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.     

Effects of a Brief Case Management Intervention Linking People With HIV to Oral Health Care: Project SMILE

Objectives. Although people with HIV experience significant oral health problems, many consistently identify oral health as an unmet health care need. We conducted a randomized controlled trial to evaluate the impact of a dental case management intervention on dental care use.Methods. We evaluated the intervention according to self-reported dental care use at 6-, 12-, and 18-month follow-ups. Multivariable logistic models with generalized estimating equations were used to assess the effects of the intervention over time.Results. The odds of having a dental care visit were about twice as high in the intervention group as in the standard care group at 6 months (adjusted odds ratio [OR] = 2.52; 95% confidence interval [CI] = 1.58, 4.08) and 12 months (adjusted OR = 1.98; 95% CI = 1.17, 3.35), but the odds were comparable in the 2 groups by 18 months (adjusted OR = 1.07; 95% CI = 0.62, 1.86). Factors significantly associated with having a dental care visit included frequent physician visits and dental care referrals.Conclusions. We demonstrated that a dental case management intervention targeting people with HIV was efficacious but not sustainable over time. Barriers not addressed in the intervention must be considered to sustain its use over time.In the era of antiretroviral therapy, people with HIV are living longer and the treatment of associated medical and oral manifestations of the disease has shifted to a chronic disease model.1 Previous studies have shown that a person living with HIV/AIDS is more likely than a person without the disease to experience oral health problems.2–5 Furthermore, the oral health problems of individuals with HIV can be more severe and difficult to treat than those of the general population and may also contribute to the onset of opportunistic infections.5The oral health complications associated with HIV are well documented,2–6 and oral manifestations are increasingly being recognized as markers for monitoring treatment efficacy and predicting treatment failure.7 Oral manifestations, including Kaposi’s sarcoma, necrotizing ulcerative periodontitis, oral hairy leukoplakia, and candidiasis, may be present in up to 50% of people with HIV and 80% of people diagnosed with AIDS,5,6 and may predict low CD4 counts.8 In addition, individuals living with HIV/AIDS may experience difficulty in maintaining adequate salivary flow, which affects chewing, swallowing, and the ability to take medication.4 Chronic use of highly active antiretroviral therapy can also contribute to diminished salivary flow as well as an increased risk of oral candidiasis and oral hairy leukoplakia.9Throughout the 1990s, a series of study findings highlighted the unmet needs for dental care among people with HIV infection.10–14 This gap in oral health care services was corroborated by findings from the oral health component of the HIV Cost and Services Utilization Study,15 which demonstrated that unmet dental needs were twice as common as unmet medical needs among HIV-positive adults16,17 and led to a national call to action to improve access to oral health care.18 That study also showed that approximately half of people living with HIV had dental insurance, and those without dental insurance had greater unmet needs for dental services.17,19,20Recently published findings suggest that an unmet need still persists. One example is an initiative, funded by the Health Resources and Services Administration, that included 2469 people living with HIV who had not received dental care during the preceding year. Nearly half of these individuals (48%) reported an unmet dental need since their HIV diagnosis, 52% had not seen a dentist in more than 2 years, and 63% rated the health of their teeth and gums as fair or poor.21,22 An earlier investigation involving baseline data from the study presented here showed that oral health problems and symptoms were very prevalent among our study population, with 63% of participants having experienced an oral health impact very often or fairly often in the preceding 4 weeks.23Barriers to dental care use among individuals living with HIV include fear of dental care, HIV-specific stigma, fear of disclosing their HIV status to health care providers, perceived cost barriers, and poor adherence to medical guidance.20,22,24–31 Compounding patient access barriers, dental care providers may be reluctant to treat patients with HIV owing to fears of HIV transmission and associated stigma.32–36Previous research conducted in Florida revealed that more than one third of people with HIV do not discuss oral health with their primary care providers.37 Although clinical guidelines recommend that HIV care providers examine the oral cavity during initial and interim physical examinations of people living with HIV, this still may not be a regular clinical practice.37 To address underuse of oral health care services among individuals with HIV, we evaluated the efficacy of an intervention that linked individuals to dental care. The sample comprised a population of HIV-positive individuals in south Florida who had received HIV primary care but had not received oral health services in the preceding 12 months.     

Brief Intervention and Follow-Up for Suicidal Patients With Repeat Emergency Department Visits Enhances Treatment Engagement

We implemented an innovative, brief, easy-to-administer 2-part intervention to enhance coping and treatment engagement. The intervention consisted of safety planning and structured telephone follow-up postdischarge with 95 veterans who had 2 or more emergency department (ED) visits within 6 months for suicide-related concerns (i.e., suicide ideation or behavior). The intervention significantly increased behavioral health treatment attendance 3 months after intervention, compared with treatment attendance in the 3 months after a previous ED visit without intervention. The trend was for a decreasing hospitalization rate.Approximately 400 000 to 500 000 US emergency department (ED) visits occur annually for suicide attempts.1,2 The ED is a primary site for the treatment of suicide attempts, and for many patients, ED interventions are the only treatment they receive.3 As many as 60% of suicidal ED patients are stabilized and discharged directly to outpatient care.1,2 Unfortunately, only 50% of these patients follow up on their referrals and attend 1 or more outpatient behavioral health sessions.3 Consequently, costly repeat ED visits and additional suicidal behavior are frequent. As many as 30% of patients presenting to the ED for a suicide-related concern return to the ED for another suicide-related concern within 1 year,4 and 2-year follow-up suicide mortality rates among suicide attempters are estimated at 2%.5 Recurrent suicidal behavior and limited outpatient treatment engagement are similarly significant problems among veterans,6–8 who may be at greater risk for suicide than civilians despite more recent reductions.9,10 Given that the ED is the only place where many suicidal individuals receive care, it could be an important intervention site to increase outpatient treatment engagement and reduce repeat suicidal behavior, ED visits, and hospitalizations.11     

Correlates of Sexual Risk Among Sexual Minority and Heterosexual South African Youths

We explored psychosocial correlates of sexual risk among heterosexual and sexual minority youths (SMYs) in Johannesburg, South Africa. Young people 16 to 18 years old (n = 822) were administered surveys assessing demographic characteristics, sexual behaviors, mental health, and parent–child communication. Adjusted multivariate regressions examining correlates of sexual risk revealed that SMYs had more sexual partners than heterosexual youths (B = 3.90; SE = 0.95; P < .001) and were more likely to engage in sex trading (OR = 3.11; CI = 1.12-8.62; P < .05). South African SMYs are at increased risk relative to their heterosexual peers.South Africa has the highest burden of HIV in the world; 9.2% of young persons aged 15 to 19 years living in the country are infected with HIV.1,2 Few studies have examined multilevel sexual risk factors (e.g., individual, partner, family) among sexual minority youths (SMYs)3 in South Africa, despite their increased vulnerability.4–8 Research has shown that rates of sexual risk behavior are high among adult men who have sex with men (MSM) in sub-Saharan Africa,5,9 and South African SMYs may be especially vulnerable given the transitional nature of adolescence, fear of discrimination, and lack of cultural acceptance of homosexuality.4,7,10Our analyses were guided by theories of syndemics (i.e., collective risk or co-occurring epidemics)11–13 and minority group stress.14 These theories posit that young MSM experience psychosocial disparities in numerous areas (substance use, abuse and victimization, mental health problems, risk taking)15–18 and that SMYs are at increased risk for poor mental health, sexual vulnerability, substance use, and violence.19,20 Moreover, stigma creates stressful environments, another cause of mental health problems among SMYs.14 This situation is especially salient in South Africa, where same-sex behavior is so highly stigmatized that even normative adolescent sexual exploration would likely be denounced.7We hypothesized that South African SMYs would be at increased sexual risk relative to heterosexual youths. To our knowledge, this is one of the first investigations to examine risk and protective factors associated with sexual risk in this population.     

Sexual Minority Women and Depressive Symptoms Throughout Adulthood

Objectives. We examined the associations between depressive symptoms and sexual identity and behavior among women with or at risk for HIV.Methods. We analyzed longitudinal data from 1811 participants in the Women’s Interagency HIV Study (WIHS) from 1994 to 2013 in Brooklyn and the Bronx, New York; Chicago, Illinois; Washington, DC; and Los Angeles and San Francisco, California, by comparing depressive symptoms by baseline sexual identity and ongoing sexual behavior. We controlled for age, socioeconomic status, violence history, and substance use.Results. In separate analyses, bisexual women and women who reported having sex with both men and women during follow-up had higher unadjusted odds of depressive symptoms compared with heterosexuals and women who reported only having male sexual partners (adjusted odd ratio [AOR] = 1.36; 95% confidence interval [CI]  = 1.10, 1.69 and AOR = 1.21; 95% CI = 1.06, 1.37, respectively). Age was a significant effect modifier in multivariable analysis; sexual minority women had increased odds of depressive symptoms in early adulthood, but they did not have these odds at midlife. Odds of depressive symptoms were lower among some sexual minority women at older ages.Conclusions. Patterns of depressive symptoms over the life course of sexual minority women with or at risk for HIV might differ from heterosexual women and from patterns observed in the general aging population.Depression is a major health concern for women. According to the Centers for Disease Control and Prevention (CDC), 10% of US women reported any depression and 5% reported major depression in the previous 2 weeks.1 Depression has been reported in 19% to 62%2–4 of HIV-infected women and is associated with reduced cognitive function,5 decreased adherence to highly active antiretroviral therapy (HAART),6 higher rates of unprotected sex among substance users,7 and increased mortality.2,6Women with or at risk for HIV are often exposed to factors such as poverty,8 substance use, and violence,9–11 which can independently and jointly contribute to depression. A recent study found that any combination of intimate partner violence (IPV), substance use, and HIV infection increased the odds of depression.12 Lower socioeconomic status (SES) in women12 and HIV infection4,5 were also independently associated with depression. However, studies showed no association among HIV stage, HAART use,4,8 CD4 count,8,13 or viral load and depression.4,8,13There is a strong association between sexual minority status (i.e., women who identify as lesbian or bisexual or have female sex partners) and poor mental health. In a US survey, lifetime major depression was reported by 42% of lesbians, 52% of bisexuals, and 27% of heterosexual women (P < .01); in the same study, major depression was reported by 15% of women who have sex with women (WSW), 51% of women who have sex with men and women (WSMW), and 27% of women who have sex with men (WSM; P < .01).14 In this study, we examined 2 aspects of sexual orientation15–17: sexual identity and sexual behavior. Although sexual attraction is also considered part of an individual’s sexual orientation, data on attraction was not collected in the original study.Despite the strong association between sexual minority status and depression, it is unknown whether sexual minority status acts as an independent predictor or effect modifier of depressive symptoms among women affected by HIV, substance use, and violence. Our original hypothesis was that lesbian, bisexual, and WSMW (but not WSW) would have higher odds of depression, with race/ethnicity acting as a potential effect modifier.     

Posttraumatic Stress Disorder and Incident Heart Failure Among a Community-Based Sample of US Veterans

Objectives. We investigated the association between posttraumatic stress disorder (PTSD) and incident heart failure in a community-based sample of veterans.Methods. We examined Veterans Affairs Pacific Islands Health Care System outpatient medical records for 8248 veterans between 2005 and 2012. We used multivariable Cox regression to estimate hazard ratios and 95% confidence intervals for the development of heart failure by PTSD status.Results. Over a mean follow-up of 7.2 years, veterans with PTSD were at increased risk for developing heart failure (hazard ratio [HR] = 1.47; 95% confidence interval [CI] = 1.13, 1.92) compared with veterans without PTSD after adjustment for age, gender, diabetes, hyperlipidemia, hypertension, body mass index, combat service, and military service period. Additional predictors for heart failure included age (HR = 1.05; 95% CI = 1.03, 1.07), diabetes (HR = 2.54; 95% CI = 2.02, 3.20), hypertension (HR = 1.87; 95% CI = 1.42, 2.46), overweight (HR = 1.72; 95% CI = 1.25, 2.36), obesity (HR = 3.43; 95% CI = 2.50, 4.70), and combat service (HR = 4.99; 95% CI = 1.29, 19.38).Conclusions. Ours is the first large-scale longitudinal study to report an association between PTSD and incident heart failure in an outpatient sample of US veterans. Prevention and treatment efforts for heart failure and its associated risk factors should be expanded among US veterans with PTSD.Posttraumatic stress disorder (PTSD) is a psychiatric illness that affects approximately 7.7 million Americans aged older than 18 years.1 PTSD typically results after the experience of severe trauma, and veterans are at elevated risk for the disorder. The National Vietnam Veterans Readjustment Study reported the prevalence of PTSD among veterans who served in Vietnam as 15.2% among men and 8.1% among women.2 In fiscal year 2009, nearly 446 045 Veterans Administration (VA) patients had a primary diagnosis of PTSD, a threefold increase since 1999.3 PTSD is of growing clinical concern as evidence continues to link psychiatric illnesses to conditions such as arthritis,4 liver disease,5 digestive disease,6 and cancer.6 When the postwar health status of Vietnam veterans was examined, those with PTSD had higher rates of diseases of the circulatory, nervous, digestive, musculoskeletal, and respiratory systems.7The evidence linking PTSD to coronary heart disease (CHD) is substantial.8–10 Veterans with PTSD are significantly more likely to have abnormal electrocardiograph results, myocardial infarctions, and atrioventricular conduction deficits than are veterans without PTSD.11 In a study of 605 male veterans of World War II and the Korean War, CHD was more common among veterans with PTSD than among those without PTSD.12 Worldwide, adults exposed to the disaster at Chernobyl experienced increased rates of CHD up to 10 years after the event,13 and studies of stressors resulting from the civil war in Lebanon found elevated CHD mortality.14,15Although the exact biological mechanism by which PTSD contributes to CHD remains unclear, several hypotheses have been suggested, including autonomic nervous system dysfunction,16 inflammation,17 hypercoagulability,18 cardiac hyperreactivity,19 altered neurochemistry,20 and co-occurring metabolic syndrome.16 One of the hallmark symptoms of PTSD is hyperarousal,21 and the neurobiological changes brought on from sustained sympathetic nervous system activation affect the release of neurotransmitters and endocrine function.22 These changes have negative effects on the cardiovascular system, including increased blood pressure, heart rate, and cardiac output.22,23Most extant literature to date examining cardiovascular sequelae has shown a positive association between PTSD and coronary artery disease.8–10 Coronary artery disease is well documented as one of the most significant risk factors for future development of heart failure.24 Despite burgeoning evidence for the role of PTSD in the development of coronary artery disease, there are few studies specifically exploring the relationship between PTSD and heart failure. Limited data suggest that PTSD imparts roughly a threefold increase in the odds of developing heart failure in both the general population5 and in a sample of the elderly.25 These investigations, however, have been limited by cross-sectional study design, a small proportion of participants with PTSD, and reliance on self-reported measures for both PTSD and heart failure.5,25 Heart failure is a uniquely large public health issue, as nearly 5 million patients in the United States are affected and there are approximately 500 000 new cases each year.26 Identifying predictors of heart failure can aid in early detection efforts while simultaneously increasing understanding of the mechanism behind development of heart failure.To mitigate the limitations of previous investigations, we undertook a large-scale prospective study to further elucidate the role of prevalent PTSD and development of incident heart failure among veterans, while controlling for service-related and clinical covariates. Many studies investigating heart failure have relied on inpatient records; we leveraged outpatient records to more accurately reflect the community burden of disease.     

Health status, neighborhood socioeconomic context, and premature mortality in the United States: The National Institutes of Health-AARP Diet and Health Study

Objectives. We examined whether the risk of premature mortality associated with living in socioeconomically deprived neighborhoods varies according to the health status of individuals.Methods. Community-dwelling adults (n = 566 402; age = 50–71 years) in 6 US states and 2 metropolitan areas participated in the ongoing prospective National Institutes of Health–AARP Diet and Health Study, which began in 1995. We used baseline data for 565 679 participants on health behaviors, self-rated health status, and medical history, collected by mailed questionnaires. Participants were linked to 2000 census data for an index of census tract socioeconomic deprivation. The main outcome was all-cause mortality ascertained through 2006.Results. In adjusted survival analyses of persons in good-to-excellent health at baseline, risk of mortality increased with increasing levels of census tract socioeconomic deprivation. Neighborhood socioeconomic mortality disparities among persons in fair-to-poor health were not statistically significant after adjustment for demographic characteristics, educational achievement, lifestyle, and medical conditions.Conclusions. Neighborhood socioeconomic inequalities lead to large disparities in risk of premature mortality among healthy US adults but not among those in poor health.Research dating back to at least the 1920s has shown that the United States has experienced persistent and widening socioeconomic disparities in premature mortality over time.^1–5 However, it has been unclear whether socioeconomic inequalities affect the longevity of persons in good and poor health equally. Socioeconomic status (SES) and health status are interrelated,^6–8 and both are strong independent predictors of mortality.⁹ Low SES is associated with greater risk of ill health and premature death,^{1–5,8,10–13} partly attributable to disproportionately high prevalence of unhealthful lifestyle practices^10,14,15 and physical and mental health conditions.^13,16 Correspondingly, risk of premature mortality is higher in poor than in more affluent areas.^16,17 Although the association between neighborhood poverty and mortality is independent of individual-level SES,^17,18 aggregation of low-SES populations in poor areas may contribute to variations in health outcomes across neighborhoods. Conversely, economic hardships resulting from ill health may lead persons in poor physical or mental health to move to poor neighborhoods.¹⁹ This interrelatedness may create spurious associations between neighborhood poverty and mortality.Although previous studies have found that the risk of premature death associated with poor health status varies according to individuals'' SES,^20,21 no published studies have examined whether the relative risks for premature mortality associated with living in neighborhoods with higher levels of socioeconomic deprivation vary by health status of individuals. Clarifying these relationships will inform social and public health policies and programs that aim to mitigate the health consequences of neighborhood poverty.^22,23We used data from a large prospective study to examine whether the risk of premature mortality associated with neighborhood socioeconomic context differs according to health status at baseline and remains after adjustment for person-level risk factors for mortality, such as SES, lifestyle practices, and chronic medical illnesses.     

Clustering of Midlife Lifestyle Behaviors and Subsequent Cognitive Function: A Longitudinal Study

Objectives. We examined the association between individual and clustered lifestyle behaviors in middle age and later in cognitive functioning.Methods. Middle-aged participants (n = 2430) in the Supplémentation en Vitamines et Minéraux Antioxydant study self-reported their low physical activity, sedentary behavior, alcohol use, smoking, low fruit and vegetable consumption, and low fish consumption. We assessed cognition 13 years later via 6 neuropsychological tests. After standardization, we summed the scores for a composite cognitive measure. We estimated executive functioning and verbal memory scores using principal component analysis. We estimated the mean differences (95% confidence intervals [CIs]) in cognitive performance by the number of unhealthy behaviors using analysis of covariance. We identified latent unhealthy behavior factor via structural equation modeling.Results. Global cognitive function and verbal memory were linearly, negatively associated with the number of unhealthy behaviors: adjusted mean differences = −0.36 (95% CI = −0.69, −0.03) and −0.46 (95% CI = −0.80, −0.11), respectively, per unit increase in the number of unhealthy behaviors. The latent unhealthy behavior factor with low fruit and vegetable consumption and low physical activity as main contributors was associated with reduced verbal memory (RMSEA = 0.02; CFI = 0.96; P = .004). No association was found with executive functioning.Conclusions. Comprehensive public health strategies promoting healthy lifestyles might help deter cognitive aging.Noncommunicable diseases with notable lifestyle components are the leading causes of death worldwide.1,2 There is also growing evidence of the critical role of different midlife health and risk behaviors in cognitive aging.3–7 Because lifestyles are inherently modifiable and no treatment of cognitive decline is available, such findings argue for the paramount importance of prevention.8,9Current data support a deleterious effect of alcohol abstinence or abuse (compared with moderate alcohol consumption),10 smoking,7 low fruit and vegetable intake,11 low fish intake,12 and low physical activity (PA) levels13 on cognitive aging. However, it has been widely documented that lifestyle factors are strongly correlated with each other, forming a cluster of healthy or unhealthy behaviors.14 Traditionally, such interrelations have been accounted for by statistical adjustment; however, it is of major public health interest to consider the cumulative and combined effect of the various lifestyle behaviors on health by using multidimensional strategies.14Research that examines the combined effect of lifestyle factors on mortality is plentiful, and data have been colligated in a recent meta-analysis.15 These authors reported a 66% reduction in mortality risk by comparing adherence to 4 or more healthy lifestyle behaviors versus engagement in any number of unhealthy behaviors.The combined effect of lifestyle factors has also been explored in relation to cardiovascular diseases,16–18 cancer,18–22 diabetes,18,23 memory complaints,24 and dementia25–27; however, very few studies have reported findings regarding cognition.28,29 Despite heterogeneity in the definition of a healthy lifestyle, study design, and residual confounding, available, but scarce, data support a critical, protective role of healthy lifestyles in cognitive health through their beneficial properties via oxidative, inflammatory, vascular, and other neuroprotective pathways.30–33Our objectives in this study were to examine the association between individual and clustered lifestyle behaviors and later cognitive functioning. We employed traditional and innovative techniques (structural equation modeling) in our epidemiological pursuit.     

Migrants in Transit: The Importance of Monitoring HIV Risk Among Migrant Flows at the Mexico–US Border

We conducted a probability-based survey of migrant flows traveling across the Mexico–US border, and we estimated HIV infection rates, risk behaviors, and contextual factors for migrants representing 5 distinct migration phases. Our results suggest that the influence of migration is not uniform across genders or risk factors. By considering the predeparture, transit, and interception phases of the migration process, our findings complement previous studies on HIV among Mexican migrants conducted at the destination and return phases. Monitoring HIV risk among this vulnerable transnational population is critical for better understanding patterns of risk at different points of the migration process and for informing the development of protection policies and programs.Previous research indicates that Mexican labor migrants in the United States are at increased risk for HIV infection1–3 and may be a bridge population for increasing rates of HIV/AIDS in rural Mexico.4–6 The behavioral ecological model posits that health behaviors are influenced by a hierarchy of factors, including individual characteristics, features of the proximal context, and broader structural factors.7 The proximal context involves the physical and social conditions in which individuals live, work, learn, and play. The broader environment comprises political, social, and economic structures and cultural factors. Bidirectional influences exist across factors at the individual, contextual, and structural level, with interventions at the structural level having the most far-reaching public health impact.7 Mexican migrants tend to be male and young, have low levels of educational attainment, and report limited HIV prevention knowledge and condom use.8,9 Increased risk for HIV in migrants may result from the interplay between these individual characteristics and the broader contextual and structural factors in migration between Mexico and the United States.10Migration is a complex and multistage process involving 5 phases: predeparture, transit, destination, interception, and return.11 Different constellations of contextual and structural factors may influence risk behaviors for HIV infection among migrants at each of these stages. Research on HIV risk among migrants must cover the different phases involved in the migration process and identify risks as well as prevention and treatment opportunities associated with each of them.12 Much of our knowledge regarding HIV prevalence and behavioral risk factors among Mexican migrants has emanated from surveys conducted among receiving communities in the United States 1^,2^,13–15 and sending communities in Mexico.16^,17 These studies have covered the destination and return phases of migration.Mexican migrants in the United States (i.e., the destination) are exposed to contexts that may heighten their HIV risk. HIV prevalence rates are higher in the United States than in Mexico,18 increasing the probability of coming into contact with the virus. Furthermore, many migrants live in environments characterized by unbalanced gender composition (i.e., male overrepresentation) and limited family- and community-based social behavioral controls.19 They experience loneliness, geographic isolation, social exclusion,20 fear,21 poor living and working conditions, and limited access to health care, including access to HIV testing and other prevention services.2^,16^,19^,21–24 All these factors coalesce to increase the probability of risk behaviors for HIV, such as alcohol and drug use, sex with sex workers, and unprotected sex practices.9,10 Surveys in Mexican sending communities have documented higher rates of behavioral risk factors, such as a higher number of sexual partners and illicit drug use, but also increased rates of condom use, knowledge of HIV transmission, and HIV testing among return migrants, compared to nonmigrants in the same communities.16,25Little research has examined HIV risk among Mexican migrants during the predeparture, transit, and interception phases of the migration process. The same factors that may push migrants away from their sending communities, such as poverty,26 violence,27 and gender power unbalances,28,29 are also structural factors that may increase their HIV risk even before they leave these communities.30 The transit phase is defined as the period when migrants are between their place of origin and their destination.11 For most Mexican migrants, the northern border of Mexico is an intermediate point in their trajectory between the 2 countries. Northbound unauthorized and deported migrants may spend time in this transit location making arrangements to enter or reenter the United States. This region has been described as at heightened risk for infectious diseases such as HIV to occur and is characterized by “an economically disadvantaged population” and “a nexus for drug use, prostitution, and mobility.”^31(p428)Research with injecting drug users and sex workers in Mexican border cities has provided critical evidence of migration as a structural risk factor for HIV infection and substance use as well as the prevention needs of these high-risk groups.14,32 These studies have offered some insights into the potential risks among migrants in this intermediate migration context. Finally, migrants apprehended while trying to enter or after reaching the destination communities (i.e., interception phase) are at a particularly critical stage. Detention in immigration centers or prisons can have detrimental effects on migrants’ health.11 Interception may also be a marker of higher social vulnerability, as migrants who have less economic and social resources are more likely to experience this migration phase. A recent survey found higher rates of HIV infection and behavioral risk factors among deported Mexican migrants in Tijuana, Mexico, than among the US and Mexico populations.33 In general, knowledge concerning HIV risk among migrants at the 5 migration phases is fragmented, and the heterogeneity of sampling and data collection methodologies that previous studies have used creates challenges for comparing data on the different phases.There are an estimated 12 million Mexican migrants in the United States.34 Although not all migrants go through all 5 migration phases (some may never be intercepted, some may settle permanently in the region of destination and never return), many Mexican migrants go through 2 or more of these phases in their lifetime. Data on Mexican migration patterns indicate that circular migration (i.e., traveling back and forth between Mexico and the United States) is relatively common among Mexican migrants.34,35 About 29% of Mexican migrants are estimated to engage in circular migration,36 and 50% of undocumented migrants leave the United States within the first year of immigration.37 Proximity, social and political conditions, transportation costs, and cultural identity make Mexicans more likely to return to their home country than are migrants from other countries. Although the strengthening and stricter enforcement of border policies has lowered this trend in recent years, the incentives to emigrate out of Mexico have also increased.38 These circular migration patterns between Mexico and the United States result in sizable migrant flows traveling across the Mexican border.It is estimated that each year more than 600 000 Mexican migrants arrive in the United States, approximately 400 000 Mexican migrants return from the United States, and approximately 400 000 Mexican migrants are deported to Mexico.39,40 The same individual may arrive, return, or be deported more than once. In 2012, the net rate of Mexicans departing Mexico (mostly to the United States) and entering Mexico (most of whom are return migrants) was 41.9 and 14.3 per 1000, respectively.41 An estimated 300 000 Mexican migrants were admitted to a detention facility and repatriated by US immigration authorities,42 and an additional 266 000 unauthorized Mexican migrants were apprehended at the Mexican border.40 The volume and mix of migrants traveling across the Mexico–US border makes this region an important setting for binational monitoring of the mobile populations’ health. Such monitoring can further our understanding of HIV infection levels and of behavioral and environmental factors that contribute to HIV infection among Mexican migrants representing different phases and contexts of the migration process. Ongoing surveillance of this region can also reveal changes in HIV infection and behavioral risk factors among migrants on the move and inform the need for interventions to reduce HIV risk among Mexican migrants in sending, receiving, and intermediate communities.We estimated and compared the levels of HIV infection, risk behaviors, and contextual factors associated with different migration phases, using data from a survey of migrant flows who traveled across the Mexico–US border region and represented the different phases and geographic contexts of migration between Mexico and the United States.     

Social Branding to Decrease Smoking Among Young Adults in Bars

Objectives. We evaluated a Social Branding antitobacco intervention for “hipster” young adults that was implemented between 2008 and 2011 in San Diego, California.Methods. We conducted repeated cross-sectional surveys of random samples of young adults going to bars at baseline and over a 3-year follow-up. We used multinomial logistic regression to evaluate changes in daily smoking, nondaily smoking, and binge drinking, controlling for demographic characteristics, alcohol use, advertising receptivity, trend sensitivity, and tobacco-related attitudes.Results. During the intervention, current (past 30 day) smoking decreased from 57% (baseline) to 48% (at follow-up 3; P = .002), and daily smoking decreased from 22% to 15% (P < .001). There were significant interactions between hipster affiliation and alcohol use on smoking. Among hipster binge drinkers, the odds of daily smoking (odds ratio [OR] = 0.44; 95% confidence interval [CI] = 0.30, 0.63) and nondaily smoking (OR = 0.57; 95% CI = 0.42, 0.77) decreased significantly at follow-up 3. Binge drinking also decreased significantly at follow-up 3 (OR = 0.64; 95% CI = 0.53, 0.78).Conclusions. Social Branding campaigns are a promising strategy to decrease smoking in young adult bar patrons.Tobacco companies1 and public health authorities2–5 recognize young adulthood as a critical time when experimenters either quit or transition to regular tobacco use. Young adults are also aspirational role models for youths.1,6,7 Tobacco companies devote considerable resources to reaching young adults to encourage tobacco use,1,8–11 and young adults have a high prevalence of smoking.12 In California in 2011, young adults had the highest smoking prevalence of any age group, and the Department of Health estimated that 32% of California smokers started smoking between the ages of 18 and 26 years.13 Although they are more likely to intend to quit and successfully quit than older adults,14–17 young adults are less likely to receive assistance with smoking cessation.18,19 Although there are few proven interventions to discourage young adult smoking,20 cessation before age 30 years avoids virtually all of the long-term adverse health effects of smoking.21Tobacco companies have a long history of using bars and nightclubs to reach young adults and to encourage smoking.1,6,9–11,22–24 Bar attendance and exposure to tobacco bar marketing is strongly associated with smoking.25 The 1998 Master Settlement Agreement and Food and Drug Administration regulations that limit tobacco advertising to youths, explicitly permit tobacco marketing in “adult only” venues, including bars and nightclubs.26,27Aggressive tobacco marketing may actually be more intensive in smoke-free bars: a 2010 study of college students attending bars found that students in the community with a smoke-free bar law were more likely to be approached by tobacco marketers, offered free gifts, and to take free gifts for themselves than in communities without a smoke-free bar law.28 Bars and nightclubs also attract young adults who are more likely to exhibit personality traits such as sensation seeking,29 increasing their risk30 independently of receptivity to tobacco advertising; tobacco promotional messages resonate with these personality traits.8,31 Tobacco marketing campaigns are tailored to specific segments of the population defined by psychographics (e.g., values, attitudes, shared interests, such as tastes in music and fashion, and friend groups) and demographic criteria, and they aim to create positive smoker images, identities, and social norms for smoking.1,8 Tobacco marketing campaigns also focus on young adult trendsetters to leverage peer influence to promote smoking.6,10In contrast to the tobacco companies’ efforts, most young adult health interventions take place in colleges or health centers rather than social environments.32–39 Bars and nightclub venues represent an opportunity to reach those at highest risk for long-term smoking morbidity and mortality.40 We evaluated the effectiveness of an intervention to decrease cigarette smoking by countering tobacco industry marketing strategies targeting young adults attending bars and nightclubs in the San Diego, California, “hipster” scene. Because tobacco and alcohol use are strongly linked,41,42 we also examined the effects of the intervention on alcohol use and among binge drinkers. We found a significant decrease in smoking in the community where the intervention took place, including significant decreases among nondaily smokers and binge drinkers, as well as a significant decrease in binge drinking.     

Mitigating HIV Health Disparities: The Promise of Mobile Health for a Patient-Initiated Solution

The HIV epidemic is an ongoing public health problem fueled, in part, by undertesting for HIV. When HIV-infected people learn their status, many of them decrease risky behaviors and begin therapy to decrease viral load, both of which prevent ongoing spread of HIV in the community.Some physicians face barriers to testing their patients for HIV and would rather their patients ask them for the HIV test. A campaign prompting patients to ask their physicians about HIV testing could increase testing.A mobile health (mHealth) campaign would be a low-cost, accessible solution to activate patients to take greater control of their health, especially populations at risk for HIV. This campaign could achieve Healthy People 2020 objectives: improve patient–physician communication, improve HIV testing, and increase use of mHealth.World AIDS Day each December reminds us of the ongoing HIV epidemic in the United States and its disproportionate toll on racial and ethnic minority communities. HIV testing is an essential strategy to curb the ongoing epidemic. When people infected with HIV learn their status, many of them decrease risky behaviors to prevent spread to others1 and begin antiretroviral therapy to decrease viral load, the main biological predictor of the ongoing spread of HIV in the community.2 Despite national recommendations to make HIV testing routine for all adults,3–6 HIV testing rates—particularly among the racial and ethnic communities hardest hit—remain low.7 Patients want to be tested.8 However, physicians face numerous HIV testing barriers, including physician discomfort with initiating HIV testing discussions,9 physicians not realizing that patients expect HIV testing to be done,8 time,10,11 and competing clinical priorities.11,12A pioneering intervention to improve HIV testing in health care settings may be a patient-initiated approach. The push–pull capacity model offers a framework to guide a solution to improve patient-initiated HIV testing.13,14 With a push–pull model, health information can be provided—or pushed—to many patients. This push creates a demand—or pull—for health services that address patient concerns. The ubiquity of cell phones and the pervasive use of text messaging provide an innovative platform for promoting an effective HIV testing campaign. Operationalizing the push–pull model through mobile health (mHealth) could be a novel approach to improving HIV testing in health care settings. This initiative would reduce demands on physicians, increase patients’ engagement in their own health, and address a significant ongoing public health problem.15 Goals of Healthy People 2020 include eliminating health disparities and increasing the number of people who have been tested for HIV.16     

Racial/Ethnic and Socioeconomic Differences in Short-Term Breast Cancer Survival Among Women in an Integrated Health System

Objectives. We examined the combined influence of race/ethnicity and neighborhood socioeconomic status (SES) on short-term survival among women with uniform access to health care and treatment.Methods. Using electronic medical records data from Kaiser Permanente Northern California linked to data from the California Cancer Registry, we included 6262 women newly diagnosed with invasive breast cancer. We analyzed survival using multivariable Cox proportional hazards regression with follow-up through 2010.Results. After consideration of tumor stage, subtype, comorbidity, and type of treatment received, non-Hispanic White women living in low-SES neighborhoods (hazard ratio [HR] = 1.28; 95% confidence interval [CI] = 1.07, 1.52) and African Americans regardless of neighborhood SES (high SES: HR = 1.44; 95% CI = 1.01, 2.07; low SES: HR = 1.88; 95% CI = 1.42, 2.50) had worse overall survival than did non-Hispanic White women living in high-SES neighborhoods. Results were similar for breast cancer–specific survival, except that African Americans and non-Hispanic Whites living in high-SES neighborhoods had similar survival.Conclusions. Strategies to address the underlying factors that may influence treatment intensity and adherence, such as comorbidities and logistical barriers, should be targeted at low-SES non-Hispanic White and all African American patients.Breast cancer is the most common cancer among women in the United States, and it is the second leading cause of cancer death.1 Despite significant improvements in breast cancer survival from 1992 to 2009,1,2 racial/ethnic and socioeconomic survival disparities have persisted.3,4 African American women have consistently been found to have worse survival after breast cancer,3,5–11 Hispanic women have worse or similar survival,3,9,11,12 and Asian women as an aggregated group have better or similar survival3,9,11,12 than do non-Hispanic White women. Underlying factors thought to contribute to these racial/ethnic disparities include differences in stage at diagnosis,8,12,13 distributions of breast cancer subtypes,14–16 comorbidities,12,13,17 access to and utilization of quality care,13,18 and treatment.12,13Numerous studies also have found poorer survival after breast cancer diagnosis among women residing in neighborhoods of lower socioeconomic status (SES).6,9,19,20 Research has shown that inadequate use of cancer screening services, and consequent late stage diagnosis and decreased survival, contribute to the SES disparities.21,22 Similar to racial/ethnic disparities, SES disparities have been attributed to inadequate treatment and follow-up care and comorbidities.18 Previous population-based studies have continued to observe racial/ethnic survival disparities after adjusting for neighborhood SES, but these studies have not considered the combined influence of neighborhood SES and race/ethnicity.3,9,11,12,23 These disparities may remain because information on individual-level SES, health insurance coverage, comorbidities, quality of care, and detailed treatment regimens have typically not been available.3,8,9,11,13 Even among studies using national Surveillance Epidemiology and End Results–Medicare linked data, in which more detailed information on treatment and comorbidities are available among some patients aged 65 years and older, survival disparities have remained.12,23,24 However, not all data on medical conditions and health care services are captured in Medicare claims, including data on Medicare beneficiaries enrolled in HMOs (health maintenance organizations).25,26Using electronic medical records data from Kaiser Permanente Northern California (KPNC) linked to data from the population-based California Cancer Registry (CCR), we recently reported that chemotherapy use followed practice guidelines but varied by race/ethnicity and neighborhood SES in this integrated health system.27 Therefore, to overcome the limitations of previous studies and address simultaneously the multiple social28 and clinical factors affecting survival after breast cancer diagnosis, we used the linked KPNC–CCR database to determine whether racial/ethnic and socioeconomic differences in short-term overall and breast cancer–specific survival persist in women in a membership-based health system. Our study is the first, to our knowledge, to consider the combined influence of neighborhood SES and race/ethnicity and numerous prognostic factors, including breast cancer subtypes and comorbidities, thought to underlie these long-standing survival disparities among women with uniform access to health care and treatment.     

Preparing for Rectal Microbicides: Sociocultural Factors Affecting Product Uptake Among Potential South American Users

Objectives. We examined views on rectal microbicides (RMs), a potential HIV prevention option, among men who have sex with men and transgender women in 3 South American cities.Methods. During September 2009 to September 2010, we conducted 10 focus groups and 36 in-depth interviews (n = 140) in Lima and Iquitos, Peru, and Guayaquil, Ecuador, to examine 5 RM domains: knowledge, thoughts and opinions about RM as an HIV prevention tool, use, condoms, and social concerns. We coded emergent themes in recorded and transcribed data sets and extracted representative quotes. We collected sociodemographic information with a self-administered questionnaire.Results. RM issues identified included limited knowledge; concerns regarding plausibility, side effects, and efficacy; impact on condom use; target users (insertive vs receptive partners); and access concerns.Conclusions. Understanding the sociocultural issues affecting RMs is critical to their uptake and should be addressed prior to product launch.The first phase 2 clinical trial of a rectal microbicide (RM) candidate—a tenofovir-based, reduced-glycerin variant of the vaginal gel evaluated in CAPRISA-0041—is under way in men who have sex with men (MSM) and transgender women (TGW) at 5 international sites.2 If this product is found to be safe and acceptable, efficacy trials could begin by 2015,3 leading to a new prevention option for people at risk for HIV infection during unprotected receptive anal intercourse. Especially for MSM and TGW, an HIV prevention option specifically for this type of intercourse is urgently needed. Despite a worldwide decrease in new HIV infections,4 the epidemic continues to expand in MSM across all income levels globally,5 and a recent meta-analysis placed the odds ratio for TGW being infected with HIV relative to all adults of reproductive age at 48.8.6In addition to myriad social, cultural, and political factors that make MSM and TGW more vulnerable to HIV infection,7 unprotected receptive anal intercourse itself is 10% to 20% riskier than unprotected vaginal intercourse.8,9 As Beyrer et al. note, if the transmission probability of unprotected receptive anal intercourse were similar to that of unprotected vaginal intercourse, the 5-year cumulative HIV incidence in MSM would drop by 80% to 90%.5 Even partially efficacious RMs could play an important role in preventing new HIV infections,10 but their effectiveness will rely on users finding such products acceptable and using them correctly and consistently.11,12 Thus a body of acceptability research has emerged to examine the factors that may affect RM use, such as different product formulations (e.g., gels and lubricants,13–16 suppositories,17 and douches18–20), the maximum volume of rectally applied product that users find tolerable,21 frequency of use, cost effectiveness, and side effects.22Overall, acceptability research has demonstrated interest in a safe and effective RM among MSM and TGW22–25; however, knowledge gaps remain. Particularly important to understand is how potential users see themselves interacting with RMs, including social, cultural, and political factors, all of which may affect the adoption of an HIV prevention technology.26 We examined views of RMs among potential users in 3 South American cities to understand the sociocultural issues that could affect their uptake.     

Effect of Depression on Risky Drinking and Response to a Screening,Brief Intervention,and Referral to Treatment Intervention

We assessed alcohol consumption and depression in 234 American Indian/Alaska Native women (aged 18–45 years) in Southern California. Women were randomized to intervention or assessment alone and followed for 6 months (2011–2013). Depression was associated with risk factors for alcohol-exposed pregnancy (AEP). Both treatment groups reduced drinking (P < .001). Depressed, but not nondepressed, women reduced drinking in response to SBIRT above the reduction in response to assessment alone. Screening for depression may assist in allocating women to specific AEP prevention interventions.Women who consume alcohol and do not practice effective contraception are at risk for an alcohol-exposed pregnancy (AEP). AEPs can lead to fetal alcohol spectrum disorders, the leading known cause of developmental disabilities.1–3 Prepregnancy drinking, particularly heavy episodic or binge drinking, is a robust predictor of AEP.4 Depression has been linked to problem alcohol consumption in women5–7 and appears to predate8,9 and perhaps predict10 alcohol problems. Among American Indian/Alaska Native (AI/AN) women, studies have linked depression to problem drinking.11–13 However, risk factors for an AEP and interventions to reduce risk for AEP have not been well studied in AI/AN women.14 This is further complicated by variability among AI/AN populations in the prevalence of alcohol consumption11,15–20 and depression.13,21–23One approach to prevention of AEPs is screening, brief intervention, and referral to treatment (SBIRT).24,25 We previously tested the effectiveness of an SBIRT intervention in AI/AN women and found that whether women received an assessment followed by the SBIRT intervention or assessment alone, they reported a significant reduction in alcohol use. We examined depression as a predictor of vulnerability to having an AEP and explored whether depressed AI/AN women respond differently than nondepressed women to an SBIRT intervention.     

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.     

Directly Observed Antidepressant Medication Treatment and HIV Outcomes Among Homeless and Marginally Housed HIV-Positive Adults: A Randomized Controlled Trial

Objectives. We assessed whether directly observed fluoxetine treatment reduced depression symptom severity and improved HIV outcomes among homeless and marginally housed HIV-positive adults in San Francisco, California, from 2002 to 2008.Methods. We conducted a nonblinded, randomized controlled trial of once-weekly fluoxetine, directly observed for 24 weeks, then self-administered for 12 weeks (n = 137 persons with major or minor depressive disorder or dysthymia). Hamilton Depression Rating Scale score was the primary outcome. Response was a 50% reduction from baseline and remission a score below 8. Secondary measures were Beck Depression Inventory-II (BDI-II) score, antiretroviral uptake, antiretroviral adherence (measured by unannounced pill count), and HIV-1 RNA viral suppression (< 50 copies/mL).Results. The intervention reduced depression symptom severity (b = −1.97; 95% confidence interval [CI] = −0.85, −3.08; P < .001) and increased response (adjusted odds ratio [AOR] = 2.40; 95% CI = 1.86, 3.10; P < .001) and remission (AOR = 2.97; 95% CI = 1.29, 3.87; P < .001). BDI-II results were similar. We observed no statistically significant differences in secondary HIV outcomes.Conclusions. Directly observed fluoxetine may be an effective depression treatment strategy for HIV-positive homeless and marginally housed adults, a vulnerable population with multiple barriers to adherence.Depressive, pain, and substance use disorders are highly prevalent among persons living with HIV/AIDS1,2 and among the homeless and marginally housed.3–5 The triple diagnosis of depression, HIV, and substance use poses unique treatment challenges for clinicians: successful management of one condition is often dependent on successful management of the others, and the optimal sequencing of depression treatment, substance use treatment, and stabilization of psychosocial comorbidities remains unclear. Adherence to the entire continuum of HIV care is often hampered by depression6–8 and substance use.9,10 For homeless persons, the need to address subsistence concerns such as obtaining food and shelter may not only adversely affect mental well-being11 but may also divert attention away from medication adherence and regular clinic attendance.12 Timely and effective depression treatment is critical for HIV-positive persons, because depression has been associated with CD4⁺ T-lymphocyte cell count decline,13 progression to AIDS,14 and AIDS-related mortality.15 Yet depression remains pervasively underdiagnosed and undertreated among the homeless16–18 and among HIV-positive persons.19,20Depression treatment might be expected to improve virological or immunologic outcomes through improved adherence, but this has not been conclusively demonstrated.21–23 We therefore sought to determine whether treatment with once-weekly fluoxetine reduced depression symptom severity among homeless and marginally housed persons with comorbid depression and HIV. Because this population faces many psychosocial barriers to successful medication adherence,12,24 in addition to depression,25 we employed a directly observed treatment strategy similar to that used for treatment and management of patients with tuberculosis and HIV.26 This strategy reduced the potential for incomplete adherence to reduce the effectiveness of antidepressant treatment. A secondary aim was to determine whether depression treatment improved antiretroviral therapy (ART) uptake among persons eligible for treatment and ART adherence and viral suppression among treated persons.     

Loose Cigarette Purchasing and Nondaily Smoking Among Young Adult Bar Patrons in New York City

Objectives. We examined loose cigarette (loosie) purchasing behavior among young adult (aged 18–26 years) smokers at bars in New York City and factors associated with purchase and use.Methods. Between June and December 2013, we conducted cross-sectional surveys (n = 1916) in randomly selected bars and nightclubs. Using multivariable logistic regression models, we examined associations of loose cigarette purchasing and use with smoking frequency, price, social norms, cessation behaviors, and demographics.Results. Forty-five percent (n = 621) of nondaily smokers and 57% (n = 133) of daily smokers had ever purchased a loosie; 15% of nondaily smokers and 4% of daily smokers reported that their last cigarette was a loosie. Nondaily smokers who never smoked daily were more likely than were daily smokers to have last smoked a loosie (odds ratio = 7.27; 95% confidence interval = 2.35, 22.48). Quitting behaviors and perceived approval of smoking were associated with ever purchasing and recently smoking loosies.Conclusions. Loosie purchase and use is common among young adults, especially nondaily smokers. Smoking patterns and attitudes should be considered to reduce loose cigarette purchasing among young adults in New York City.Widespread adoption of clean indoor air laws and cigarette tax increases denormalize smoking behavior1 and decrease smoking rates.2,3 Although increasing taxes is one of the most effective means of smoking prevention and reduction,3 the increased price of cigarettes can also lead to tax-avoidant behaviors, such as buying untaxed packs smuggled from states with lower cigarette taxes and purchasing loose cigarettes, or “loosies.”4–6 In New York City (NYC), where a cigarette pack costs about $11.50, it has become common for smokers to purchase discounted packs and individual cigarettes from street peddlers and friends.7,8Much of the research exploring loosie purchasing in the United States has focused on underage or low-income minority populations, often in urban areas.7,9,10 One study found that in early 1993, 70% of stores in central Harlem sold loosies to minors.7 Another study conducted with a 2005–2006 convenience sample in inner-city Baltimore found that 77% of African American smokers aged 18 to 24 years had purchased loosies in the past month.11 Similarly, loosie purchasing in Mexico was more common among younger smokers with lower incomes.12Availability and visibility of loosies can promote smoking and encourage relapse.13 We defined nondaily smokers as those who smoked on 1 to 29 of the past 30 days.14,15 Shiffman et al. found that nondaily smokers were more likely than daily smokers to report that social and environmental stimuli motivated their smoking behavior.16 More specifically, cues such as taste, smell, social goading to smoke, and specific situations (e.g., smoking after meals) are more likely to be reported as motivators to smoke by nondaily smokers than by daily smokers.16 Because social–environmental cues have substantial impact on nondaily smokers’ motivation to smoke, it is likely that the cue of seeing loosies in one’s environment also motivates nondaily smokers to smoke.16Previous research substantiates this claim, with 1 study showing that people who regularly saw loosies available for purchase were more likely to be current smokers.17 Therefore, the widespread availability of loosies may have a greater impact on nondaily smokers. Nondaily smokers make up a third of US smokers,18,19 and nondaily smoking is increasingly common among young adults.20 Many young adults who smoke on only some days do not self-identify as smokers,21 and nondaily smoking is frequently paired with alcohol consumption.22–24 Nondaily and light smoking carry a lower, but substantial, risk for lung cancer and a similar risk as does daily smoking for cardiovascular disease.25–27 Occasional smokers also have higher smoking-related morbidity and mortality than do people who have never smoked.26,28–30Nondaily smoking can be a long-term behavior pattern31,32 or a transition to or from daily smoking.31 Nondaily smokers include different subgroups that may have very different smoking patterns or motivations to quit.33,34 Nondaily smokers who previously smoked daily have been defined in previous research as converted nondaily smokers. Nondaily smokers who have never smoked daily are defined as native nondaily smokers.18,19 Important differences exist between these subgroups of smokers: converted nondaily smokers are more likely to quit smoking than are native nondaily smokers and daily smokers,18,19 although most converted and native nondaily smokers were unable to remain abstinent for more than 90 days.19Loosie purchasing and use may play an important role in promoting continued tobacco use among nondaily smokers. The 2010 NYC Community Health Survey35 found that more than one third (34%) of young adult nondaily smokers (aged 18–26 years) reported that their last cigarette smoked was a loosie, compared with 14% of young adult daily smokers. Another study of NYC adults demonstrated that nondaily smokers were more likely to purchase loose cigarettes than were light and heavy smokers.36 To the best of our knowledge, little is known about the factors associated with loosie purchasing among nondaily smokers in the United States.We sought to better understand the factors associated with loosie purchasing among NYC young adults, specifically to determine (1) loosie purchase and use rates among converted nondaily, native nondaily, and daily smokers; (2) whether loosie purchase or use are associated with perceived social norms of smoking behavior; and (3) whether loosie purchasing is associated with smoking cessation intention or behavior.     

Latent Tuberculosis Infection Screening in Foreign-Born Populations: A Successful Mobile Clinic Outreach Model

Objectives. We evaluated the efficacy of a mobile medical clinic (MMC) screening program for detecting latent tuberculosis infection (LTBI) and active tuberculosis.Methods. A LTBI screening program in a MMC in New Haven, Connecticut, used medical surveys to examine risk factors and tuberculin skin test (TST) screening eligibility. We assessed clinically relevant correlates of total (prevalent; n = 4650) and newly diagnosed (incident; n = 4159) LTBI from 2003 to 2011.Results. Among 8322 individuals, 4159 (55.6%) met TST screening eligibility criteria, of which 1325 (31.9%) had TST assessed. Similar to LTBI prevalence (16.8%; 779 of 4650), newly diagnosed LTBI (25.6%; 339 of 1325) was independently correlated with being foreign-born (adjusted odds ratio [AOR] = 8.49; 95% confidence interval [CI] = 5.54, 13.02), Hispanic (AOR = 3.12; 95% CI = 1.88, 5.20), Black (AOR = 2.16; 95% CI = 1.31, 3.55), employed (AOR = 1.61; 95% CI = 1.14, 2.28), and of increased age (AOR = 1.04; 95% CI = 1.02, 1.05). Unstable housing (AOR = 4.95; 95% CI = 3.43, 7.14) and marijuana use (AOR = 1.57; 95% CI = 1.05, 2.37) were significantly correlated with incident LTBI, and being male, heroin use, interpersonal violence, employment, not having health insurance, and not completing high school were significantly correlated with prevalent LTBI.Conclusions. Screening for TST in MMCs successfully identifies high-risk foreign-born, Hispanic, working, and uninsured populations and innovatively identifies LTBI in urban settings.Foreign-born populations are at greatest risk for having both latent tuberculosis infection (LTBI) and developing tuberculosis (TB) disease within high-income countries and, in 2012, accounted for 63.0% of the 9951 TB cases in the United States.1 Newly diagnosed and reactivated TB infection among foreign-born individuals in the United States is currently 12 times greater (15.8 vs 1.4 cases per 100 000 population) than among US-born persons.1 Among foreign-born individuals, LTBI often reactivates within 5 to 10 years after arrival to the United States.2,3 Undocumented migrants and visitors from high-TB-prevalence countries, however, do not undergo routine LTBI screening and thus remain outside traditional health care screening and treatment programs in primary or specialty care settings except when they are acutely ill.3,4 Thus, identifying and treating LTBI cases among these high-risk populations before transforming to TB disease and resultant transmission to others is crucial to ending the cycle of ongoing TB infection within the United States.Workplace screening,4,5 mandatory criminal justice system screening,6–8 screening for entry into medication-assisted therapy and drug treatment programs,9 and refugee and naturalization programs10,11 have been successful for reaching legal and domestic populations, but innovative options are needed to target foreign-born populations that are not yet integrated into mainstream care.Culturally and geographically isolated foreign-born groups may be overlooked especially if there is low self-perception of tuberculosis risk.12 Tuberculin skin testing (TST), though imperfect, is internationally recognized and has been shown to be a reasonably accurate assessment of LTBI status in immunocompetent adults, despite receiving previous Bacillus Calmette-Guérin vaccine.13 Whereas other studies have focused on traditional clinics or statewide programs,14 we present an innovative mobile medical clinic (MMC) as a model to target “hidden” foreign-born populations for LTBI screening.New Haven, Connecticut, the country’s fourth poorest city for its size, with a census of 130 000, is a medium-sized urban setting in New England that has experienced extraordinary social and medical disparities including a high prevalence of poverty, drug addiction, HIV/AIDS, and unemployment and is disproportionately comprised of people of color, including 35.4% and 27.4% being Black or Hispanic, respectively.15 As New Haven is an industrial city with low-paying jobs, there has been an influx of foreign-born people, now officially comprising 11.6% of the population, with many having an undocumented residency status. Health care access for this group is absent unless individuals pay directly for fee-for-service, and concern for deportation and arrest further hinders willingness to seek care.16The Community Health Care Van (CHCV) is an MMC that provides free health care 5 days per week in 4 impoverished neighborhoods in New Haven. Though at inception the program was linked to the needle and syringe exchange program,17 it has since expanded over 20 years to become a vital bridge to a diverse array of health and addiction treatment services that includes services for medically underserved populations, including directly administered antiretroviral therapy to treat HIV,18–21 buprenorphine maintenance therapy,22–25 community transitional programs from the criminal justice system,26–33 hepatitis B vaccination,34 rapid hepatitis C screening,35 and other ongoing primary health care programs such as screening and monitoring of sexually transmitted infections,36 diabetes, and hypertension. In addition, the CHCV provides outreach and intensive case management services.37 Screening for LTBI and TB disease began in 2003 to target high-risk undocumented and foreign-born clients, as well as clients entering drug treatment programs or homeless shelters, who were concerned about TB infection yet were reluctant to seek care in traditional health care settings for fear of deportation, prohibitive cost, or language barriers. The LTBI screening program shortly thereafter became successfully incorporated into the country’s first mobile buprenorphine maintenance therapy program.9     

Impact of Rurality,Broiler Operations,and Community Socioeconomic Factors on the Risk of Campylobacteriosis in Maryland

Objectives. We evaluated the combined impact of community-level environmental and socioeconomic factors on the risk of campylobacteriosis.Methods. We obtained Campylobacter case data (2002–2010; n = 3694) from the Maryland Foodborne Diseases Active Surveillance Network. We obtained community-level socioeconomic and environmental data from the 2000 US Census and the 2007 US Census of Agriculture. We linked data by zip code. We derived incidence rate ratios by Poisson regressions. We mapped a subset of zip code–level characteristics.Results. In zip codes that were 100% rural, incidence rate ratios (IRRs) of campylobacteriosis were 6 times (IRR = 6.18; 95% confidence interval [CI] = 3.19, 11.97) greater than those in urban zip codes. In zip codes with broiler chicken operations, incidence rates were 1.45 times greater than those in zip codes without broilers (IRR = 1.45; 95% CI = 1.34, 1.58). We also observed higher rates in zip codes whose populations were predominantly White and had high median incomes.Conclusions. The community and environment in which one lives may significantly influence the risk of campylobacteriosis.Campylobacter is a leading cause of bacterial gastroenteritis in much of the developed and developing world.1,2 In addition to the diarrhea and vomiting associated with gastroenteritis, infection with Campylobacter can lead to more serious sequelae, such as Guillain-Barré syndrome, a demyelinating autoimmune disorder that can sometimes lead to death.3 Scallan et al.4 estimated that Campylobacter causes approximately 845 000 domestically acquired illnesses in the United States each year, along with 8463 hospitalizations and 76 deaths. Although the majority of these illnesses are estimated to be foodborne,4 attributing specific infections to specific sources has been challenging.Commonly reported risk factors for Campylobacter outbreaks include exposure to undercooked poultry,5 unpasteurized milk,6,7 and contaminated water.8 Eating in restaurants,9 not observing proper food preparation practices,10 and traveling abroad9,11 have also been associated with both outbreaks and sporadic (nonoutbreak) cases of campylobacteriosis. Additional risk factors for sporadic infections include contact with pets,5,12 contact with farm animals and livestock,13,14 and contact with animal feces.15 Significant associations of living in rural areas with risk of campylobacteriosis also have been identified in Europe and Canada.16–18 Moreover, a specific feature of rural environments—animal density—has been identified as a significant predictor of Campylobacter incidence in Canada and New Zealand.16,17Several sociodemographic risk factors for campylobacteriosis have also been identified, the 2 most consistent being gender (males) and age (< 5 years).8,16–19 Previous studies have also evaluated socioeconomic factors associated with the incidence of Campylobacter infection, and the findings suggest that these infections may occur more frequently among individuals characterized by higher socioeconomic status.16,20 Moreover, Samuel et al.21 reported that the incidence of campylobacteriosis among African Americans was lower than that among other ethnic groups across multiple sites in the United States, although hospitalization rates for this group were higher. These findings, however, may be influenced by differentials in illness reporting among varying races and ethnic groups.Nonetheless, these previous reports have largely resulted from population-based case–control studies focused on individual-level data. To our knowledge, no US study has examined the combined effect of community-level environmental and socioeconomic risk factors on the risk of campylobacteriosis. Such an analysis can be useful in (1) identifying (and possibly predicting) “hot spot” communities that bear high burdens of this illness, and (2) addressing significant research gaps concerning potential health disparities in the risk of infectious diseases.22 We linked Maryland Foodborne Diseases Active Surveillance (FoodNet) data to US Census data and US Department of Agriculture Census of Agriculture data at the zip code level to evaluate associations between community-level environmental and socioeconomic risk factors and the incidence of Campylobacter infections in Maryland.