Epidemiology & Biostatistics
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Item Pre-Exposure Prophylaxis Interventions among Black Sexual Minority Men: A Systematic Literature Review(MDPI, 2022-02-09) Turpin, Rodman E.; Hawthorne, David J.; Rosario, Andre D.Background: Interventions to promote HIV pre-exposure prophylaxis (PrEP) among Black sexual minority men (BSMM) are especially important, given the disproportionate HIV incidence and relatively low uptake of PrEP among BSMM. Methods: We conducted a systematic literature review to identify the characteristics of interventions between 2016 and 2021 promoting PrEP use among BSMM. We synthesized these studies based on sample size, location, the use of peer-based delivery, and key intervention targets. Results: Of the starting total 198 articles, 10 were included in the final review, with the majority of included studies being randomized controlled trials. We identified providing PrEP access, PrEP counseling, HIV and PrEP education, linkage to general health care, and peer-based support as key successful intervention components. The starkest difference between interventions with and without demonstrated PrEP improvements was the outcome: all interventions focused on PrEP initiation led to large improvements, but those focused on PrEP adherence did not. No other factors demonstrated distinct differences between successful and unsuccessful interventions. Conclusion: We identified notable differences in intervention efficacy between PrEP initiation and PrEP adherence outcomes; PrEP adherence is necessary for optimal HIV prevention. Future interventions promoting and measuring PrEP adherence, with a focus on cultural competence and peer components, are recommended.Item Sexual Risk Behavior and Lifetime HIV Testing: The Role of Adverse Childhood Experiences(MDPI, 2022-04-05) Dyer, Typhayne V.; Turpin, Rodman E.; Hawthorne, David J.; Jain, Vardhmaan; Sayam, Sonica; Mittal, MonaDespite the success of HIV prevention drugs such as PrEP, HIV incident transmission rates remain a significant problem in the United States. A life-course perspective, including experiences of childhood adversity, may be useful in addressing the HIV epidemic. This paper used 2019 BRFSS data to elucidate the role that childhood adversity plays in the relationship between HIV risk and HIV testing. Participants (n = 58,258) completed self-report measures of HIV risk behaviors, HIV testing, and adverse childhood experiences (ACEs). The median number ACEs in the sample was 1, with verbal abuse (33.9%), and parental separation (31.3%) being the most common ACEs reported. Bivariate findings showed that all ACEs were associated with increased HIV risk and testing. However, increased risk was not correlated with increased HIV testing, with the highest incongruence related to mental health problems of household member (53.48%). While both self-reported HIV risk and ACEs were positively associated with HIV testing, their interaction had a negative association with testing (aPR = 0.51, 95%CI 0.42, 0.62). The results highlight the need for targeted HIV prevention strategies for at-risk individuals with a history of childhood adversity.Item The effects of HIV criminalization laws (and their enforcement) on HIV risk among Black and Hispanic populations(2022) Keralis, Jessica Maciel; Nguyen, Quynh C; Epidemiology and Biostatistics; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Background: In the U.S., 25 states have laws that explicitly criminalize the transmission or exposure of HIV. This study, grounded in Nancy Krieger's ecosocial theory, estimated the association between HIV criminalization laws and state- (Aim 1) and county-level (Aim 2) HIV incidence rates, as well as individual HIV testing history (Aim 3), and assessed effect modification by overpolicing, using incarceration rates as a proxy. Methods: The study uses data from state- and county-level HIV incidence data from AIDSVu (2010-2019), incarceration data from the Vera Institute of Justice (2010-2018), and HIV testing data from BRFSS (2016-2019). For Aim 1, a longitudinal analysis was conducted using multivariate marginal Poisson GEE models to estimate rate ratios. For Aim 2, count-rate hierarchical (multilevel) models were fitted to estimate rate ratios. For Aim 3, logistic regression models were fitted to estimate odds ratios. Results: The presence of a state HIV testing law was associated with a higher state HIV incidence in the general and Hispanic populations (aRR=1.48 and 1.68, respectively), but higher incarceration at the state level did not significantly modify the relationship between the law and HIV incidence. At the county level, being in a state with an HIV-specific criminalization statute was associated with a higher county-wide HIV incidence rate for all three populations (aRR=1.14, 1.30, and 1.32 for the general, Black, and Hispanic populations, respectively). Unlike the state-level analysis, this association was attenuated by a higher jailed population rate for the general and Black populations. The effect modification was statistically significant for the general population (p=0.01) and marginally significant for the Black population (p=0.06). Finally, the presence of a state HIV testing law (aOR=1.06) was associated with a greater likelihood of HIV testing history in the general population. However, in HIV criminalization states, heavier policing negatively modified the effect of the law on the likelihood of having ever received an HIV test (p<0.01). Public health implications: This study contributes to a gap in the literature by using recent data to estimate the association of HIV criminalization laws and their enforcement with HIV incidence rates and HIV testing behavior.Item Exploring Psychosocial and Structural Syndemic Effects as Predictors for HIV-Related Outcomes among Black Women(2022) Watson, Lakeshia; Dyer, Typhanye; Epidemiology and Biostatistics; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Black women continue to be disproportionately affected by HIV with marked disparities in HIV incidence, prevalence, and care outcomes. There is a critical need to explore the role of psychosocial and structural factors and the negative impact of these factors on HIV-related outcomes, including HIV risk behaviors, HIV medication adherence, and healthcare utilization. This research uses the syndemic theory to measure the effects of both psychosocial and structural syndemics on HIV-related outcomes among Black women. Syndemic theory is a theoretical framework, which posits there are multiple, overlapping factors that form a cumulative and synergistic effect on HIV disease burden. The substance abuse, violence and AIDS (SAVA) syndemic, clustering effects of substance use, intimate partner abuse, and HIV/AIDS, have been applied in studies exploring HIV outcomes among women; however, the SAVA syndemic framework does not include additional psychosocial and structural factors such as food insecurity, housing instability, incarceration, post -traumatic stress disorder, and depression to better understand the syndemic profiles of Black women. Using study data from the HIV Prevention Trials Network 061 Women’s Seroincidence study and the Women’s Interagency HIV Study, we tested whether a cumulative syndemic of psychosocial and structural factors contributed to sexual risk behaviors and HIV care outcomes. The studies will assess three parameterizations of syndemic factors: cumulative syndemic index, syndemic group indices reflecting the level of influence (psychosocial, participant-level, and neighborhood), and number of syndemic groups (0, 1, 2, or 3). We also tested whether HIV status modified the relationships between a cumulative syndemic of psychosocial and structural factors and sexual risk behaviors. In study 1, a higher syndemic score was significantly associated with increased prevalence of unknown HIV status of last male sex partner (aPR = 1.07, 95% CI: 1.04-1.10), engaging in exchange sex (aPR = 1.17, 95% CI: 1.14-1.20), and having multiple sex partners (aPR = 1.07, 95% CI: 1.06-1.09) among a sample of 1,347 Black women. In study 2, generalized linear mixed models found that being in two syndemic groups was associated with increased odds of reporting unknown HIV status of last male sex partners (aOR=3.04, 95% CI: 1.24-7.44) and having multiple sex partners (aOR=4.29, 95% CI: 1.81-10.18) among 1,364 Black women living with and without HIV across twelve follow-up visits. We also found that being in all three syndemic groups was associated with increased odds of reporting inconsistent condom use (aOR= 2.15, 95% CI: 1.28-3.61), unknown HIV status of last male sex partners (aOR=5.26, 95% CI: 1.94-14.25), and having multiple sex partners (aOR=7.47, 95% CI: 2.85-19.58). Among a total of 969 Black women living with HIV in study 3, a higher cumulative syndemic score and a higher neighborhood-level structural syndemic group score was associated with increased odds of reporting sub-optimal HIV medication adherence (aOR=1.04, 95% CI: 1.01-1.06 and 1.08, respectively). Black women in all three syndemic groups had increased odds of reporting sub-optimal HIV medication adherence (OR=2.88, 95% CI: 1.32-6.29) and missed HIV appointments (OR=3.39, 95% CI: 1.06-10.92). Results from these studies highlight the evidence of psychosocial and structural syndemic effects on multiple HIV risk and care outcomes among Black women.Item Individual and partnership characteristics associated with consistent condom use in a cohort of cisgender men who have sex with men and transgender women in Nigeria(Springer Nature, 2021-06-30) Olawore, Oluwasolape; Crowell, Trevor A.; Ketende, Sosthenes C.; Ramadhani, Habib O.; Liu, Hongjie; Ake, Julie A.; Kokogho, Afoke; Adebajo, Sylvia; Charurat, Man E.; Nowak, Rebecca G.; Baral, Stefan D.This study reports on the individual and partnership characteristics that influence consistent condom use in cisgender men who have sex with men (MSM) and transgender women (TGW) attending trusted community centers that provide HIV prevention and treatment services in Nigeria. Adults assigned male at birth who reported anal sex with male partners who enrolled between March 2013–2019 and had information about at least one male sexual partner were included in these analyses. At enrollment and follow-up visits every 3 months for up to 18 months, participants were administered detailed questionnaires that collected information about demographics, sexual practices, HIV risk behaviors, and characteristics and behaviors of their partners in the previous year (at enrollment) or the preceding 3 to 6-months (at follow-up visits). Logistic regression models with generalized estimating equations were used to assess the odds ratio (OR) and 95% confidence intervals (CI) of individual, partner, and partnership characteristics associated with consistent condom use (CCU). A participant was defined as consistently using condom if they reported always using condoms all the time they had insertive, receptive or both types of anal sex with a male partner. At the individual level, CCU was positively associated with higher education, disclosure of key population status to a healthcare worker and negatively associated with poor access to condoms. At the partner and partnership level, CCU was associated with partners with higher education (aOR: 1.36; 95% CI: 1.07–1.72), casual relationships (aOR: 1.22; 95% CI: 1.11–1.34) and relationships in which partners encouraged the participant to use condoms with other partners (aOR: 1.14; 95% CI: 1.02–1.28). Relationships in which the partner was married to a woman and/or the partner’s HIV status positive or unknown were negatively associated with CCU. These findings suggest that individuals in relationships where partners were more open and encouraged safer sex were more likely to consistently use condoms. HIV prevention programs should consider leveraging communication to sexual partners to encourage condom use as this may support condom use with other sexual partners. Given sustained and growing HIV and STI epidemics among MSM and TGW, even with pre-exposure prophylaxis scale-up, it is crucial to continue to study optimal implementation strategies to increase condom use.Item Effects of the 2014-2016 Ebola Epidemic on Infectious Disease Prevention in Guinea(2021) Callaway, Julia; Dyer, Typhanye V; Epidemiology and Biostatistics; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)From 2014-2016, Ebola ravaged the three West African countries of Guinea, Sierra Leone, and Liberia. There were more than 28,000 cases and 11,000 deaths, with more than 10,600 additional deaths due to other medical conditions. We aimed to examine how utilization of infectious disease prevention services changed in Guinea over the course of the Ebola epidemic, using Andersen’s model of healthcare utilization as a theoretical framework. The specific aims of this study were: 1) to examine differences in measles vaccination rates among children ages 12-35 months before and after the Ebola epidemic by wealth quintile; 2) to estimate mosquito net possession at two time points post-epidemic compared to pre-epidemic among households with at least one child under five, nationally and regionally; and 3) to quantify how much of the association between exposure to the Ebola epidemic and HIV testing prevalence can be explained by changes in urban/rural residence rates among adults in Guinea. The studies use data from the 2012 and 2018 Guinea DHS, and the 2016 MICS. Studies 1 and 2 use quasi-Poisson regression models to estimate prevalence ratios, and study 3 uses log-binomial regression models in a mediation analysis. In study 1 (n = 2,573 children ages 12-35 months), the poorest children were 54% (95% CI = 58%-67%) as likely to be vaccinated for measles in 2018 compared to 2012, and the wealthiest children were 78% (95% CI = 69%-90%) as likely. In study 2 (n = 14,756 households with at least one child under five), mosquito net possession in 2016 was 72% (95% CI = 56%-90%) higher and in 2018 was 12% (95% CI = 8%-15%) higher than in 2012. In study 3 (n = 27,809 adults), of the 4.59% (95% CI = 4%-6%) increase in the log-likelihood of ever having been tested for HIV due to being in the 2018 cohort, an estimated 0.269% of the effect (95% CI = 0.04%-1%) could be attributed to differences in urban/rural residence. Understanding these changes gives a more complete picture of the effects of epidemics on infectious disease prevention and can help public health officials plan for future epidemics.Item LEVERAGING SOCIAL NETWORKS TO FIGHT HIV: THE BATTLE OF FEMALE SEX WORKERS(2020) Li, Yuruo; Liu, Hongjie; Epidemiology and Biostatistics; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)This dissertation aims to assess the applicability of the social network method on HIV research among female sex workers (FSWs). Manuscript 1 reported the findings from a systematic literature review which examined the application of social network method in HIV studies focusing on FSWs. The majority of the identified studies were limited to local social networks or FSW establishments and did not use sophisticated statistical approaches to analyze sociocentric network data. The discrepancies in network definitions and data collections made it difficult in interpreting their findings and assessing validity. Most of the analytic plans for egocentric studies were limited to information at the individual level rather than that at the ego-alter ties. The project reported in manuscripts 2 and 3 used empirical data from a multi-center egocentric network study among mid-age FSWs in China to assess the extent to which social network components influence HIV testing behaviors (paper 2), and the associations between Chinese collectivist culture and FSWs’ social networks (paper 3). As reported in the manuscript 2, among 1,245 FSWs, 62.2% of them received an HIV test. HIV testing was positively associated with higher network transitivity (AOR: 1.77; 95% CI: 1.18-2.64) and inversely associated with network trust (AOR: 0.74; 95% CI: 0.56-0.97). Although social support was not associated with HIV testing, the increase in social cohesion may provide substantial support for HIV testing. As documented in manuscript 3, Chinese collectivism tendency was negatively associated with their perceived social support (95% CI: -0.33, -0.04), network effective size (95% CI: -0.30, -0.01), and network betweenness (95% CI: -0.33, -0.09). FSWs who had the highest level of collectivistic tendency and perceived a higher level of stigma are more likely to stay at a “bridging” position and connect with weak social ties rather than a strong cohesive group. This dissertation projects provide empirical evidence that social networks can be used to analyze the social environment of FSWs and its impact on HIV preventive behaviors among this HIV vulnerable population. The findings make additional contributions to the application of social network methods in social and behavioral research with a focus on FSWs.Item THE SYNDEMIC EFFECT OF PSYCHOSOCIAL AND STRUCTURAL FACTORS ON HIV TESTING AMONG BLACK MEN AND THE MODERATING EFFECT OF SEXUAL IDENTITY(2018) Turpin, Rodman Emory; Dyer, Typhanye; Epidemiology and Biostatistics; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Black populations experience the highest incidence and prevalence of HIV in the United States. It has been posited that numerous structural and psychosocial factors contribute to HIV disparities among Black populations, these factors can have an adverse effect on healthcare utilization, including HIV testing. Given the burden of HIV rates among Black men, especially Black gay and bisexual men, it is important to consider possible barriers to HIV testing in this population. Syndemic theory posits a mutually reinforcement of social and structural conditions that cumulatively affects disease outcomes. While syndemic theory has been applied to HIV acquisition, this framework has not been utilized for HIV testing. We tested for a syndemic of depression, poverty, and a lack of healthcare access impacting HIV testing and tested sexual identity as a moderator of healthcare access in a nationally representative sample of Black men. Participants with 2 or 3 syndemic factors were significantly more likely to have never been HIV tested compared to those with 0 or 1 (49.2% to 31.7%). Having 3 syndemic factors was associated with greater prevalence of never having been HIV tested (aPR=1.46, 95% CI 1.09, 1.95). Gay/bisexual identity moderated the association between health insurance and ever having been HIV tested in adjusted models (aPR=4.36; 95% CI 1.40, 13.62), with not having health insurance being associated with HIV testing among gay/bisexual participants only (aPR=4.84, 95% CI 1.19, 19.70). Using latent class analysis, four syndemic classes were identified as significant predictors of having never been HIV tested. In adjusted log-binomial models, compared to the class with the lowest proportion of syndemic factors, the highest prevalence of never having been HIV tested was among the class with the highest proportions of syndemic component factors (aPR=2.27, 95% CI 1.83, 2.82). Overall, there is evidence of a syndemic of depression, poverty, and a lack of healthcare access that negatively affects HIV testing among Black men, with a lack of healthcare access being a significantly greater barrier to HIV testing among gay/bisexual men compared to heterosexual men.