, and effective communication with doctors.By contrast, other factors have been shown to have a positive effect on management of HIV. For example, Thailand is a strongly family-oriented society, and typical Thai families are tightly knit. Therefore, family social support may help people living with HIV increase their adherence to ART and decrease their risk of depression.^9,10 Parents of children living with HIV need information about how their children may respond to their illness, how to parent children while dealing with their own illness, how to maintain positive family routines, and how to generate positive parental bonds with their children. Knowledge in such areas is hypothesized to improve patients’ quality of life and their children''s long-term adjustment.^11–13Past behavioral interventions in Thailand have framed HIV as an individual stressor for people living with the disease.^14,15 To address the multiple negative and positive factors faced by people living with HIV and their families in Thailand, we conducted a randomized controlled intervention trial in the northern and northeastern areas of the country. On the basis of the work of Rotheram-Borus et al.,^13,16–21 we identified common factors, processes, and principles shared across evidence-based interventions^22–24 and adapted them to address the specific needs of people living with HIV in Thailand. Here we describe findings based on data collected at baseline, 6 months, and 12 months to assess the efficacy of a cognitive-based intervention designed to improve the quality of life of people living with HIV.     

Risks of Recreational Exposure to Waterborne Pathogens Among Persons With HIV/AIDS in Baltimore, Maryland

Objectives. We assessed the prevalence of recreational activities in the waterways of Baltimore, MD, and the risk of exposure to Cryptosporidium among persons with HIV/AIDS.Methods. We studied patients at the Johns Hopkins Moore Outpatient AIDS Clinic. We conducted oral interviews with a convenience sample of 157 HIV/AIDS patients to ascertain the sites used for recreational water contact within Baltimore waters and assess risk behaviors.Results. Approximately 48% of respondents reported participating in recreational water activities (fishing, crabbing, boating, and swimming). Men and women were almost equally likely to engage in recreational water activities (53.3% versus 51.3%). Approximately 67% (105 of 157) ate their own catch or that of friends or family members, and a majority (61%, or 46 of 75) of respondents who reported recreational water contact reported consumption of their own catch.Conclusions. Baltimoreans with HIV/AIDS are engaging in recreational water activities in urban waters that may expose them to waterborne pathogens and recreational water illnesses. Susceptible persons, such as patients with HIV/AIDS, should be cautioned regarding potential microbial risks from recreational water contact with surface waters.Persons with HIV/AIDS are at high risk for increased morbidity and mortality associated with a range of opportunistic infections, some of which are caused by Cryptosporidium. Cryptosporidium species are of particular public health and medical importance because they are prevalent in surface waters of the United States,^1–7 are efficiently transmitted via water,⁸ and can be consumed in foods contaminated by fecal matter.^9–11 Exposures to Cryptosporidium are common in the US population,¹² and past studies have demonstrated that Cryptosporidium infections significantly contribute to illness and mortality in persons with HIV/AIDS.^13–15 In the 1980s, Cryptosporidium was identified as a major opportunistic pathogen.^16–21 Infection continues to be frequently diagnosed in persons with HIV/AIDS.^22–27 Before the advent of highly active antiretroviral therapy, Cryptosporidium was a relatively common opportunistic infection even in developed countries.^28,29Cryptosporidiosis manifests as an acute gastroenteritis, accompanied by cramps, anorexia, vomiting, abdominal pains, fever, and chills²⁹ and by histological presentation of gastrointestinal mucosal injury.^30,31 Persons with AIDS who become infected with this parasite are at increased risk of developing chronic and often life-threatening diarrhea, biliary tract diseases, pancreatitis, colitis, and chronic asymptomatic infection and recurrence. These developments are especially likely in those who are severely immunosuppressed (CD4 counts < 150 cells/mL).^29,32–35 Infection is diagnosed by the presence of oocysts in unpreserved or preserved stools.³⁶ Histological and ultrastructural examination of biopsy material for different Cryptosporidium life stages, detection of Cryptosporidium DNA and antigens, and identification of species through molecular techniques can also aid in diagnosis.^36–38Cryptosporidium species are enteric protozoan organisms and are prevalent in US watersheds, especially in urban waters.^1,6,39 These parasites have natural hosts in domestic and wild animals such as cattle (especially newborn calves), horses, fish, and birds.^5,40–42 These parasites cause cryptosporidiosis by infecting and damaging the cells of the small intestine and other organs.^13,41 For persons with HIV/AIDS, increased risk for infection by Cryptosporidium has been related to sexual practices such as engaging in sexual intercourse within the past 2 years, having multiple partners during that time, and engaging in anal intercourse.⁴³ Use of spas and saunas has also been identified as a risk factor.⁴³In the United States, Cryptosporidium is the most commonly identified pathogen in cases of recreationally acquired gastroenteritis⁴⁴; the majority of those affected are children. Increased risk of cryptosporidiosis in persons with HIV/AIDS has been associated with swimming.^45,46 US residents make an estimated 360 million annual visits to recreational water venues such as swimming pools, spas, and lakes; swimming is the second most popular physical activity in the country and the most popular among children.⁴⁷Recreational swimming, even in highly chlorinated water, carries a high risk of exposure to enteric pathogens, including Cryptosporidium, Norovirus, Shigella, Escherichia coli, and Giardia.⁴⁸ Cryptosporidiosis and some other enteric illnesses are seasonal, with spikes in occurrence in the summer months from contact with recreational water venues.⁴⁹ Extreme precipitation⁵⁰ and high ambient temperatures⁵¹ can also affect patterns of disease outbreaks. Because not all infections with Cryptosporidium lead to apparent illness or symptoms, infected persons may unknowingly transmit these pathogens to others, such as household members and other recreationists.^12,52 Cryptosporidiosis from swimming, wading, and splashing is prevalent in the United States.^44,46,53,54Risks from the presence of pathogens in waterways include (1) waterborne gastroenteritis and other recreational water illnesses in anglers and other recreationists^44,55–59; (2) transmission of pathogens to humans from caught seafood acting as fomites, or surface carriers⁶⁰; (3) food-borne gastroenteritis from consumption of raw or improperly cooked fish and shellfish^61,62; and (4) hand-to-mouth transmission of pathogens while eating, drinking, or smoking during activities such as fishing and crabbing.⁷Recreational water activities in the Baltimore, Maryland, area take place in Jones Falls and Baltimore Harbor. These and other waterways are used for angling, crabbing, swimming, kayaking, and boating (including paddle boating).^7,63 In addition, Baltimore-area residents often catch and consume fish and crabs from the Baltimore Harbor and local waterways, many of which are already highly contaminated by persistent chemicals such as mercury and polychlorinated biphenyls.⁶⁴ These activities are known to increase risks of exposure to waterborne pathogens through direct contact with contaminated waters or through contact with or handling and consumption of caught seafood (fish, crabs, oysters).^7,65,66To investigate the potential contribution of recreational water contact to Cryptosporidium exposures among persons with HIV/AIDS, we carried out a cross-sectional study at the Johns Hopkins Moore Outpatient AIDS Clinic. The Baltimore metropolitan area has a high prevalence rate of HIV/AIDS among both men and women,⁶⁷ and its population makes intensive recreational use of a contaminated watershed. In addition, laboratory experiments have indicated that crabs can become superficially contaminated by Cryptosporidium and transfer the pathogen to hands.⁶⁸ Local anglers are at risk from Cryptosporidium on wild-caught fish.⁷Our objective was to address the risks of exposure to Cryptosporidium for an urban subpopulation, persons with HIV/AIDS, as a result of recreational contact with Baltimore waterways. We also assessed the patterns and locations of recreational water activities in Baltimore waters.     

Hombres Sanos: evaluation of a social marketing campaign for heterosexually identified Latino men who have sex with men and women

Objectives. We evaluated the effectiveness of Hombres Sanos [Healthy Men] a social marketing campaign to increase condom use and HIV testing among heterosexually identified Latino men, especially among heterosexually identified Latino men who have sex with men and women (MSMW).Methods. Hombres Sanos was implemented in northern San Diego County, California, from June 2006 through December 2006. Every other month we conducted cross-sectional surveys with independent samples of heterosexually identified Latino men before (n = 626), during (n = 752), and after (n = 385) the campaign. Respondents were randomly selected from 12 targeted community venues to complete an anonymous, self-administered survey on sexual practices and testing for HIV and other sexually transmitted infections. About 5.6% of respondents (n = 98) were heterosexually identified Latino MSMW.Results. The intervention was associated with reduced rates of recent unprotected sex with both females and males among heterosexually identified Latino MSMW. The campaign was also associated with increases in perception of HIV risk, knowledge of testing locations, and condom carrying among heterosexual Latinos.Conclusions. Social marketing represents a promising approach for abating HIV transmission among heterosexually identified Latinos, particularly for heterosexually identified Latino MSMW. Given the scarcity of evidence-based HIV prevention interventions for these populations, this prevention strategy warrants further investigation.In the United States, adult and adolescent Latino males represent 5.6% of the total population¹ but 18.7% of HIV/AIDS cases.² Low rates of condom use^3–5 and limited HIV testing^5–7 likely contribute to the risk for infection and transmission among Latinos.Sex between men continues to account for the majority of new HIV infections in the United States.² HIV prevention efforts have traditionally targeted gay and bisexual men. However, individuals’ self-identified sexual orientation frequently does not correspond to their sexual behavior,^8–12 and recent research has been focused on men who self-identify as heterosexual but have sex with men. The results of studies on men who have sex with both men and women (MSMW) suggest that, regardless of sexual identity, this population is at greater risk for HIV than are men who exclusively have sex with men; likewise, MSMW are at greater risk than are men who exclusively have sex with women (MSW).^11,13–16 Reasons for greater risk among MSMW may include lower rates of condom use^11,16 and having sexual partners who engage in high-risk sexual practices.¹¹Previous studies have suggested that Latino men are more likely than are White men to engage in bisexual sexual behavior^9,11,17,18 but less likely than are White men to self-identify as gay or bisexual or to disclose their sexual orientation.^19–23 Cultural factors such as homophobia, social stigma related to same-sex practices, and sexual conservatism may inhibit Latino men from self-identifying as homosexual or bisexual.^{10,13,23–26} The degree to which Latinos integrate same-sex sexual practices into their sexual identities may influence their risk for HIV infection.²⁷ Latino MSMW who identify as heterosexual may perceive that they are at lower risk for sexually transmitted infections (STIs) than are gay or bisexual men, and Latino MSMW may thus be less likely to use condoms to protect themselves or their partners. Latino MSMW who identify as heterosexual may also be more likely to resort to substance use to reduce sexual inhibition, thus increasing the likelihood that they will engage in unsafe sex.^19,27Nondisclosure of same-sex sexual practices among MSMW also has significant implications for the health of their female sexual partners.^9,17 More than 70% of Latinas living with HIV/AIDS in the United States were infected via heterosexual contact.² Most cases of heterosexual transmission to Latinas are related to sex with partners who use injection drugs,²⁸ but unprotected sex with men who have multiple partners, including MSMW, has likely contributed to a subset of HIV cases among Latina women.^2,29Social marketing involves applying the principles and techniques of commercial marketing to the promotion of behavioral change for the good of a target audience.^30,31 Social marketing has been successfully used for HIV prevention with gay and bisexual males,^32,33 racial and ethnic minorities,³⁴ and youths.^35–38 Interventions using social marketing have been associated with improvements in HIV/STI testing^32,34 and condom use.^36,37,39,40 To our knowledge, no social marketing campaigns have been designed to reduce HIV risk among heterosexually identified Latino MSMW. Because of the secrecy of their sexual practices and the perceived association of HIV infection with homosexuality,^24,41,42 heterosexually identified Latino MSMW are difficult to reach with HIV prevention efforts. This population is not likely to be exposed to prevention messages or programs targeted to the gay and bisexual communities.¹⁸ Moreover, interventions requiring active recruitment of heterosexually identified MSMW may fail to reach sufficient numbers or may not reach those who are most secretive about their same-sex sexual practices.⁴¹ We sought to evaluate the effectiveness of a social marketing campaign to increase condom use and HIV testing among heterosexual Latino men in northern San Diego County, California, with a special emphasis on heterosexually identified Latino MSMW.     

Pregnancy as a Window of Opportunity for HIV Prevention: Effects of an HIV Intervention Delivered Within Prenatal Care

Objectives. We sought to determine whether an HIV prevention program bundled with group prenatal care reduced sexually transmitted infection (STI) incidence, repeat pregnancy, sexual risk behavior, and psychosocial risks.Methods. We conducted a randomized controlled trial at 2 prenatal clinics. We assigned pregnant women aged 14 to 25 years (N = 1047) to individual care, attention-matched group care, and group care with an integrated HIV component. We conducted structured interviews at baseline (second trimester), third trimester, and 6 and 12 months postpartum.Results. Mean age of participants was 20.4 years; 80% were African American. According to intent-to-treat analyses, women assigned to the HIV-prevention group intervention were significantly less likely to have repeat pregnancy at 6 months postpartum than individual-care and attention-matched controls; they demonstrated increased condom use and decreased unprotected sexual intercourse compared with individual-care and attention-matched controls. Subanalyses showed that being in the HIV-prevention group reduced STI incidence among the subgroup of adolescents.Conclusion. HIV prevention integrated with prenatal care resulted in reduced biological, behavioral, and psychosocial risks for HIV.Young pregnant women are at high risk for HIV and sexually transmitted infections (STIs).¹ In a systematic review of sexual risk behavior among pregnant or mothering adolescents, 19% to 39% had an STI during pregnancy, and 14% to 39% had an STI 6 to 10 months postpartum. Furthermore, young pregnant women were 5 times less likely to use condoms compared with nulliparous women.²Despite the risks of STI and HIV infection among women of reproductive age, few HIV interventions have specifically targeted pregnant women. The Children''s Health and Responsible Mothering project (Project CHARM), a school-based intervention of pregnant and mothering adolescents, found increases in condom-use intentions, but no difference in number of unprotected acts of sexual intercourse compared with a general health promotion control group.³ Another study found that pregnant women given a 4-session HIV intervention had moderate increases in knowledge and safer sexual behaviors that were sustained 6 months after the intervention.⁴Although few studies of HIV and STI interventions have targeted pregnant women, some have focused on women attending primary care clinics.^5–8 Interventions for STI clinic patients documented significant declines in STI incidence.^8,9 However, most HIV interventions are limited because they do not integrate HIV prevention with the provision of other services,^10,11 and are not theory based.^12–14Pregnancy offers a unique opportunity for intervention as it is a time when women engage in high-risk behaviors, make behavioral changes, and have frequent contact with health care professionals.^15–18 Finally, interventions integrated with existing care systems (e.g., prenatal care) can be sustained because care is reimbursable by insurance.¹⁹The bundling of HIV prevention with existing systems can increase the accessibility of HIV prevention by providing opportunities to reach individuals who may not have the motivation or time to attend stand-alone HIV prevention sessions.¹⁹ HIV and STI prevention programs have been successfully integrated in care settings such as psychiatric, drug treatment, and palliative medicine.^20–22 We developed an HIV intervention that was integrated with a model of prenatal care.CenteringPregnancy group prenatal care^23,24 has been shown to reduce preterm birth and increase prenatal care satisfaction.^23,25 We created a modified program, CenteringPregnancy Plus, by integrating HIV prevention with the group prenatal care model. The purpose of this study was to evaluate the effects of this integrated HIV prevention program on biological outcomes (STI, repeat pregnancy), sexual risk behaviors (condom use, unprotected sexual intercourse), and psychosocial variables (communication, perceived risk, self-efficacy).     

Posttraumatic stress disorder and HIV risk among poor, inner-city women receiving care in an emergency department

Objectives. We examined the associations between posttraumatic stress disorder (PTSD) and HIV risk behaviors among a random sample of 241 low-income women receiving care in an urban emergency department.Methods. We recruited participants from the emergency department waiting room during randomly selected 6-hour blocks of time. Multivariate analyses and propensity score weighting were used to examine the associations between PTSD and HIV risk after adjustment for potentially confounding sociodemographic variables, substance use, childhood sexual abuse, and intimate partner violence.Results. A large majority of the sample self-identified as Latina (49%) or African American (44%). Almost one third (29%) of the participants met PTSD criteria. Women who exhibited symptoms in 1 or more PTSD symptom clusters were more likely than women who did not to report having had sex with multiple sexual partners, having had sex with a risky partner, and having experienced partner violence related to condom use in the preceding 6 months.Conclusions. The high rate of PTSD found in this sample and the significant associations between PTSD symptom clusters and partner-related risk behaviors highlight the need to take PTSD into account when designing HIV prevention interventions for low-income, urban women.The relationship between posttraumatic stress disorder (PTSD) and HIV risk behaviors remains relatively underresearched. However, several studies have shown that PTSD is associated with sexual HIV risk behaviors and HIV seropositive status.^1–3 Emergency departments have been identified as the first and primary source of medical treatment of many women infected with or at high risk for HIV^4–6 and for those with high rates of interpersonal violence and trauma, including those suffering from PSTD.^7–11Hutton et al. found that, after adjustment for potentially confounding factors, a PTSD diagnosis was associated with engaging in anal intercourse and exchanging sex for money or drugs in a sample of 177 female inmates.¹² High rates of PTSD have also been found among HIV-positive women,^3,13,14 many of whom have experienced repeated traumas associated with PTSD, such as childhood sexual abuse and intimate partner violence (IPV).^3,13,14 In a study of HIV-positive women, 35% of those with a trauma history met the criteria for PTSD,¹⁵ a rate far exceeding both the lifetime PTSD rate (10.4%) among women in the general population¹⁶ and the PTSD rate (4.6%) in a nationally representative sample of female crime victims.¹⁷The relationship between PTSD and HIV risk behaviors has been found to vary according to the presence of different PTSD symptoms (avoidance, hyperarousal, and reexperiencing trauma). In their study of 64 HIV-positive women and men, Gore-Felton and Koopman found that moderate to severe reexperiencing symptoms were associated with multiple sexual partners and unprotected sex during the preceding 3 months.¹⁸ Individuals with avoidant symptoms were less likely to have engaged in unprotected sex, possibly as a result of deficits in establishing and maintaining intimate partnerships.¹⁸ The presence of hyperarousal symptoms may trigger individuals to seek sexual stimulation and engage in riskier sex, and they may experience difficulty in problem solving and negotiating safe sex.¹⁹The research just described highlights mechanisms of how different PTSD symptom clusters may increase the likelihood of engaging in HIV risks. However, it should also be acknowledged that the relationship may be bidirectional: a traumatic experience (e.g., forced unprotected sex) associated with a risk of HIV may lead to PTSD.Furthermore, research suggests that the relationship between PTSD and HIV risk may be mediated by several factors, including childhood sexual abuse, IPV, and substance abuse. Those who have experienced childhood sexual abuse are at increased risk of developing PTSD,^20–22 engaging in subsequent sexual HIV risk behaviors, and HIV transmission.^3,23 Similarly, IPV has been found to increase the risk of both developing PTSD and engaging in a range of HIV risk behaviors, including unprotected sex,^24–38 sexual practices leading to a high risk of sexually transmitted infections,^6,32,39–42 sex with multiple partners,^31,32,43 trading of sex for money or drugs,^40,44 sex with risky partners,^38,45 and sex with HIV-positive partners.³⁸ Finally, substantial research indicates that drug and alcohol dependencies are associated with both PTSD^46,47 and engaging in a range of HIV risk behaviors.^48–51We examined the relationship between PTSD (and the symptom clusters of avoidance, reexperiencing trauma, and hyperarousal) and sexual HIV risk behaviors in a random sample of 241 women attending an emergency department in a low-income neighborhood of the Bronx, New York. We hypothesized that women who met the criteria for PTSD and the symptom clusters of hyperarousal, reexperiencing trauma, or avoidance would be more likely than women who did not meet these criteria to engage in sexual HIV risk behaviors after adjustment and matching for potentially confounding factors such as sociodemographic characteristics, childhood sexual abuse, substance abuse, and IPV.     

Determinants of the Availability of Hepatitis C Testing Services in Opioid Treatment Programs: Results From a National Study

Objectives. We examined trends and organizational-level correlates of the availability of HCV testing in opioid treatment programs.Methods. We used generalized ordered logit models to examine associations between organizational characteristics of 383 opioid treatment programs from the 2005 and 2011 National Drug Abuse Treatment System Survey and HCV testing availability.Results. Between 2005 and 2011, the proportion of opioid treatment programs offering HCV testing increased but largely because of increases in off-site referrals rather than on-site testing. HCV testing availability was higher in opioid treatment programs affiliated with a hospital and those receiving federal funds. Opioid treatment programs providing both methadone and buprenorphine were more likely to offer any HCV testing, whereas opioid treatment programs providing only buprenorphine treatment were less likely to offer on-site testing. HCV testing availability was associated with more favorable staff-to-client ratios.Conclusions. The increasing use of off-site referrals for HCV testing in opioid treatment programs likely limits opportunities for case finding, prevention, and treatment. Declines in federal funding for opioid treatment programs may be a key determinant of the availability of HCV testing in opioid treatment programs.HCV is the most common blood-borne infection in the United States. An estimated 3.2 million people in the United States are chronically infected with HCV,1 making it 3 to 5 times more frequent than HIV.2 Results from a recent study showed that HCV has surpassed HIV as a cause of death in the United States.3 New HCV treatment regimens that are more effective and have fewer side effects have recently become available.4 Unfortunately, fewer than half of the patients living with HCV are aware of their infection.5 This is because infected persons tend to be asymptomatic: in some cases, signs of the disease do not manifest for decades.6 It is thus important to encourage and offer extensive opportunities for HCV testing, especially to the most at-risk populations.6Advancements in testing technologies (HCV rapid testing)7 and recommendations for the identification of HCV in the general population (i.e., individuals born between 1945 and 1965) present opportunities for increasing the availability of HCV testing.8 Testing could foster increased case finding, as well as earlier linkages to HCV care and treatment services. Ensuring access to HCV testing and increasing awareness of HCV status also could help promote the adoption of preventive behaviors: for example, engaging in safer injection practices or other protective behaviors. Ultimately, this may also have a positive influence on compliance with substance abuse treatment and abstinence.9The Centers for Disease Control and Prevention (CDC) recommends routine HCV antibody (anti-HCV) testing for injection drug users (IDUs).3,10 IDUs are particularly at risk for HCV infection as a result of sharing and reusing of needles or other injection paraphernalia.6 The estimated anti-HCV prevalence among IDUs ranges from 35% to 65%, depending on factors such as geography and rate of injection drug use.11 Unfortunately, despite the CDC recommendation, IDUs have very low rates of uptake for HCV testing and treatment.12One factor that may account for such low testing rates is that IDUs less frequently use preventive health care services than do other population groups.13 Outpatient substance abuse treatment programs are one exception: the number of IDUs entering treatment programs has increased in recent years.14 Because injection drug use is strongly associated with opioid use (e.g., heroin), opioid treatment programs are an especially important setting for HCV testing, counseling, prevention, and links to medical care. In the case of HIV testing and case management, on-site services in substance abuse treatment programs have been associated with high-quality prevention, increased service use, earlier initiation of treatment, declines in disease transmission, improved treatment outcomes for substance use disorders, and links to ancillary services.15–17 Hence integrating HCV testing with substance abuse treatment services, particularly in opioid treatment programs, may have similar beneficial effects and is crucial for addressing the HCV epidemic in the United States.18Unfortunately, trends in the availability of HCV testing services in opioid treatment programs across the nation are not well understood.19,20 Large gaps exist in the availability of on-site HCV testing in opioid treatment programs,21–24 with programs that have the largest proportion of IDUs among their clients being less likely to offer on-site HCV testing, even when phlebotomists were on staff.24 Opioid treatment programs often prefer to refer their clients to off-site facilities for HCV testing. Yet off-site referrals for testing and treatment of HCV are associated with significant reductions in the uptake of these services.25There is also an urgent need to examine the organizational-level characteristics of treatment programs that may serve as facilitators or barriers to the availability of HCV testing services, either on-site or off-site, in the nation’s opioid treatment programs.26 HCV testing services may not be offered in opioid treatment programs in the United States for several potential reasons. First, opioid treatment programs may lack the required financial resources, including reimbursement and funding, to implement testing services.23,27–29 Second, treatment programs may not have the human resource capacity (e.g., low staff-to-client ratio) to effectively offer both substance abuse treatment services and ancillary services. Similarly, the ownership and affiliations of opioid treatment programs may influence the extent to which they can offer HCV testing services. For example, publicly owned opioid treatment programs might be more likely to have a prevention-driven mission, whereas hospital-affiliated opioid treatment programs may have access to networks that enable them to provide HCV testing services. Organizational-level predictors for HIV testing services in drug abuse treatment programs have been examined extensively, but similar national studies for the provision of HCV testing services are scarce.19,30–32We first describe trends in HCV testing availability in the nation’s opioid treatment programs between 2005 and 2011. We then examine the role of organizational factors in promoting the availability of HCV testing services among opioid treatment programs.     

Individual and Network Interventions With Injection Drug Users in 5 Ukraine Cities

Objectives. We evaluated the effects of an individual intervention versus a network intervention on HIV-related injection and sexual risk behaviors among street-recruited opiate injection drug users in 5 Ukraine cities.Methods. Between 2004 and 2006, 722 opiate injection drug users were recruited to participate in interventions that were either individually based or based on a social network model in which peer educators intervened with their network members. Audio computer-assisted self-interview techniques were used to interview participants at baseline and follow-up.Results. Multiple logistic analyses controlling for baseline injection and sexual risks revealed that both peer educators and network members in the network intervention reduced injection-related risk behaviors significantly more than did those in the individually based intervention and that peer educators increased condom use significantly more than did those in the individual intervention. Individual intervention participants, however, showed significantly greater improvements than did network members with respect to reductions in sexual risk behaviors.Conclusions. Social network interventions may be more effective than individually based interventions in changing injection risk behaviors among both peer educators and network members. The effectiveness of network interventions in changing sexual risk behaviors is less clear, probably owing to network composition and inhibitions regarding discussing sexual risk behaviors.Ukraine has experienced a dramatic and rapid rise in HIV infections, fueled initially by injection drug users. Yet, as recently as 1995 the World Health Organization characterized Ukraine as a low-prevalence country.¹ Within 2 years, however, all 25 regional capitals had reported cases of HIV.² Annual diagnoses have more than doubled each year since 2001, reaching 16 094 in 2006.³In 2007 it was estimated that 1.63% of the adult population (440 000 residents of Ukraine) was living with HIV/AIDS, an increase from 1.46% in 2005.⁴ Of note is that 75% of new infections are among those in the most active reproductive age group (20–34 years), contributing to a decline in Ukraine''s population from 47 million in 2004 to less than 46 million in 2006.⁵ The World Bank and the International HIV/AIDS Alliance in Ukraine have estimated that up to 820 400 citizens will be infected by 2014 ⁶ and that more than 140 will die each day, the majority under age 35 years and half female.⁷Over the past decade, the epidemic has begun to spread through heterosexual transmission.⁸ In Donetsk and Odessa, 55% to 60% of new infections in 2005 were attributed to sexual transmission.⁹ As in many countries, the epidemic is unevenly distributed across Ukraine. The HIV prevalence in the southern and eastern oblasts, including Odessa, Donetsk, Simferopol, and Nikolayev, is approximately 3 times that of the remaining areas of Ukraine.³A number of factors were probably responsible for the HIV epidemic among injection drug users in Ukraine. Following the collapse of the Soviet Union in December 1991, there was widespread social and economic disintegration throughout Eastern Europe, but particularly in Ukraine.^10–12 The illicit economy, including drug trafficking and money laundering, was estimated to have tripled in the first 5 years after the Soviet withdrawal, accounting for more than 40% of the gross national product from 1994 to 1995.¹³ With the withdrawal of the Soviet Union, police controls became ineffective, drugs more readily available, and corruption rampant.^14–17 Locally produced opiates and stimulants proliferated,^11,18 as did the number of substance users.The number of registered drug users increased between 1990 and 1996 from 30 000 to 63 000, and new cases of drug dependence grew from an estimated 4544 in 1991 to 11 443 in 2001.¹⁹ After this sharp rise in the number of drug users, new cases of HIV began to appear as well, coinciding with cuts in most government services, including health care and education.^20,21 As late as 2005, Ukraine had no public health information service, no HIV prevention policy or substance abuse treatment services, no sex education in schools, and no dissemination strategy to address the HIV/AIDS epidemic.²²The injecting practices of Ukraine drug users also probably played a critical role in the epidemic.^23–25 In Ukraine, liquid poppy straw, liquid poppy straw mixed with Demerol (an opiate–sedative mix), and pseudoephedrine (a stimulant) are the most commonly injected drugs by street users.¹¹ Liquid poppy straw is typically purchased from dealers or in the form of preloaded syringes from open-air markets.²⁶ Drug dealers, most of whom are also users, extract the solution from a common container with the user''s needle or syringe or use their own needle or syringe and frontload or backload (i.e., remove the needle or plunger and squirt the solution into the front or back of the user''s syringe).²⁷ In a single day, numerous needles could be used to withdraw the drug solution. By the late 1990s, it had been reported that HIV serostatus was associated with the use of liquid opiates.²⁸Pseudoephedrine (known as boltushka, vint, and jeff) is typically obtained in over-the-counter cold medicines and also involves the use of shared drug-mixing containers.^16,29,30 It is a common practice for a group of Ukraine injection drug users to inject ephedrine-based solutions together, which involves the sharing of both the drug solution and needles or syringes.^16,31We compared 2 intervention projects we conducted with injection drug users in Ukraine. The first was an individually focused intervention implemented between 2004 and 2006 in Kiev, Odessa, and Donetsk. The second was a network intervention conducted in 2005 and 2006 in Nikolayev and Simferopol, 2 cities in the Crimea. HIV prevalence at baseline ranged from 20% (Donetsk) to 65% (Nikolayev). In each location, notable for their high concentrations of injection drug users, interventions were delivered by nongovernmental agencies (NGOs) selected as a result of their experience in working with injection drug users and their expressed interest in HIV prevention.The 2 interventions (both guided via instruction manuals) were implemented in their respective cities to reduce injection and sexual risk behaviors. The sampling plan was similar across all sites, as were the study methodology, participant eligibility criteria, and measures used, including audio computer-assisted self-interview (ACASI) techniques. Also, intervention training was conducted by the same staff, including the principal investigator, data manager, and intervention trainers.     

Learning From Successful Interventions: A Culturally Congruent HIV Risk�CReduction Intervention for African American Men Who Have Sex With Men and Women

Few HIV prevention interventions have been developed for African American men who have sex with men or who have sex with both men and women. Many interventions neglect the historical, structural or institutional, and sociocultural factors that hinder or support risk reduction in this high-risk group.We examined ways to incorporate these factors into Men of African American Legacy Empowering Self, a culturally congruent HIV intervention targeting African American men who have sex with men and women.We also studied how to apply key elements from successful interventions to future efforts. These elements include having gender specificity, a target population, a theoretical foundation, cultural and historical congruence, skill-building components, and well-defined goals.AFRICAN AMERICAN MEN WHO have sex with men (MSM) or who have sex with both men and women (MSMW) have the highest HIV prevalence among African Americans and among other racial/ethnic groups of MSM.^1–3 However, HIV risk behaviors alone do not explain the disproportionate HIV rates among African American MSM.^4,5 Attention to the sociocultural challenges facing African American MSM is needed.Only 1 published HIV behavioral intervention targets African American MSM⁶; none specifically target African American MSMW. Inclusion of culture is believed to improve the ability of public health programs to meet members'' needs.^7–9 However, inherent abstractness and a lack of operationalized definitions and cultural competency pose challenges for those designing and implementing interventions.^10–14 Understanding the experiences of African American MSM requires attention to definitions of what it means to be African American and of male sexuality that are rooted in African American history and culture. Choices regarding identification with gay or bisexual labels and disclosure of Black same-gender sexual activities must be contextualized within African American communities.^15–17Health improvement among African American MSM requires attention to racism; gender role expectations; connection to partners, families, and communities; and HIV-related stigma.^18–22 Double minority status is made worse by high HIV rates and perceived responsibility for spreading HIV.^23–25 Even if family and community provide social support, homophobia and racism can deter African American MSM from disclosing their sexuality and seeking HIV prevention and care.²⁶ Interventions must engage protective factors and address structural or institutional and sociocultural barriers to prevention.     

The association between perceived discrimination and obesity in a population-based multiracial and multiethnic adult sample

Objectives. We examined whether perceived chronic discrimination was related to excess body fat accumulation in a random, multiethnic, population-based sample of US adults.Methods. We used multivariate multinomial logistic regression and logistic regression analyses to examine the relationship between interpersonal experiences of perceived chronic discrimination and body mass index and high-risk waist circumference.Results. Consistent with other studies, our analyses showed that perceived unfair treatment was associated with increased abdominal obesity. Compared with Irish, Jewish, Polish, and Italian Whites who did not experience perceived chronic discrimination, Irish, Jewish, Polish, and Italian Whites who perceived chronic discrimination were 2 to 6 times more likely to have a high-risk waist circumference. No significant relationship between perceived discrimination and the obesity measures was found among the other Whites, Blacks, or Hispanics.Conclusions. These findings are not completely unsupported. White ethnic groups including Polish, Italians, Jews, and Irish have historically been discriminated against in the United States, and other recent research suggests that they experience higher levels of perceived discrimination than do other Whites and that these experiences adversely affect their health.It is estimated that 2 of every 3 adults in the United States are overweight or obese.^1,2 Obesity is a major risk factor for chronic health conditions, such as type 2 diabetes, coronary heart disease, hypertension, stroke, some forms of cancer, and osteoarthritis.³ Although it is widely accepted that high-fat diets and physical inactivity are preventable risk factors,⁴ obesity continues to increase.^1,2,5There is a growing interest in the relationship between psychosocial risk factors and excess body fat accumulation.^6–16 In particular, some evidence suggests that psychosocial stressors may play a role in disease progression in general and in excess body fat in particular.^7,8,17 The key factors underlying physiological reactions to psychosocial stress have not been completely elucidated, but McEwen and Seeman¹⁷ and others^7,18,19 posit that the continued adaptation of the physiological system to external challenges alters the normal physiological stress reaction pathways and that these changes are related to adverse health outcomes.^8,17,18,20 For example, in examining the association between psychosocial stress and excess body fat accumulation, Björntorp and others have suggested that psychosocial stress is linked to obesity, especially in the abdominal area.^7,8Perceived discrimination, as a psychosocial stressor, is now receiving increased attention in the empirical health literature.^21–24 Such studies suggest perceived discrimination is inversely related to poor mental and physical health outcomes and risk factors, including hypertension,^24,25 depressive symptoms,^26–28 smoking,^29–31 alcohol drinking,^32,33 low birthweight,^34,35 and cardiovascular outcomes.^36–38Internalized racism, the acceptance of negative stereotypes by the stigmatized group,³⁹ has also been recognized as a race-related psychosocial risk factor.⁴⁰ Recent studies have also suggested that race-related beliefs and experiences including perceived discrimination might be potentially related to excess body fat accumulation. Three of these studies^9,13,41 showed that internalized racism was associated with an increased likelihood of overweight or abdominal obesity among Black Caribbean women in Dominica⁴¹ and Barbados¹³ and adolescent girls in Barbados.⁹ These researchers posit that individuals with relatively high levels of internalized racism have adopted a defeatist mindset, which is believed to be related to the physiological pathway associated with excess body fat accumulation. However, Vines et al.¹⁶ found that perceived racism was associated with lower waist-to-hip ratios among Black women in the United States. Although the assessment of race-related risk factors varied across these studies, the findings suggest that the salience of race-related beliefs and experiences may be related to excess body fat accumulation.Collectively, the results of these studies are limited. First, because they examined the relationship between race-related beliefs and experiences and excess body fat only among women, we do not know if this relationship is generalizable to men.^13,16,41 Second, these studies only examined this relationship among Blacks, even though perceived unfair treatment because of race/ethnicity has been shown to be adversely related to the health of multiple racial/ethnic population groups in the United States^42–49 and internationally.^27,50–55 Third, none of the studies have examined the relationship between excess body fat accumulation and perceived nonracial/nonethnic experiences of interpersonal discrimination. Some evidence suggests that the generic perception of unfair treatment or bias is adversely related to health, regardless of whether it is attributed to race, ethnicity, or some other reason.^45,55,56 Fourth, none of these studies included other measures of stress. We do not know if the association between race-related risk factors and obesity is independent of other traditional indicators of stress.Using a multiethnic, population-based sample of adults, we examined the association of perceived discrimination and obesity independent of other known risk factors for obesity, including stressful major life events. Additionally, because reports of perceived racial/ethnic discrimination and non-racial/ethnic discrimination vary by racial/ethnic groups^24,45,46,57 and because Whites tend to have less excess body fat than do Blacks and Hispanics,^1,3 we examined the relationships between perceived discrimination and excess body fat accumulation among Hispanics, non-Hispanic Whites, and non-Hispanic Blacks.     

Connecting Discovery and Delivery: The Need For More Evidence on Effective Smoking Cessation Strategies for People Living With HIV/AIDS

Smoking prevalence among the 1.1 million Americans living with HIV/AIDS is 2 to 3 times higher than the 19.8% rate among the general population. Since 1990, scientists have worked toward the discovery of health risks related to smoking in people living with HIV/AIDS; however, few studies have evaluated the delivery of smoking cessation interventions for this population. Increasing linkages between discovery science and delivery science may facilitate a faster transition to delivery of smoking cessation interventions for people living with HIV/AIDS.Health research often focuses on the discovery of risk factors associated with disease and death.¹ Although discovery of health risks is necessary to protect health, the delivery of interventions to improve health is equally important.^1–5 Information regarding how science moves from discovery to delivery points to substantial time lag and little cross-talk between discovery and delivery research.^1,6 This may be especially problematic in areas such as HIV/AIDS and smoking, where delay between discovery of smoking-related health outcomes in people living with HIV/AIDS and the delivery of interventions to reduce smoking among this population has serious consequences.Smoking prevalence in people living with HIV/AIDS is 2 to 3 times higher than is the 19.8% rate among the general population.^7–16 Discovery research has concluded that smokers with HIV/AIDS are more likely to be nonadherent to treatment, have a greater chance of being diagnosed with an AIDS-defining condition or dying, and report lower quality of life than do nonsmoking persons with HIV/AIDS.^13,17–21 Smokers living with HIV/AIDS have a higher risk of disease and opportunistic infection than do smokers who do not have HIV/AIDS.^9,22–34Delivery research indicates that population-specific smoking cessation interventions can be effective.^35–52 Although few studies have examined such strategies for persons living with HIV/AIDS,³⁵ a recent study found that 86% of smokers with HIV/AIDS would not benefit from standard cessation programs.⁵³ I used citation network analysis^54–56 to examine the characteristics of—and possible relationships between—discovery research relating health outcomes to smoking in persons living with HIV/AIDS and delivery research on interventions to reduce smoking among this population.     

Reinforcement of smoking and drinking: tobacco marketing strategies linked with alcohol in the United States

Objectives. We investigated tobacco companies’ knowledge about concurrent use of tobacco and alcohol, their marketing strategies linking cigarettes with alcohol, and the benefits tobacco companies sought from these marketing activities.Methods. We performed systematic searches on previously secret tobacco industry documents, and we summarized the themes and contexts of relevant search results.Results. Tobacco company research confirmed the association between tobacco use and alcohol use. Tobacco companies explored promotional strategies linking cigarettes and alcohol, such as jointly sponsoring special events with alcohol companies to lower the cost of sponsorships, increase consumer appeal, reinforce brand identity, and generate increased cigarette sales. They also pursued promotions that tied cigarette sales to alcohol purchases, and cigarette promotional events frequently featured alcohol discounts or encouraged alcohol use.Conclusions. Tobacco companies’ numerous marketing strategies linking cigarettes with alcohol may have reinforced the use of both substances. Because using tobacco and alcohol together makes it harder to quit smoking, policies prohibiting tobacco sales and promotion in establishments where alcohol is served and sold might mitigate this effect. Smoking cessation programs should address the effect that alcohol consumption has on tobacco use.Smoking remains the leading preventable cause of premature mortality in the United States, accounting for more than 440 000 deaths annually.¹ Alcohol consumption is the third-leading cause of mortality in the nation.² Each year, approximately 79 000 deaths are attributable to excessive alcohol use.³ The concurrent use of cigarettes and alcohol further increases risks for certain cancers, such as cancer of the mouth, throat, and esophagus.^4,5 In addition, the use of both tobacco and alcohol makes it more difficult to quit either substance.⁶Smoking and drinking are strongly associated behaviors.^7–13 Smokers are more likely to drink alcohol,¹¹ drink more frequently,^8,11 consume a higher quantity of alcohol,^8,11,14 and demonstrate binge drinking (5 or more drinks per episode) than are nonsmokers.^9,11,12 Alcohol drinkers, especially binge drinkers, are also more likely to smoke^7,8,10 and are more likely to smoke half a pack of cigarettes or more per day.¹⁰The association between tobacco use and alcohol use becomes stronger with the heavier use of either substance.^8,15,16 Alcohol consumption increases the desire to smoke,^17,18 and nicotine consumption increases alcohol consumption.¹⁹ Experimental studies have demonstrated that nicotine and alcohol enhance each other''s rewarding effects.^16,18 Alcohol increases the positive subjective effects of smoking,^8,15,16,20 and smoking while using alcohol is more reinforcing than is smoking without concurrent alcohol use.⁸ Smokers smoke more cigarettes while drinking alcohol,^8,15,18 especially during binge-drinking episodes.^8,15 This behavior has also been observed among nondaily smokers^8,15 and light smokers.¹⁷The concurrent use of alcohol and tobacco is common among young adults,^8,10,12,21 including nondaily smokers,^19,22–24 nondependent smokers,⁸ and novice smokers.¹³ Young adult smokers have reported that alcohol increases their enjoyment of and desire for cigarettes^8,25 and that tobacco enhances the effect of alcohol: it “brings on the buzz” or “gave you a double buzz.”^13,23,26 Young adult nondaily smokers described the pairing of alcohol and cigarettes as resembling “milk and cookies” or “peanut butter with jelly.”²⁴ Young adults have also been the focus of aggressive tobacco promotional efforts in places where alcohol is consumed, such as bars and nightclubs.^27,28Consumer products often fall into cohesive groups (sometimes referred to as “Diderot unities”) that may reinforce certain patterns of consumption,²⁹ and these groupings may be influenced by marketing activities. In the case of tobacco and alcohol, these product links may have been further enhanced by cooperation between tobacco and alcohol companies (e.g., cosponsorship) or corporate ownership of both tobacco and alcohol companies (e.g., Philip Morris''s past ownership of Miller Brewing Company).We used tobacco industry documents to explore tobacco companies’ knowledge regarding linked tobacco and alcohol use and the companies’ marketing strategies that linked cigarettes with alcohol. We were interested in 3 basic issues: (1) what tobacco companies knew about the association between drinking and smoking, especially about smokers’ drinking behaviors, (2) how tobacco and alcohol companies developed cross promotions featuring cigarettes and alcohol, and (3) how tobacco companies linked cigarettes with alcohol in their marketing activities and the benefits they expected to gain from those activities.     

Impact of individual-, environmental-, and policy-level factors on health care utilization among US farmworkers

Objectives. We examined individual-, environmental-, and policy-level correlates of US farmworker health care utilization, guided by the behavioral model for vulnerable populations and the ecological model.Methods. The 2006 and 2007 administrations of the National Agricultural Workers Survey (n = 2884) provided the primary data. Geographic information systems, the 2005 Uniform Data System, and rurality and border proximity indices provided environmental variables. To identify factors associated with health care use, we performed logistic regression using weighted hierarchical linear modeling.Results. Approximately half (55.3%) of farmworkers utilized US health care in the previous 2 years. Several factors were independently associated with use at the individual level (gender, immigration and migrant status, English proficiency, transportation access, health status, and non-US health care utilization), the environmental level (proximity to US–Mexico border), and the policy level (insurance status and workplace payment structure). County Federally Qualified Health Center resources were not independently associated.Conclusions. We identified farmworkers at greatest risk for poor access. We made recommendations for change to farmworker health care access at all 3 levels of influence, emphasizing Federally Qualified Health Center service delivery.US farmworkers face significant disease burden¹ and excessive mortality rates for some diseases (e.g., certain cancers and tuberculosis) and injuries.² Disparities in health outcomes likely stem from occupational exposures and socioeconomic and political vulnerabilities. US farmworkers are typically Hispanic with limited education, income, and English proficiency.³ Approximately half are unauthorized to work in the United States.³ Despite marked disease burden, health care utilization appears to be low.^1,4–9 For example, only approximately half of California farmworkers received medical care in the previous year.⁶ This rate parallels that of health care utilization for US Hispanics, of whom approximately half made an ambulatory care visit in the previous year, compared with 75.7% of non-Hispanic Whites.¹⁰ Disparities in dental care have a comparable pattern.^6,8,11,12 However, utilization of preventive health services is lower for farmworkers^5,7,13,14 than it is for both US Hispanics and non-Hispanic Whites.^15,16Farmworkers face numerous barriers to health care^1,4,17: lack of insurance and knowledge of how to use or obtain it,^6,18 cost,^{5,6,12,13,18–20} lack of transportation,^{6,12,13,19–21} not knowing how to access care,^6,18,20,21 few services in the area or limited hours,^12,20,21 difficulty leaving work,¹⁹ lack of time,^5,13,19 language differences,^6,8,18–20 and fear of the medical system,¹³ losing employment,⁶ and immigration officials.²¹ Few studies have examined correlates of health care use among farmworkers. Those that have are outdated or limited in representativeness.^5,7,14,22,23 Thus, we systematically examined correlates of US health care use in a nationally representative sample of farmworkers, using recently collected data. The sampling strategy and application of postsampling weights enhance generalizability. We selected correlates on the basis of previous literature and the behavioral model for vulnerable populations.²⁴ The behavioral model posits that predisposing, enabling, and need characteristics influence health care use.²⁵ The ecological model, which specifies several levels of influence on behavior (e.g., policy, environmental, intrapersonal),²⁶ provided the overall theoretical framework. To our knowledge, we are the first to extensively examine multilevel correlates of farmworker health care use. We sought to identify farmworkers at greatest risk for low health care use and to suggest areas for intervention at all 3 levels of influence so that farmworker service provision can be improved.     

Relation of Childhood Sexual Abuse,Intimate Partner Violence,and Depression to Risk Factors for HIV Among Black Men Who Have Sex With Men in 6 US Cities

Objectives. We assessed the relation of childhood sexual abuse (CSA), intimate partner violence (IPV), and depression to HIV sexual risk behaviors among Black men who have sex with men (MSM).Methods. Participants were 1522 Black MSM recruited from 6 US cities between July 2009 and December 2011. Univariate and multivariable logistic regression models were used.Results. Participants reported sex before age 12 years with someone at least 5 years older (31.1%), unwanted sex when aged 12 to 16 years (30%), IPV (51.8%), and depression (43.8%). Experiencing CSA when aged 12 to 16 years was inversely associated with any receptive condomless anal sex with a male partner (adjusted odds ratio [AOR] = 0.50; 95% confidence interval [CI] = 0.29, 0.86). Pressured or forced sex was positively associated with any receptive anal sex (AOR = 2.24; 95% CI = 1.57, 3.20). Experiencing CSA when younger than 12 years, physical abuse, emotional abuse, having been stalked, and pressured or forced sex were positively associated with having more than 3 male partners in the past 6 months. Among HIV-positive MSM (n = 337), CSA between ages 12 and 16 years was positively associated with having more than 3 male partners in the past 6 months.Conclusions. Rates of CSA, IPV, and depression were high, but associations with HIV sexual risk outcomes were modest.Despite significant medical advances, the HIV epidemic remains a health crisis in Black communities. The Black population represents only 14% of the total US population but accounted for 44% of all new HIV infection (68.9 of 100 000) in 2010.1 Black men who have sex with men (MSM) are disproportionately impacted by HIV compared with other racial/ethnic groups of MSM.1,2 Male-to-male sexual contact accounted for 72% of new infections among all Black men.1 Young Black MSM (aged 13–24 years) have a greater number of new infections than any other age or racial group among MSM.1 Researchers have been challenged with developing HIV prevention strategies for Black MSM.3–7 Higher frequencies of sexual risk behaviors, substance use, and nondisclosure of sexual identities do not adequately explain this disparity.8,9 High rates of sexually transmitted infections (STIs), which facilitate HIV transmission, and undetected or late diagnosis of HIV infection only partially explain disproportionate HIV rates.8Researchers have begun to examine a constellation of health factors that may contribute to HIV among MSM. For example, syndemic theory or the interaction of epidemics synergistically, such as intimate partner violence (IPV) and depression, may help explain HIV-related sexual risk behaviors among Black MSM.9 Childhood sexual abuse (CSA), IPV, and mental health disorders including depression may comprise such a constellation and warrant further exploration.Experiences of CSA have been identified as being associated with negative sexual health outcomes, with MSM reporting higher CSA rates than the general male population.10–12 Men with CSA experiences are more likely than men without CSA experiences to engage in high-risk sexual behaviors,13–21 have more lifetime sexual partners,13–16 use condoms less frequently,13,14,16 and have higher rates of STIs,13,14,17 exchanging sex for drugs or money,13,14,17 HIV,13,14 alcohol and substance use,13–21 and depression.13–15,18,21 Such findings suggest that sexual risk reduction counseling may need to be tailored for MSM with CSA experiences.15Childhood sexual abuse histories have also been correlated with sexual revictimization, including IPV.22–24 One study with population-based estimates of CSA found that gay and bisexually identified men had higher odds of reporting CSA (9.5 and 12.8, respectively) compared with heterosexual men.25 For sexual minority men, CSA histories were associated with higher HIV and STI incidence.25 However, research examining CSA, revictimization, and sexual risk behaviors is lacking among Black MSM.In one existing study, Black and Latino MSM with CSA histories identified their trauma experiences as influencing their adult sexual decision-making.26 Among Black MSM in 2 additional studies, emotional distress and substance use were attributed to having CSA experiences (Leo Wilton, PhD, written communication, October 2, 2013).27 In an ethnically diverse sample of 456 HIV-positive MSM, CSA was associated with insertive and receptive condomless anal sex.19Similar to CSA, IPV has not been extensively examined among MSM or Black MSM,28 but may be associated with sexual risk behaviors. Intimate partner violence is defined as a pattern of controlling, abusive behavior within an intimate relationship that may include physical, psychological or emotional, verbal, or sexual abuse.29 Little research exists on IPV among same-sex couples despite incidence rates being comparable to or greater than that of heterosexual women.28,30–34 Important IPV information comes from the National Intimate Partner and Sexual Violence Survey, a nationally representative survey for experiences of sexual violence, stalking, and IPV among men and women in the United States.28 Among men who experienced rape, physical violence, or stalking by an intimate partner, perpetrator differences by gender were found among gay, bisexual, and heterosexual men; 78% of bisexual and 99.5% of heterosexual men reported having only female perpetrators, and 90.7% of gay men reported having only male perpetrators.28 Being slapped, pushed, or shoved by an intimate partner during their lifetime was reported by gay (24%), bisexual (27%), and heterosexual (26.3%) men.28Intimate partner violence has been linked to condomless anal sex, HIV infection, substance use, CSA, and depression.35–37 Being an HIV-positive MSM has been linked with becoming a victim of IPV.38,39 Welles et al. found that being an African American MSM who initially disclosed having male partners and early life sexual abuse experiences was associated with IPV victimization.39 Wilton found that a high percentage of Black MSM reported IPV histories: emotional abuse (48.3%), physical abuse (28.3%), sexual abuse (21.7%), and stalking abuse (29.2%; Leo Wilton, PhD, written communication, October 2, 2013). Such findings lend to the importance of exploring, both independently and together, the association of CSA and IPV with sexual risk behaviors.Some studies have reported the influence of mental health (e.g., depression) on sexual risk behaviors among MSM,9,40,41 whereas others have not corroborated such findings.42 Greater rates of depression among MSM than among non-MSM samples43–45 and elevated rates of depression and anxiety among Black MSM have been reported.46 The Urban Men’s Health Study, a cross-sectional sample of MSM in 4 US cities, did not find a significant relationship between high depressive symptoms and condomless anal sex.42 However, the EXPLORE study, a randomized behavioral intervention for MSM in 6 US cities, supported the association between moderate depressive symptoms and an increased risk for HIV infection.47 Moderate levels of depression and higher rates of sexual risk were also reported for HIV-infected MSM over time.48 Another study conducted with 197 Black MSM found that moderate depressive symptoms were associated with having condomless anal sex with a serodiscordant casual partner.49 These mixed findings support the need to better understand the relationship between the severity of depression (i.e., moderate vs severe) and HIV risk behaviors.The HIV Prevention Trials Network 061 study, also known as the BROTHERS (Broadening the Reach of Testing, Health Education, Resources, and Services) Project, was a multisite study to determine the feasibility and acceptability of a multicomponent intervention for Black MSM. The current analysis aims to assess the prevalence of CSA, IPV, and depressive symptomology, and examine the relationships between these factors and insertive and receptive condomless anal sex and number of sexual partners in a large cohort of Black MSM.     

A Systematic Review of Neighborhood Disparities in Point-of-Sale Tobacco Marketing

We systematically reviewed evidence of disparities in tobacco marketing at tobacco retailers by sociodemographic neighborhood characteristics. We identified 43 relevant articles from 893 results of a systematic search in 10 databases updated May 28, 2014. We found 148 associations of marketing (price, placement, promotion, or product availability) with a neighborhood demographic of interest (socioeconomic disadvantage, race, ethnicity, and urbanicity).Neighborhoods with lower income have more tobacco marketing. There is more menthol marketing targeting urban neighborhoods and neighborhoods with more Black residents. Smokeless tobacco products are targeted more toward rural neighborhoods and neighborhoods with more White residents. Differences in store type partially explain these disparities.There are more inducements to start and continue smoking in lower-income neighborhoods and in neighborhoods with more Black residents. Retailer marketing may contribute to disparities in tobacco use. Clinicians should be aware of the pervasiveness of these environmental cues.Tobacco products and their marketing materials are ubiquitous in US retailers from pharmacies to corner stores.1 A similar presence is found across the globe, except in countries that ban point-of-sale (POS) tobacco marketing (e.g., Australia, Canada, Thailand2). In the United States, the POS has become the main communications channel for tobacco marketing3,4 and is reported as a source of exposure to tobacco marketing by more than 75% of US youths.5 Burgeoning evidence6,7 suggests that marketing at the POS is associated with youths’ brand preference,8 smoking initiation,9 impulse purchases,10,11 and compromised quit attempts.12,13The marketing of tobacco products is not uniform; it is clear from industry documents that the tobacco industry has calibrated its marketing to target specific demographic groups defined by race,14 ethnicity,15 income,16 mental health status,17 gender,18,19 and sexual orientation.20 Framed as an issue of social and environmental justice,14 research has documented historical racial, ethnic, and socioeconomic disparities in the presence of tobacco billboards,21–25 racial disparities in total tobacco marketing volume,24 and targeting of menthol cigarettes to communities with more Black residents.25,26 Targeted marketing of a consumer product that kills up to half27 of its users when used as directed exacerbates inequities in morbidity and mortality. Smoking is estimated to be responsible for close to half of the difference in mortality between men in the lowest and highest socioeconomic groups.28 However, evidence of marketing disparities is scattered across multiple disciplines and marketing outcomes, such as product availability, advertising quantity, presence of promotional discounts, and price. A synthesis of this literature would provide valuable information for intervention on tobacco marketing in the retail environment and inform etiological research on health disparities.To address this gap in the literature, we systematically reviewed observational studies that examined the presence and quantity of POS tobacco marketing to determine the extent to which marketing disparities exist by neighborhood demographic characteristic (i.e., socioeconomic disadvantage, race, ethnicity, and urbanicity).