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Social science and public health literature has framed residential segregation as a potent structural determinant of the higher HIV burden among black heterosexuals, but empirical evidence has been limited. The purpose of this study is to test, for the first time, the association between racial segregation and newly diagnosed heterosexually acquired HIV cases among black adults and adolescents in 95 large US metropolitan statistical areas (MSAs) in 2008-2015. We operationalized racial segregation (the main exposure) using Massey and Denton's isolation index for black residents; the outcome was the rate of newly diagnosed HIV cases per 10,000 black adult heterosexuals. We tested the relationship of segregation to this outcome using multilevel multivariate models of longitudinal (2008-2015) MSA-level data, controlling for potential confounders and time. All covariates were lagged by 1 year and centered on baseline values. We preliminarily explored mediation of the focal relationship by inequalities in education, employment, and poverty rates. Segregation was positively associated with the outcome: a one standard deviation decrease in baseline isolation was associated with a 16.2% reduction in the rate of new HIV diagnoses; one standard deviation reduction in isolation over time was associated with 4.6% decrease in the outcome. Exploratory mediation analyses suggest that black/white socioeconomic inequality may mediate the relationship between segregation and HIV. Our study suggests that residential segregation may be a distal determinant of HIV among black heterosexuals. The findings further emphasize the need to address segregation as part of a comprehensive strategy to reduce racial inequities in HIV. [ABSTRACT FROM AUTHOR]

Prior research has found that places and people that are more economically disadvantaged have higher rates and risks, respectively, of sexually transmitted infections (STIs). Economic disadvantages at the level of places and people, however, are themselves influenced by economic policies. To enhance the policy relevance of STI research, we explore, for the first time, the relationship between state-level minimum wage policies and STI rates among women in a cohort of 66 large metropolitan statistical areas (MSAs) in the US spanning 2003–2015. Our annual state-level minimum wage measure was adjusted for inflation and cost of living. STI outcomes (rates of primary and secondary syphilis, gonorrhea and chlamydia per 100,000 women) were obtained from the CDC. We used multivariable hierarchical linear models to test the hypothesis that higher minimum wages would be associated with lower STI rates. We preliminarily explored possible socioeconomic mediators of the minimum wage/STI relationship (e.g., MSA-level rates of poverty, employment, and incarceration). We found that a $1 increase in the price-adjusted minimum wage over time was associated with a 19.7% decrease in syphilis rates among women and with an 8.5% drop in gonorrhea rates among women. The association between minimum wage and chlamydia rates did not meet our cutpoint for substantive significance. Preliminary mediation analyses suggest that MSA-level employment among women may mediate the relationship between minimum wage and gonorrhea. Consistent with an emerging body of research on minimum wage and health, our findings suggest that increasing the minimum wage may have a protective effect on STI rates among women. If other studies support this finding, public health strategies to reduce STIs among women should include advocating for a higher minimum wage. [ABSTRACT FROM AUTHOR]

This exploratory analysis investigates relationships of place characteristics to HIV testing among people who inject drugs (PWID). We used CDC's 2012 National HIV Behavioral Surveillance (NHBS) data among PWID from 19 US metropolitan statistical areas (MSAs); we restricted the analytic sample to PWID self-reporting being HIV negative (N = 7477). Administrative data were analyzed to describe the 1. Sociodemographic Composition; 2. Economic disadvantage; 3. Healthcare Service/Law enforcement; and 4. HIV burden of the ZIP codes, counties, and MSAs where PWID lived. Multilevel models tested associations of place characteristics with HIV testing. Fifty-eight percent of PWID reported past-year testing. MSA-level per capita correctional expenditures were positively associated with recent HIV testing among black PWID, but not white PWID. Higher MSA-level household income and imbalanced sex ratios (more women than men) in the MSA were associated with higher odds of testing. HIV screening for PWID is suboptimal (58%) and needs improvement. Identifying place characteristics associated with testing among PWID can strengthen service allocation and interventions in areas of need to increase access to HIV testing. [ABSTRACT FROM AUTHOR]

This paper reviews and then discusses selected findings from a seventeen year study about the population prevalence of people who inject drugs (PWID) and of HIV prevalence and mortality among PWID in 96 large US metropolitan areas. Unlike most research, this study was conducted with the metropolitan area as the level of analysis. It found that metropolitan area measures of income inequality and of structural racism predicted all of these outcomes, and that rates of arrest for heroin and/or cocaine predicted HIV prevalence and mortality but did not predict changes in PWID population prevalence. Income inequality and measures of structural racism were associated with hard drug arrests or other properties of policing. These findings, whose limitations and implications for further research are discussed, suggest that efforts to respond to HIV and to drug injection should include supra-individual efforts to reduce both income inequality and racism. At a time when major social movements in many countries are trying to reduce inequality, racism and oppression (including reforming drug laws), these macro-social issues in public health should be both addressable and a priority in both research and action. [ABSTRACT FROM AUTHOR]

Objectives. We sought to determine whether contextual factors shape injection drug use among Black adolescents and adults. Methods. For this longitudinal study of 95 US metropolitan statistical areas (MSAs), we drew annual MSA-specific estimates of the prevalence of injection drug use (IDU) among Black adolescents and adults in 1993 through 2007 from 3 surveillance databases. We used existing administrative data to measure MSA-level socioeconomic status; criminal justice activities; expenditures on social welfare, health, and policing; and histories of Black uprisings (1960-1969) and urban renewal funding (1949-1974). We regressed Black IDU prevalence on these predictors by using hierarchical linear models. Results. Black IDU prevalence was lower in MSAs with declining Black high-school dropout rates, a history of Black uprisings, higher percentages of Black residents, and, in MSAs where 1992 White income was high, higher 1992 Black income. Incarceration rates were unrelated. Conclusions. Contextual factors shape patterns of drug use among Black individuals. Structural interventions, especially those that improve Black socioeconomic security and political strength, may help reduce IDU among Black adolescents and adults. [ABSTRACT FROM AUTHOR]

Background: People who inject drugs (PWID) have increased risk of morbidity and mortality. We update and present estimates and trends of the prevalence of current PWID and PWID subpopulations in 96 US metropolitan statistical areas (MSAs) for 1992–2007. Current estimates of PWID and PWID subpopulations will help target services and help to understand long-term health trends among PWID populations. Methodology: We calculated the number of PWID in the US annually from 1992–2007 and apportioned estimates to MSAs using multiplier methods. We used four types of data indicating drug injection to allocate national annual totals to MSAs, creating four distinct series of component estimates of PWID in each MSA and year. The four component estimates are averaged to create the best estimate of PWID for each MSA and year. We estimated PWID prevalence rates for three subpopulations defined by gender, age, and race/ethnicity. We evaluated trends using multi-level polynomial models. Results: PWID per 10,000 persons aged 15–64 years varied across MSAs from 31 to 345 in 1992 (median 104.4) to 34 to 324 in 2007 (median 91.5). Trend analysis indicates that this rate declined during the early period and then was relatively stable in 2002–2007. Overall prevalence rates for non-Hispanic black PWID increased in 2005 as compared to other racial/ethnic groups. Hispanic prevalence, in contrast, declined across time. Importantly, results show a worrisome trend in young PWID prevalence since HAART was initiated – the mean prevalence was 90 to 100 per 10,000 youth in 1992–1996, but increased to >120 PWID per 10,000 youth in 2006–2007. Conclusions: Overall, PWID rates remained constant since 2002, but increased for two subpopulations: non-Hispanic black PWID and young PWID. Estimates of PWID are important for planning and evaluating public health programs to reduce harm among PWID and for understanding related trends in social and health outcomes. [ABSTRACT FROM AUTHOR]

Background: Among the largest US metropolitan areas, trends in mortality rates for injection drug users (IDUs) with AIDS vary substantially. Ecosocial, risk environment and dialectical theories suggest many metropolitan areas characteristics that might drive this variation. We assess metropolitan area characteristics associated with decline in mortality rates among IDUs living with AIDS (per 10,000 adult MSA residents) after highly active antiretroviral therapy (HAART) was developed. Methods: This is an ecological cohort study of 86 large US metropolitan areas from 1993–2006. The proportional rate of decline in mortality among IDUs diagnosed with AIDS (as a proportion of adult residents) from 1993–1995 to 2004–2006 was the outcome of interest. This rate of decline was modeled as a function of MSA-level variables suggested by ecosocial, risk environment and dialectical theories. In multiple regression analyses, we used 1993–1995 mortality rates to (partially) control for pre-HAART epidemic history and study how other independent variables affected the outcomes. Results: In multivariable models, pre-HAART to HAART era increases in ‘hard drug’ arrest rates and higher pre-HAART income inequality were associated with lower relative declines in mortality rates. Pre-HAART per capita health expenditure and drug abuse treatment rates, and pre- to HAART-era increases in HIV counseling and testing rates, were weakly associated with greater decline in AIDS mortality. Conclusions: Mortality among IDUs living with AIDS might be decreased by reducing metropolitan income inequality, increasing public health expenditures, and perhaps increasing drug abuse treatment and HIV testing services. Given prior evidence that drug-related arrest rates are associated with higher HIV prevalence rates among IDUs and do not seem to decrease IDU population prevalence, changes in laws and policing practices to reduce such arrests while still protecting public order should be considered. [ABSTRACT FROM AUTHOR]

Little information exists on the population prevalence or geographic distribution of injection drug users (IDUs) who are Hispanic in the USA. Here, we present yearly estimates of IDU population prevalence among Hispanic residents of the 96 most populated US metropolitan statistical areas (MSAs) for 1992-2002. First, yearly estimates of the proportion of IDUs who were Hispanic in each MSA were created by combining data on (1) IDUs receiving drug treatment services in Substance Abuse and Mental Health Services Administration (SAMHSA)'s Treatment Entry Data System, (2) IDUs being tested in the Centers for Disease Control and Prevention (CDC) HIV-Counseling and Testing System, and (3) incident AIDS diagnoses among IDUs, supplemented by (4) data on IDUs who were living with AIDS. Then, the resulting proportions were multiplied by published yearly estimates of the number of IDUs of all racial/ethnic groups in each MSA to produce Hispanic IDU population estimates. These were divided by Hispanic population data to produce population prevalence rates. Time trends were tested using mixed-effects regression models. Hispanic IDU prevalence declined significantly on average (1992 mean = 192, median = 133; 2002 mean = 144, median = 93; units are per 10,000 Hispanics aged 15-64). The highest prevalence rates across time tended to be in smaller northeastern MSAs. Comparing the last three study years to the first three, prevalence decreased in 82% of MSAs and increased in 18%. Comparisons with data on drug-related mortality and hepatitis C mortality supported the validity of the estimates. Generally, estimates of Hispanic IDU population prevalence were higher than published estimates for non-Hispanic White residents and lower than published estimates for non-Hispanic Black residents. Further analysis indicated that the proportion of IDUs that was Hispanic decreased in 52% and increased in 48% of MSAs between 2002 and 2007. The estimates resulting from this study can be used to investigate MSA-level social and economic factors that may have contributed to variations across MSAs and to help guide prevention program planning for Hispanic IDUs within MSAs. Future research should attempt to determine to what extent these trends are applicable to Hispanic national origin subgroups. [ABSTRACT FROM AUTHOR]

Objectives. We examined relationships of spatial access to syringe exchange programs (SEPs) and pharmacies selling over-the-counter (OTC) syringes with New York City drug injectors' harm reduction practices. Methods. Each year from 1995 to 2006, we measured the percentage of 42 city health districts' surface area that was within 1 mile of an SEP or OTC pharmacy. We applied hierarchical generalized linear models to investigate relationships between these exposures and the odds that injectors (n=4003) used a sterile syringe for at least 75% of injections in the past 6 months. Results. A 1-unit increase in the natural log of the percentage of a district's surface area within a mile of an SEP in 1995 was associated with a 26% increase in the odds of injecting with a sterile syringe; a 1-unit increase in this exposure over time increased these odds 23%. A 1-unit increase in the natural log of OTC pharmacy access improved these odds 15%. Conclusions. Greater spatial access to SEPs and OTC pharmacies improved injectors' capacity to engage in harm reduction practices that reduce HIV and HCV transmission. [ABSTRACT FROM AUTHOR]

Abstract: Aims: A prior study concluded that drug treatment coverage, defined as the percentage of injection drug users in drug treatment, varied from 1 percent to 39 percent (median 9 percent) in 96 metropolitan statistical areas (MSAs) in the United States. Here, we determine which metropolitan area characteristics are associated with drug treatment coverage. Methods: We conducted secondary analysis of official data, including the number of injection drug users in treatment and other variables, for 94 large US MSAs. We estimated the number of injection drug users in these metropolitan areas using previously described methods. We used lagged cross-sectional analyses where the independent variables, chosen on the basis of a Theory of Community Action, preceded the dependent variable (drug treatment coverage) in time. Predictors were determined using ordinary least squares multiple regression and confirmed with robust regression. Results: Independent predictors of higher drug treatment coverage for injectors were: presence of organisations that support treatment (unstandardized beta=1.64; 95 percent CI .59 to 2.69); education expenditures per capita in the MSA (unstandardized beta=.12; 95 percent CI −.34 to 2.69); lower percentage of drug users in treatment who are non-injection drug users (unstandardized beta=−0.18; 95 percent CI −0.24 to −0.12); higher percentage of the population who are non-Hispanic White (unstandardized beta=.14; 95 percent CI .08 to .20); lower per capita long-term debt of governments in the metropolitan area (unstandardized beta=−0.93; 95 percent CI −1.51 to −0.35). Conclusions: In conditions of scarce treatment coverage for drug injectors, an indicator of epidemiologic need (the per capita extent of AIDS among injection drug users) does not predict treatment coverage, and competition for treatment slots by non-injectors may reduce injectors’ access to treatment. Metropolitan finances limit treatment coverage. Political variables (racial structures, the presence of organisations that support drug treatment, and budget priorities) may be important determinants of treatment coverage for injectors. Although confidence in these results would be higher if we had used a longitudinal design, these results suggest that further research and action that address structural, political, and other barriers to treatment expansion are sorely needed. [Copyright &y& Elsevier]

Community activism can be important in shaping public health policies. For example, political pressure and direct action from grassroots activists have been central to the formation of syringe exchange programs (SEPs) in the United States. We explored why SEPs are present in some localities but not others, hypothesizing that programs are unevenly distributed across geographic areas as a result of political, socioeconomic, and organizational characteristics of localities, including needs, resources, and local opposition. We examined the effects of these factors on whether SEPs were present in different US metropolitan statistical areas in 2000. Predictors of the presence of an SEP included percentage of the population with a college education, the existence of local AIDS Coalition to Unleash Power (ACT UP) chapters, and the percentage of men who have sex with men in the population. Need was not a predictor. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: We focus on a little-researched issue—how human immunodeficiency virus (HIV) epidemics and programs in key populations in metropolitan areas affect epidemics in other key populations. We consider (1) How are earlier epidemics among people who inject drugs (PWID) and men who have sex with men (MSM) related to later AIDS incidence and mortality among heterosexuals?; (2) Were prevention programs targeting PWID or MSM associated with lower AIDS incidence and mortality among heterosexuals?; and (3) Was the size of the potential bridge population of noninjecting drug users (NIDUs) in a metropolitan area associated with later AIDS incidence and mortality among heterosexuals? Methods: Using data for 96 large U.S. metropolitan areas, Poisson regression assessed associations of population prevalences of HIV-infected PWID and MSM (1992); NIDU population prevalence (1992–1994); drug use treatment coverage for PWID (1993); HIV counseling and testing coverage for MSM and for PWID (1992); and syringe exchange presence (2000) with CDC data on AIDS incidence and mortality among heterosexuals in 2006–2008, with appropriate socioeconomic controls. Results: Population density of HIV+ PWID and of NIDUs were positively related, and prevention programs for PWID negatively related to later AIDS incidence among heterosexuals and later mortality among heterosexuals living with AIDS. HIV+ MSM population density and prevention programs for MSM were not associated with these outcomes. Conclusions: Efforts to reduce HIV transmission among PWID and NIDUs may reduce AIDS and AIDS-related mortality among heterosexuals. More research is needed at metropolitan area, network, and individual levels into HIV bridging across key populations and how interventions in one key population affect HIV epidemics in other key populations. [Copyright &y& Elsevier]

Abstract: City-specific studies have suggested the quality of the local environment and economic circumstances are associated with greater risk of injection drug use (IDU). No studies have assessed the relation among the quality of the local environment, economic circumstances, and IDU over time across US metropolitan areas. Annual numbers of IDUs in the 88 largest US metropolitan statistical areas (MSAs) were estimated by extrapolating, adjusting, and allocating existing estimates using various data sources. Generalized estimating equations were used to assess the relation among the quality of the local environment, metropolitan political economy, and IDU prevalence using lagged models taking into account potential confounders. MSAs with a worse local environment (measured as a one standard deviation difference) had a greater risk of IDU (relative risk [RR]=1.03, 95% confidence interval [CI]: 1.01, 1.06); similarly, a one-percentage point worsening of the political economy for an MSA was associated with greater risk of IDU (RR=1.04–1.10). Final models stratified by region indicated heterogeneity of effect by region whereby the quality of the local environment was associated with IDU strongest in the South (RR=1.12, CI: 1.05, 1.12) followed by the West (RR=1.04, CI: 1.01, 1.07) and Midwest (RR=1.03, CI: 1.00, 1.06), and the metropolitan political economy was associated with IDU in the West (RR=1.03–1.09) and Northeast (RR=1.04–1.12). Our results underscore the importance of sociopolitical factors as determinants of IDU in MSAs. Structural solutions targeted at improving environmental conditions and economic circumstances should be considered as drug use interventions. [Copyright &y& Elsevier]

Purpose: To assess cross-population linkages in HIV/AIDS epidemics, we tested the hypothesis that the number of newly diagnosed AIDS cases among Black people who inject drugs (PWID) was positively related to the natural log of the rate of newly diagnosed HIV infections among Black non-PWID heterosexuals in 84 large U.S. metropolitan statistical areas (MSAs) in 2008-2016.Methods: We estimated a multilevel model centering the time-varying continuous exposures at baseline between the independent (Black PWID AIDS rates) and dependent (HIV diagnoses rate among Black heterosexuals) variables.Results: At MSA level, baseline (standardized β = 0.12) Black PWID AIDS rates and change in these rates over time (standardized β = 0.11) were positively associated with the log of new HIV diagnoses rates among Black heterosexuals. Thus, MSAs with Black PWID AIDS rates that were 1 standard deviation= higher at baseline also had rates of newly diagnosed HIV infections among Black non-PWID heterosexuals that were 10.3% higher. A 1 standard deviation increase in independent variable over time corresponded to a 7.8% increase in dependent variable.Conclusions: Black PWID AIDS rates may predict HIV rates among non-PWID Black heterosexuals. Effective HIV programming may be predicated, in part, on addressing intertwining of HIV epidemics across populations. [ABSTRACT FROM AUTHOR]