Journal Article Annotations
2019, 1st Quarter

HIV Psychiatry

Annotations by John Grimaldi, MD; and Mary Ann Cohen MD, FAPM
March 2019

Individual and Network Factors Associated With Racial Disparities in HIV Among Young Men Who Have Sex With Men: Results From the RADAR Cohort Study.

Also of interest:

Parker CM¹, Hirsch JS¹, Hansen HB¹, Branas C¹, Martins S¹: Facing Opioids in the Shadow of the HIV Epidemic.
N Engl J Med. 2019 Jan 3;380(1):1-3. doi: 10.1056/NEJMp1813836.Drawing from lessons learned from the HIV epidemic, this perspective piece reminds us of the importance of addressing social and structural factors driving the opioid epidemic and warns us of the consequences of failing to do so. Advances in the treatment of HIV have not benefitted all ethnic, racial and sexuality-related groups equally, suggesting the need to reverse inequities by coupling biomedical treatments with interventions at the level of population health. Based on experience and research of the social factors influencing who benefits from HIV treatment, the authors propose 4 intervention targets for insuring that all people with opioid use disorders (OUD) benefit equally from medication-assisted treatment (MAT). Availability of MAT must be augmented by removal of economic and cultural barriers to reach the large of majority of people with OUD who currently receive no treatment. Changes in structural drivers such as unequal access to healthcare and economic opportunities are necessary at all levels of government. Research into reducing stigma at the individual level should be extended to inform interventions at family, community and societal levels. Examples include discriminatory government policies and legislation, such as criminalization of substance use disorders. Mobilization of family and community support networks have been a powerful tool in opening treatment resources for people living with HIV. Similar resources could be developed and leveraged for people with OUD. Finally, in the same way that HIV community activism led to development of and access to effective treatment, an analogous “opioid movement” may lead to greater acceptance of treatment of OUD.
Eisinger RW¹, Dieffenbach CW², Fauci AS¹: HIV Viral Load and Transmissibility of HIV Infection: Undetectable Equals Untransmittable.
JAMA. 2019 Feb 5;321(5):451-452. doi: 10.1001/jama.2018.21167.

This JAMA viewpoint from leaders at the National Institute of Allergy and Infectious Diseases affirms the positive effect of durable viral suppression below the level of detection in preventing sexual transmission of HIV. The authors review the clinical studies that constitute the scientific basis for treatment as prevention and paved the way for Undetectable Equals Untransmittable (U=U) Initiative’s role in the campaign to end the HIV/AIDS pandemic. From a psychosocial perspective, U=U carries the potential to mitigate the corrosive effect of both internal and external HIV stigma. A key contributor to the social disenfranchisement that people living with HIV experience is their sense of shame, which in turn may both limit access to care and adherence to treatment, as well as interfere with social connections. This scientific advance may also lead to re-examination of the legal system’s criminalization of potentially exposing another person to HIV.

PUBLICATION #1 — HIV Psychiatry

Individual and Network Factors Associated With Racial Disparities in HIV Among Young Men Who Have Sex With Men: Results From the RADAR Cohort Study.

Mustanski B1,2, Morgan E1, DʼAquila R3, Birkett M1, Janulis P1, Newcomb ME1.

Abstract: J Acquir Immune Defic Syndr.2019 Jan 1;80(1):24-30.

Background: Individual sexual risk behaviors have failed to explain the observed racial disparity in HIV acquisition. To increase understanding of potential drivers in disparities, we assessed differences across individual, network, and social determinants.

Methods: Data come from RADAR (N = 1015), a longitudinal cohort study of multilevel HIV-risk factors among young men who have sex with men (YMSM) aged 16-29 years in Chicago, IL. Data collection includes biological specimens; network data, including detailed information about social, sexual, and drug-use networks; and psychosocial characteristics of YMSM.

Results: Compared to white YMSM (24.8%) and Hispanic YMSM (30.0%), black YMSM (33.9%) had a higher prevalence of both HIV (32%; P < 0.001) and rectal sexually transmitted infections (26.5%; P = 0.011) with no observed differences in pre-exposure prophylaxis use. Black YMSM reported lower rates of sexual risk behaviors and more lifetime HIV tests (P < 0.001) compared with all other YMSM; however, they were also significantly less likely to achieve viral suppression (P = 0.01). Black YMSM reported the highest rate of cannabis use (P = 0.03) as well as greater levels of stigma (P < 0.001), victimization (P = 0.04), trauma (P < 0.001), and childhood sexual abuse (P < 0.001). White YMSM reported higher rates of depression (P < 0.001) and alcohol use (P < 0.001). In network analyses, significant differences existed across network characteristics with black YMSM having the lowest transitivity (P = 0.002), the highest density (P < 0.001), and the highest homophily (P < 0.001).

Conclusions: Black YMSM do not report higher rates of HIV-risk behaviors, but social and network determinants are aligned toward increased HIV risk. These results suggest that network interventions and those addressing social determinants may help reduce disparities.

PMID: 30365451

PMCID: PMC6289601

[Available on 2020-01-01]

DOI: 10.1097/QAI.0000000000001886

Annotation

Type of study: This study used data from a longitudinal cohort study of multilevel HIV-risk factors among young men who have sex with men (YMSM) aged 16-29 in Chicago, IL, RADAR (N=1015).

Findings:Data from a longitudinal cohort study of multilevel HIV-risk factors among young men who have sex with men (YMSM) aged 16-29 in Chicago, IL, RADAR (N=1015), were used to understand individual, network and social drivers of racial/ethnic disparities in HIV acquisition among YMSM. Analyses of individual and social characteristics revealed that black YMSM had significantly higher HIV prevalence despite lower rates of sexual risk behaviors compared to white and Hispanic YMSM. There was no difference in pre-exposure prophylaxis (PrEP) use across all groups. Black YMSM were less likely than other groups to achieve viral suppression and more likely to report stigma, victimization, trauma and childhood sexual abuse. These social determinants along with the following network characteristics heighten HIV risk among black YMSM. Compared to other groups, black YMSM have significantly higher network homophily and density and lower transitivity. These measures reflect dynamics underlying disease spread. Homophily refers to the degree of same-race sexual relationships; density is the proportion of all possible sexual pairs in a network that are actual sexual pairs; transitivity refers to the degree of connectiveness within a network.

Strengths and limitations: This longitudinal study comprises a large cohort of racially and ethnically diverse MSM whose young age may amplify the effect of individual, biological and structural characteristics on HIV prevention and care. An existing rich data set is employed to advance a nuanced understanding of ways in which racial and ethnic differences in network characteristics may account for disparities in HIV acquisition. Although conducted in Chicago, the study reveals insights that may apply to the South where an even larger proportion of black YMSM are affected by HIV. Limitations include the use of a community rather than a population sample which may not generalize to the general population, the use of some self-reported data, and the inclusion of few HIV-negative white MSM in the sample.

Relevance:Racial and ethnic disparities in HIV incidence, prevention, and care persist despite significant advances in biomedical HIV prevention strategies. The urgent need to address inequalities is supported by CDC estimates of lifetime risk of acquiring HIV which are 1:2 for black MSM, 1:5 for Hispanic MSM and 1:11 for white MSM. Studies of individual factors related to HIV transmission suggest that HIV-risk behaviors don’t account for racial and ethnic disparities. By enhancing our understanding of social and network determinants, this study moves us closer to our goal of reducing disparities and stopping HIV transmission. For example, this study suggests the potential public health benefit of interventions that target stigma, trauma and victimization. Findings from studies of network and social determinants of HIV could be integrated with data from partner services programs and molecular surveillance to develop more sophisticated interventions to facilitate both access to testing, prevention and care as well as identification of influential members of sexual networks. Other relevant findings include higher rates of suicide attempts in black YMSM and lowest rates of PrEP use, network homophily and number of visits to a healthcare provider in Hispanics. This study suggests the need for mental health interventions for black YMSM and prevention interventions informed by findings for Hispanic YMSM.