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Background Direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) is well tolerated, cost-effective, and yields high sustained virologic response rates, yet it has remained financially inaccessible to many patients. Methods Participants of the Women's Interagency HIV Study (an observational US cohort) with human immunodeficiency virus (HIV) and HCV (RNA+) reporting no prior hepatitis C treatment were followed for DAA initiation (2015–2019). We estimated risk ratios (RRs) of the relationship between time-varying health insurance status and DAA initiation, adjusting for confounders with stabilized inverse probability weights. We also estimated weighted cumulative incidences of DAA initiation by health insurance status. Results A total of 139 women (74% Black) were included; at baseline, the median age was 55 years and 86% were insured. Most had annual household incomes ≤$18 000 (85%); advanced liver fibrosis (21%), alcohol use (45%), and recreational drug use (35%) were common. Across 439 subsequent semiannual visits, 88 women (63%) reported DAA initiation. Compared with no health insurance, health insurance increased the likelihood of reporting DAA initiation at a given visit (RR, 4.94; 95% confidence limit [CL], 1.92 to 12.8). At 2 years, the weighted cumulative incidence of DAA initiation was higher among the insured (51.2%; 95% CL, 43.3% to 60.6%) than the uninsured (3.5%; 95% CL, 0.8% to 14.6%). Conclusions Accounting for clinical, behavioral, and sociodemographic factors over time, health insurance had a substantial positive effect on DAA initiation. Interventions to increase insurance coverage should be prioritized to increase HCV curative therapy uptake for persons with HIV.

Purpose Research examining the association between crime and health outcomes has been hampered by a lack of reliable small-area (e.g., census tract or census block group) crime data. Our objective is to assess the accuracy of synthetically estimated crime indices for use in health research by using preterm birth as a case study. Methods We used violent crime data reported by 47 law enforcement agencies in 15 counties in Atlanta, Georgia and compared them with commercially estimated crime rates from the same year to assess (1) how two measures of crime were correlated and (2) if the associations between violent crime rate indices and preterm birth (PTB) varied as a function of the source of crime index. To assess the association between violent crime and PTB, we used multilevel logistic regression and controlled for potential individual- and neighborhood-level confounders. Results Violent crime, both estimated and observed, was positively correlated with poverty, neighborhood proportion Black, and neighborhood deprivation index; however, the association was stronger using estimated rates as compared with observed crime rates. The association between living in a high violent crime neighborhood and PTB was only consistent for white women across the two crime indices after covariate adjustment. For Black women, the association between living in a high violent crime neighborhood and PTB is systematically underestimated across all models when the estimated crime rate is used. Conclusions There is evidence that model-estimated crime rates are not reliable proxies for crime in an urban area even when appropriate confounders are adjusted for.

Background People with HIV are disproportionately coinfected with hepatitis C virus (HCV) and experience accelerated liver-related mortality. Direct-acting antivirals (DAAs) yield high sustained virologic response (SVR) rates, but uptake is suboptimal. This study characterizes the DAA-era HCV treatment cascade and barriers among US men and women with or at risk for HIV. Methods We constructed HCV treatment cascades using the Women’s Interagency HIV Study (women, 6 visits, 2015–2018, n = 2447) and Multicenter AIDS Cohort Study (men, 1 visit, 2015–2018, n = 2221). Cascades included treatment-eligible individuals (ie, HCV RNA-positive or reported DAAs). Surveys captured self-reported clinical (eg, CD4), patient (eg, missed visits), system (eg, appointment access), and financial/insurance barriers. Results Of 323/92 (women/men) treatment eligible, most had HIV (77%/70%); 69%/63% were black. HIV-positive women were more likely to attain cascade outcomes than HIV-negative women (39% vs 23% initiated, 21% vs 12% SVR); similar discrepancies were noted for men. Black men and substance users were treated less often. Women initiating treatment (vs not) reported fewer patient barriers (14%/33%). Among men not treated, clinical barriers were prevalent (53%). Conclusions HIV care may facilitate HCV treatment linkage and barrier navigation. HIV-negative individuals, black men, and substance users may need additional support. Clinical trials registration NCT00000797 (Women’s Interagency HIV Study); NCT00046280 (Multicenter AIDS Cohort Study).

Background Merely having the tools to end HIV is insufficient. Effectively ending the epidemic necessitates addressing barriers that impede engagement in biomedical and behavioral prevention and wide scale implementation and utilization of existing interventions. This qualitative study identifies suggestions for increasing access to, engagement in, and impact of HIV prevention among women living in cities in high HIV burden counties in the eastern US. Methods Data analyzed for the current study were collected via a qualitative sub-study within the HIV Prevention Trials Network Study 064 (HPTN 064), a multisite observational cohort study designed to estimate HIV incidence among women residing in communities with elevated HIV prevalence who also reported personal or partner characteristics associated with increased risk of HIV acquisition. Focus group and interview participants in the qualitative sub-study (N = 288) were from four cities in the eastern US. Results Thematic analyses revealed four themes describing women’s most frequently stated ideas for improving prevention efforts: 1) Promote Multilevel Empowerment, 2) Create Engaging Program Content, 3) Build “Market Demand”, and 4) Ensure Accessibility. We conducted additional analyses to identify contradictory patterns in the data, which revealed an additional three themes: 1) Address Structural Risk Factors, 2) Increase Engagement via Pleasure Promotion, 3) Expand Awareness of and Access to Prevention Resources. Conclusions Findings may be useful for enhancing women’s engagement in and uptake of behavioral and biomedical HIV prevention resources, improving policy, and addressing multilevel risk factors. Trial registration Clinicaltrials.gov: NCT00995176, prospectively registered.

To explore the associations of urbanicity with clinical/behavioral outcomes and sociodemographic factors among women living with HIV in the Southern United States, 523 participants of the Women’s Interagency HIV Study were classified into population density quartiles. Rural-Urban Commuting Area codes revealed that 7% resided in areas where >30% commute to urban areas, 2% resided in small towns or rural areas, and 91% resided in varying densities of urban areas. Although women in lower density, mostly suburban areas reported higher socioeconomic indicators such as advanced education and greater annual household income, larger proportions of women in the lowest density quartile (compared to those in more dense and urban areas) perceived discrimination in health care settings and agreed with several internalized HIV stigma scale items. Women in the lower quartiles had higher CD4 counts, while those in the lowest quartile were more likely to have a suppressed HIV viral load, report being employed, and not report a history of drug use or current heavy alcohol use. More research is needed to understand the interplay between population density and mechanisms contributing to HIV control as well as increased internalized stigma and perceived discrimination, along with how to target interventions (including for stigma alleviation) to improve outcomes for individuals with HIV across urban, suburban, and rural areas.

Neighborhood social and physical factors shape sexual network characteristics in HIV-seronegative adults in the United States. This multilevel analysis evaluated whether these relationships also exist in a predominantly HIV-seropositive cohort of women. This cross-sectional multilevel analysis included dm 734 women enrolled in the Women's Interagency HIV Study's sites in the U S South. Center track-level contextual data captured socioeconomic disadvantage (e.g., tract poverty), number of alcohol outlets, and number of nonprofits in the census tracts where women lived; participant-level data, including perceived neighborhood cohesion, were gathered via survey. We used hierarchical generalized linear models to evaluate relationships between tract characteristics and two outcomes: perceived main sex partner risk level (e.g., partner substance use) and perceived main sex partner non-monogamy. We tested whether these relationships varied by women's HIV. Greater tract-level socioeconomic disadvantage was associated with greater sex partner risk (OR = 1.29, 95 % CI = 1.06-1.58) among HIV-seropositive women and less partner non-monogamy among HIV-seronegative women (OR = 0.69, 95 % CI = 0.51-0.92). Perceived neighborhood trust and cohesion was associated with lower partner risk (OR = 0.83, 95 % CI = 0.69-1.00) for HIV-seropositive and HIV-seronegative women. The tract-level number of alcohol outlets and non-profits were not associated with partner risk characteristics. Neighborhood characteristics are associated with perceived sex partner risk and non-monogamy among women in the South; these relationships vary by HIV status. Future studies should examine causal relationships and explore the pathways through which neighborhoods influence partner selection and risk characteristics.

Transactional sex is associated with socioeconomic disadvantage and HIV risk but few studies in the United States (US) have examined both individual and area-level predictors of transactional sex or distinguished transactional sex from sex work. We combined data from HIV Prevention Trials Network 064 study and the US Census to estimate prevalence ratios (PR) for the relationship between census-level and individual measures of economic deprivation and housing instability on transactional sex in 417 women in North Carolina. Increased transactional sex was associated with food insecurity (PR 1.86; 95%; CI 1.57, 2.19), housing instability (PR 1.33; 95% CI 1.11, 1.59), substance abuse (PR 1.90; 95% CI 1.64, 2.19) and partner incarceration (PR 1.32; 95% CI 1.09, 1.61). Census-level indicators were not associated with transactional sex, adjusted for individual-level covariates. Interventions should support housing stability and financial opportunities among southern African American women to reduce HIV risk, particularly among women with incarcerated partners.

Introduction. Cross-sectional research suggests that neighborhood characteristics and transportation access shape unmet need for medical care. This longitudinal analysis explores relationships of changes in neighborhood socioeconomic disadvantage and trans- portation access to unmet need for medical care. Methods. We analyzed seven waves of data from African American adults (N = 172) relocating from severely distressed public housing complexes in Atlanta, Georgia. Surveys yielded individual-level data and admin- istrative data characterized census tracts. We used hierarchical generalized linear models to explore relationships. Results. Unmet need declined from 25% pre-relocation to 12% at Wave 7. Post-relocation reductions in neighborhood disadvantage were inversely associated with reductions in unmet need over time (OR = 0.71, 95% CI = 0.51-0.99). More frequent transportation barriers predicted unmet need (OR = 1.16, 95% CI = 1.02-1.31). Conclusion. These longitudinal findings support the importance of neighborhood environments and transportation access in shaping unmet need and suggest that improvements in these exposures reduce unmet need for medical care in this vulnerable population.

Background African American women bear disproportionate human immunodeficiency virus (HIV) burden in the United States, yet are often underrepresented in clinical research. Community engagement may decrease research mistrust and increase participation. We describe strategies used to engage community partners and female participants in a multisite HIV incidence study, HIV Prevention Trials Network (HPTN) 064. Objectives HPTN 064 assessed HIV incidence among women in 10 geographic areas chosen for both high prevalence of HIV and poverty. Methods Women were recruited using venue-based sampling and followed for six to 12 months. Recruitment and engagement approaches aligned with the National Institutes of Health (NIH) Director's Council of Public Representatives (COPR) Community Engagement Framework's. Results Results showed engagement activities increased rapport and established new partnerships with community stakeholders. Study sites engaged 56 community organizations with 2,099 women enrolled in 14 months. Final retention was 94%. Conclusions The COPR model maximized inclusiveness and participation of African American women impacted by HIV, supported recruitment and retention, and was the cornerstone of community engagement.

Using data from HIV Prevention Trials Network 064, a multisite, observational cohort study conducted to estimate HIV incidence rates among women living in areas of high poverty and HIV prevalence in the United States, we examined the use of HIV risk characteristics to predict emotional abuse, physical violence, and forced sex.Participants included 2099 women, 18-44 years of age, who reported unprotected vaginal or anal sex with a male partner and an additional personal or perceived male partner HIV risk characteristic in the past 6 months. Adjusting for time-varying covariates, generalized estimating equations were used to assess the ability of HIV risk characteristics to predict violence 6 months later.Reported analyses were limited to the 1980 study participants who reported having a male sex partner at that assessment. Exchanging sex, perceived partner concurrency, and perceived partner incarceration were significantly predictive of emotional abuse 6 months later (adjusted odds ratio [AOR]: 1.60; 1.59; 1.34, respectively). Prior sexually transmitted infection diagnosis, exchanging sex, and binge drinking were significantly predictive of physical violence 6 months later (AOR: 1.62; 1.71; 1.47, respectively). None of the variables measured was significantly predictive of forced sex.Strategies that address reducing violence against women should be studied further in the context of HIV prevention programs.

Women living in poverty suffer more post-traumatic stress disorder (PTSD) symptoms than do members of the general population; however we know little about factors associated with changes in their PTSD symptoms over time. Using data from HPTN 064, a cohort of women from low-income, high-HIV-prevalence communities across six eastern states (n=1,860), we assessed the prevalence of and changes in PTSD symptoms over 12 months and the effect of potential predictors on symptom acquisition and remission (via the Primary Care-PTSD symptoms scale). Forty-three percent screened positive for PTSD symptoms. Those reporting food insecurity, ongoing abuse, depressive symptoms, or binge drinking were more likely to acquire PTSD symptoms. Those with ongoing abuse or depressive symptoms were less likely to experience PTSD symptom remission. Findings suggest a need to integrate programs to reduce abuse, depression, and economic hardship with those that address sexual health risks among women living in low-income, high-HIV-prevalence neighborhoods.

Identifying venues where women meet sexual partners, particular partners who increase women's risk of acquiring HIV, could inform prevention efforts. We categorized venues where women enrolled in HPTN 064 reported meeting their last three sex partners as: (1) Formal, (2) Public, (3) Private, and (4) Virtual spaces. We used multinomial logistic regression to assess the association between these venues and women's individual characteristics and reports of their partners' HIV risk characteristics. The 2099 women reported meeting 3991 partners, 51 % at Public, 30 % Private, 17 % Formal and 3 % at Virtual venues. Women meeting partners at Formal venues reported more education and condom use than women meeting partners at other venues. Fewer partners met through Formal venues had "high" risk characteristics for HIV than through other venues and hence may pose less risk of HIV transmission. HIV prevention interventions can help women choose partners with fewer risk characteristics across all venue types.

Introduction The United States has experienced an increase in reportable sexually transmitted infections (STIs) while simultaneously experiencing a decline in safety net services for STI testing and treatment. This multilevel study assessed relationships between neighborhood-level access to health care and STIs among a predominantly Human Immunodeficiency Virus (HIV)-seropositive cohort of women living in the south. Methods This cross-sectional multilevel analysis included baseline data from HIV-seropositive and HIV-seronegative women enrolled in the Women's Interagency HIV Study sites in Alabama, Florida, Georgia, Mississippi, and North Carolina between 2013 and 2015 (N = 666). Administrative data (eg, United States Census) described health care access (eg, percentage of residents with a primary care provider, percentage of residents with health insurance) in the census tracts where women lived. Sexually transmitted infections (chlamydia, gonorrhea, trichomoniasis, or early syphilis) were diagnosed using laboratory testing. Generalized estimating equations were used to determine relationships between tract-level characteristics and STIs. Analyses were conducted using SAS 9.4. Results Seventy percent of participants were HIV-seropositive. Eleven percent of participants had an STI. A 4-unit increase in the percentage of residents with a primary care provider was associated with 39% lower STI risk (risk ratio, 0.61, 95% confidence interval, 0.38-0.99). The percentage of tract residents with health insurance was not associated with STIs (risk ratio, 0.98, 95% confidence interval, 0.91-1.05). Relationships did not vary by HIV status. Conclusions Greater neighborhood health care access was associated with fewer STIs. Research should establish the causality of this relationship and pathways through which neighborhood health care access influences STIs. Structural interventions and programs increasing linkage to care may reduce STIs.

We describe the sexual behaviors of women at elevated risk of HIV acquisition who reside in areas of high HIV prevalence and poverty in the US. Participants in HPTN 064, a prospective HIV incidence study, provided information about participants’ sexual behaviors and male sexual partners in the past 6 months at baseline, 6- and 12-months. Independent predictors of consistent or increased temporal patterns for three high-risk sexual behaviors were assessed separately: exchange sex, unprotected anal intercourse [UAI] and concurrent partnerships. The baseline prevalence of each behavior was >30% among the 2,099 participants, 88% reported partner(s) with > one HIV risk characteristic and both individual and partner risk characteristics decreased over time. Less than high school education and food insecurity predicted consistent/increased engagement in exchange sex and UAI, and partner's concurrency predicted participant concurrency. Our results demonstrate how interpersonal and social factors may influence sustained high-risk behavior by individuals and suggest that further study of the economic issues related to HIV risk could inform future prevention interventions.

Theories of social causation and social influence, which posit that neighborhood and social network characteristics are distal causes of substance use, are frequently used to interpret associations among neighborhood characteristics, social network characteristics and substance use. These associations are also hypothesized to result from selection processes, in which substance use determines where people live and who they interact with. The potential for these competing selection mechanisms to co-occur has been underexplored among adults. This study utilizes path analysis to determine the paths that relate census tract characteristics (e.g., economic deprivation), social network characteristics (i.e., having ≥ 1 illicit drug-using network member) and illicit drug use, among 172 African American adults relocated from public housing in Atlanta, Georgia and followed from 2009 to 2014 (7 waves). Individual and network-level characteristics were captured using surveys. Census tract characteristics were created using administrative data. Waves 1 (pre-relocation), 2 (1st wave post-relocation), and 7 were analyzed. When controlling for individual-level sociodemographic factors, residing in census tracts with prior economic disadvantage was significantly associated with illicit drug use at wave 1; illicit drug use at wave 1 was significantly associated with living in economically-disadvantaged census tracts at wave 2; and violent crime at wave 2 was associated with illicit drug-using social network members at wave 7. Findings from this study support theories that describe social causation and neighborhood selection processes as explaining relationships of neighborhood characteristics with illicit drug use and illicit drug-using social networks. Policies that improve local economic and social conditions of neighborhoods may discourage substance use. Future studies should further identify the barriers that prevent substance users from obtaining housing in less disadvantaged neighborhoods.

Knowledge of sexual partners’ HIV infection can reduce risky sexual behaviors. Yet, there are no published studies to-date examining prevalence and characteristics associated with knowledge among African-American women living in high poverty communities disproportionately affected by HIV. Using the HIV Prevention Trial Network’s (HPTN) 064 Study data, multivariable logistic regression was used to examine individual, partner, and partnership-level determinants of women’s knowledge (n = 1,768 women). Results showed that women’s demographic characteristics alone did not account for the variation in serostatus awareness. Rather, lower knowledge of partner serostatus was associated with having two or more sex partners (OR = 0.49, 95 % CI 0.37–0.65), food insecurity (OR = 0.68, 95 % CI 0.49–0.94), partner age >35 years (OR = 0.68, 95 % CI 0.49–0.94), and partner concurrency (OR = 0.63, 95 % CI 0.49–0.83). Access to financial support (OR = 1.42, 95 % CI 1.05–1.92) and coresidence (OR = 1.43, 95 % CI 1.05–1.95) were associated with higher knowledge of partner serostatus. HIV prevention efforts addressing African-American women’s vulnerabilities should employ integrated behavioral, economic, and empowerment approaches.

Substance use is associated with HIV sexual risk behaviors, yet few studies have examined substance use patterns longitudinally. We evaluated the types and frequency of substances used over a six-month period among U.S. women at risk for HIV acquisition.Women reporting unprotected sex with a man in the previous six months and at least one other personal or partner HIV risk characteristic enrolled in a multisite cohort study and completed interviews about substance use at study visits. Prevalence and frequency of substance use at the baseline and six-month visits were compared and correlates of decreased substance use at the six-month visit were assessed.Of 2099 women enrolled, 1882 had substance use data at baseline and six-months. Of these, 76.1% reported using at least one drug or binge drinking in the previous six months; 37.5% were frequent and 38.6% non-frequent substance users. Binge drinking was most frequently reported (63.3%), followed by cocaine (25.0%) and opioids (16.5%). Fifty-five percent of opiate users and 30% of cocaine users reported daily/almost daily use. At the six-month visit, 40.5% reported a decrease in frequency of use. Adjusting for income and type of drug used, poly-substance users were less likely to decrease frequency of use compared to those who only used one substance.A substantial decrease in frequency of substance use over time was observed in this cohort. Poly-substance users were less likely to reduce frequency of use over time, suggesting that specific substance use interventions targeting these users are warranted.

USA is experiencing a paradigm shift in public housing policy: while policies used to place people who qualified for housing assistance into spatially concentrated housing complexes, they now seek to geographically disperse them, often to voucher-subsidized rental units in the private market. Programs that relocate residents from public housing complexes tend to move them to neighborhoods that are less impoverished and less violent. To date, studies have reached conflicting findings about the relationship between public housing relocations and depression among adult relocaters. The present longitudinal multilevel analysis tests the hypothesis that pre-/postrelocation improvements in local economic conditions, social disorder, and perceived community violence are associated with declines in depressive symptoms in a cohort of African-American adults; active substance misusers were oversampled. We tested this hypothesis in a cohort of 172 adults who were living in one of seven public housing complexes scheduled for relocation and demolition in Atlanta, GA; by design, 20 % were dependent on substances and 50 % misused substances but were not dependent. Baseline data captured prerelocation characteristics of participants; of the seven census tracts where they lived, three waves of postrelocation data were gathered approximately every 9 months thereafter. Surveys were administered at each wave to assess depressive symptoms measured using the Center for Epidemiologic Studies Depression Scale (CES-D), perceived community violence, and other individual-level covariates. Participants' home addresses were geocoded to census tracts at each wave, and administrative data sources were used to characterize tract-level economic disadvantage and social disorder. Hypotheses were tested using multilevel models. Between waves 1 and 2, participants experienced significant improvements in reported depressive symptoms and perceived community violence and in tract-level economic disadvantage and social disorder; these reductions were sustained across waves 2–4. A 1 standard deviation improvement in economic conditions was associated with a 1-unit reduction in CES-D scores; the magnitude of this relationship did not vary by baseline substance misuse or gender. Reduced perceived community violence also predicted lower CES-D scores. Our objective measure of social disorder was unrelated to depressive symptoms. We found that relocaters who experienced greater pre-/postrelocation improvements in economic conditions or in perceived community violence experienced fewer depressive symptoms. Combined with past research, these findings suggest that relocation initiatives should focus on the quality of the places to which relocaters move; future research should also identify pathways linking pre-/postrelocation changes in place characteristics to changes in mental health.

This chapter describes the study from which these data were taken. The study was designed to estimate HIV incidence among women living in neighborhoods characterized by high levels of poverty and high prevalence of HIV infection. Anticipating that the incidence might be high, we wished to contextualize our findings by describing the lives of these women living in poverty. The chapter gives some background information on poverty and HIV in women, and then describes the study design, eligibility criteria, procedures, and results.

We sought to understand the multilevel syndemic factors that are concurrently contributing to the HIV epidemic among women living in the USA. We specifically examined community, network, dyadic, and individual factors to explain HIV vulnerability within a socioecological framework. We analyzed data from four diverse locations: Atlanta, New York City (the Bronx), Raleigh/Durham, and Washington, D.C. The following themes were identified at four levels including (1) exosystem (community): poverty prevalence, discrimination, gender imbalances, community violence, and housing challenges; (2) mesosystem (network): organizational social support and sexual concurrency; (3) microsystem (dyadic): sex exchange, interpersonal social support, and intimate partner violence; and (4) individual: HIV/STI awareness, risk taking, and substance use. A strong theme emerged with over 80 % of responses linked to the fundamental role of financial insecurity underlying risk-taking behavioral pathways. Multilevel syndemic factors contribute to women’s vulnerability to HIV in the USA. Financial insecurity is a predominant theme, suggesting the need for tailored programming for women to reduce HIV risk.

Residents of disadvantaged neighborhoods, or communities that are burdened by the lack of financial resources and economic stability, are exposed to higher levels of crime and violence. These residents also lack the economic mobility needed to increase earning potential as a way of climbing up the proverbial socioeconomic ladder. Since disadvantaged neighborhoods tend to be racially homogenous, historical and systematic discrimination has led to a creation of poverty that negatively impacts minorities, especially African Americans who reside in these areas. Social disorder and diminishing resources to deter crime serve as two primary characteristics seen in disadvantaged neighborhoods. Over time, the intersection of poverty, race, and economic disadvantage has led to a decrease in the quality of life and higher rates of health disparities among residents of impoverished communities, especially among African-American women. This chapter discusses how historical aspects of racism and the creation of power systematically led to the racial divide that plagues most disadvantaged neighborhoods. We use results from the HPTN 064 study to illustrate how social disorder and lack of economic mobility lead to negative health outcomes for women of color.

This chapter discusses the methods used to collect and analyze data for the HIV Prevention Trials Network (HPTN) 064 Study. Four study sites (the Bronx, NY; Washington, D.C.; Raleigh/Durham, NC; and Atlanta/Decatur, GA) conducted semi-structured interviews (SSIs) and focus groups (FGs) between June 2009 and August 2010 designed to explore social, structural, and contextual factors related to HIV risk among participants. We conducted 120 SSIs (30 per site) and 32 FGs (6–12 per site). SSI participants were selected using sequential sampling and quota sampling was used to identify FG participants. All transcripts were structurally coded, a method that identified text associated with each question in the SSI/FG guide. A random sample of transcripts (36 [30 %] of SSIs, 16 [51 %] of FGs) was selected for advanced systematic coding and analysis. Saturation (i.e., no new codes emerged) was achieved once 90 % of the sample was coded. Twenty percent of the transcripts were double-coded and intercoder reliability (ICR) was assessed throughout coding. The final ICR was a combined average Kappa score of 0.92. Data were analyzed using NVivo (QSR International Zty Ltd. Version 9.0).

Location, quality, and reliability of housing are associated with physical and mental health. Financial resources (or lack thereof) and availability of affordable housing may restrict housing choice and mobility. Women, and unmarried women with children in particular, experience greater poverty rates than other groups, and, as a result, are particularly vulnerable to the ill effects of precarious housing conditions. This chapter explores interview and focus group themes as they relate to women’s experiences of their housing environment. The aims of this chapter are to (1) describe the physical attributes of housing where women reside, and the social and built characteristics of the neighborhoods where this housing is situated, and (2) explore how poverty affects housing choice and mobility. Participants felt trapped by marginal living situations resulting from limited housing choice, financial constraints, and transportation needs. Participants believed that their environments affected their physical and emotional well-being and described trade-offs that had immediate and long-term health implications (e.g., exchanging sex for housing, staying in dilapidated housing to keep benefits), and perceived low control over these situations. Women living in poverty require assistance identifying and relocating to safe, affordable housing with adequate transportation access. Programming should be coupled with interventions to increase women’s financial assets and mental health and with reevaluations of policies contributing to poverty and unstable housing.

Objectives Neighbourhood characteristics (eg, high poverty rates) are associated with STIs among HIV-uninfected women in the USA. However, no multilevel analyses investigating the associations between neighbourhood exposures and STIs have explored these relationships among women living with HIV infection. The objectives of this study were to: (1) examine relationships between neighbourhood characteristics and current STI status and (2) investigate whether the magnitudes and directions of these relationships varied by HIV status in a predominantly HIV-infected cohort of women living in the Southern USA. Methods This cross-sectional multilevel analysis tests relationships between census tract characteristics and current STI status using data from 737 women enrolled at the Women's Interagency HIV Study's southern sites (530 HIV-infected and 207 HIV-uninfected women). Administrative data (eg, US Census) described the census tract-level social disorder (eg, violent crime rate) and social disadvantage (eg, alcohol outlet density) where women lived. Participant-level data were gathered via survey. Testing positive for a current STI was defined as a laboratory-confirmed diagnosis of chlamydia, gonorrhoea, trichomoniasis or syphilis. Hierarchical generalised linear models were used to determine relationships between tract-level characteristics and current STI status, and to test whether these relationships varied by HIV status. Results Eleven per cent of participants tested positive for at least one current STI. Greater tract-level social disorder (OR=1.34, 95% CI 0.99 to 1.87) and social disadvantage (OR=1.34, 95% CI 0.96 to 1.86) were associated with having a current STI. There was no evidence of additive or multiplicative interaction between tract-level characteristics and HIV status. Conclusions Findings suggest that neighbourhood characteristics may be associated with current STIs among women living in the South, and that relationships do not vary by HIV status. Future research should establish the temporality of these relationships and explore pathways through which neighbourhoods create vulnerability to STIs. Trial registration number NCT00000797; results.

We investigated the implications of one structural intervention--public housing relocations--for partnership dynamics among individuals living areas with high sexually transmitted infection (STI) prevalence. High-prevalence areas fuel STI endemicity and are perpetuated by spatially assortative partnerships.We analyzed 7 waves of data from a cohort of black adults (n = 172) relocating from 7 public housing complexes in Atlanta, Georgia. At each wave, data on whether participants' sexual partners lived in the neighborhood were gathered via survey. Participant addresses were geocoded to census tracts, and measures of tract-level STI prevalence, socioeconomic conditions, and other attributes were created for each wave. "High-prevalence tracts" were tracts in the highest quartile of STI prevalence in Georgia. Descriptive statistics and hierarchical generalized linear models examined trajectories of spatially assortative partnerships and identified predictors of assortativity among participants in high-prevalence tracts.All 7 tracts containing public housing complexes at baseline were high-prevalence tracts; most participants relocated to high-prevalence tracts. Spatially assortative partnerships had a U-shaped distribution: the mean percent of partners living in participants' neighborhoods at baseline was 54%; this mean declined to 28% at wave 2 and was 45% at wave 7. Participants who experienced greater postrelocation improvements in tract-level socioeconomic conditions had a lower odds of having spatially assortative partnerships (adjusted odds ratio, 1.55; 95% confidence interval [95% CI], 1.06-2.26).Public housing relocation initiatives may disrupt high-prevalence areas if residents experience significant postrelocation gains in tract-level socioeconomic conditions.

Purpose Voting may play a critical role in the allocation of social and structural resources to communities, which in turn shapes neighborhood environments, and ultimately, an individual's sexually transmitted infection (STI) risk. We assessed relationships among county-level voter turnout and felony voter disenfranchisement, and STIs. Methods This cross-sectional multilevel analysis included 666 women in Alabama, Florida, Georgia, Mississippi, and North Carolina enrolled in the Women's Interagency HIV Study between 2013 and 2015. Having a baseline bacterial STI (chlamydia, gonorrhea, trichomoniasis, or early syphilis) was determined by laboratory testing. We used generalized estimating equations to test relationships between county-level voter turnout in the 2012 general election, county-level percentage of felony disenfranchised voters, and STI prevalence. Results Eleven percent of participants had an STI. Higher voter turnout corresponded to lower STI prevalence (prevalence ratio = 0.84, 95% confidence interval = 0.73–0.96 per 4 percentage point higher turnout). Greater felony voter disenfranchisement corresponded to higher STI prevalence (prevalence ratio = 1.89, 95% confidence interval = 1.10–3.24 per 4 percentage point higher disenfranchisement). Conclusions STI prevalence was inversely associated with voter turnout and positively associated with felony voter disenfranchisement. Research should assess causality and mechanisms through which civic engagement shapes sexual health. Expanding political participation, including eliminating discriminatory voting laws, could influence sexual health.

HIV/AIDS trends in the United States depict a concentrated epidemic with hot spots that vary by location, poverty, race/ethnicity, and transmission mode. HIV/AIDS is a leading cause of death among US women of color; two thirds of new infections among women occur in black women, despite the fact that black women account for just 14% of the US female population. The gravity of the HIV epidemic among US women is often not appreciated by those at risk as well as by the broader scientific community. We summarize the current epidemiology of HIV/AIDS among US women and discuss clinical, research, and public health intervention components that must be brought together in a cohesive plan to reduce new HIV infections in US women. Only by accelerating research and programmatic efforts will the hidden epidemic of HIV among US women emerge into the light and come under control.

Understanding whether and how the places where people live, work, and play are associated with health behaviors and health is essential to understanding the social determinants of health. However, social-spatial data which link a person and their attributes to a geographic location (e.g., home address) create potential confidentiality risks. Despite the growing body of literature describing approaches to protect individual confidentiality when utilizing social-spatial data, peer-reviewed manuscripts displaying identifiable individual point data or quasi-identifiers (attributes associated with the individual or disease that narrow identification) in maps persist, suggesting that knowledge has not been effectively translated into public health research practices. Using sexual and reproductive health as a case study, we explore the extent to which maps appearing in recent peer-reviewed publications risk participant confidentiality. Our scoping review of sexual and reproductive health literature published and indexed in PubMed between January 1, 2013 and September 1, 2015 identified 45 manuscripts displaying participant data in maps as points or small-population geographic units, spanning 26 journals and representing studies conducted in 20 countries. Notably, 56% (13/23) of publications presenting point data on maps either did not describe approaches used to mask data or masked data inadequately. Furthermore, 18% (4/22) of publications displaying data using small-population geographic units included at least two quasi-identifiers. These findings highlight the need for heightened education for researchers, reviewers, and editorial teams. We aim to provide readers with a primer on key confidentiality considerations when utilizing linked social-spatial data for visualizing results. Given the widespread availability of place-based data and the ease of creating maps, it is critically important to raise awareness on when social-spatial data constitute protected health information, best practices for masking geographic identifiers, and methods of balancing disclosure risk and scientific utility. We conclude with recommendations to support the preservation of confidentiality when disseminating results.

Background Few studies assess whether place characteristics are associated with social network characteristics that create vulnerability to substance use. Methods This longitudinal study analyzed 7 waves of data (2009–2014) from a predominantly substance-using cohort of 172 African American adults relocated from public housing complexes in Atlanta, GA, to determine whether post-relocation changes in exposure to neighborhood conditions were associated with four network characteristics related to substance use: number of social network members who used illicit drugs or alcohol in excess in the past six months (“drug/alcohol network”), drug/alcohol network stability, and turnover into and out of drug/alcohol networks. Individual- and network-level characteristics were captured via survey and administrative data were used to describe census tracts where participants lived. Multilevel models were used to assess relationships of census tract-level characteristics to network outcomes over time. Results On average, participants relocated to census tracts that had less economic disadvantage, social disorder, and renter-occupied housing. Post-relocation reductions in exposure to economic disadvantage were associated with fewer drug/alcohol network members and less turnover into drug/alcohol networks. Post-relocation improvements in exposure to multiple census tract-level social conditions and reductions in perceived community violence were associated with fewer drug/alcohol network members, less turnover into drug/alcohol networks, less drug/alcohol network stability, and more turnover out of drug/alcohol networks. Conclusion Relocating to neighborhoods with less economic disadvantage and better social conditions may weaken relationships with substance-using individuals.

Neighborhood conditions and sexual network turnover have been associated with the acquisition of HIV and other sexually transmitted infections (STIs). However, few studies investigate the influence of neighborhood conditions on sexual network turnover. This longitudinal study used data collected across 7 visits from a predominantly substance-misusing cohort of 172 African American adults relocated from public housing in Atlanta, Georgia, to determine whether post-relocation changes in exposure to neighborhood conditions influence sexual network stability, the number of new partners joining sexual networks, and the number of partners leaving sexual networks over time. At each visit, participant and sexual network characteristics were captured via survey, and administrative data were analyzed to describe the census tracts where participants lived. Multilevel models were used to longitudinally assess the relationships of tract-level characteristics to sexual network dynamics over time. On average, participants relocated to neighborhoods that were less economically deprived and violent, and had lower alcohol outlet densities. Post-relocation reductions in exposure to alcohol outlet density were associated with fewer new partners joining sexual networks. Reduced perceived community violence was associated with more sexual partners leaving sexual networks. These associations were marginally significant. No post-relocation changes in place characteristics were significantly associated with overall sexual network stability. Neighborhood social context may influence sexual network turnover. To increase understanding of the social-ecological determinants of HIV/STIs, a new line of research should investigate the combined influence of neighborhood conditions and sexual network dynamics on HIV/STI transmission over time.

Despite the significant advances in the prevention and treatment of human immunodeficiency virus (HIV) in the United States, the story of the HIV epidemic among women has remained the same for the past 20 years. Women account for 23% of new AIDS (acquired immunodeficiency syndrome) diagnoses,1 a proportion that has hovered around the same mark since 1999.2 Heterosexual sex continues to be the predominant mode of HIV transmission, and significant racial disparities remain,1 with the heaviest HIV burden on black women, as first noted in 1983.3 This lack of progress calls for new ways to study the HIV epidemic among women in the United States. Specific behaviors, such as substance use and multiple sexual partners, are associated with sexually transmitted infections, including HIV.4 As a result, research and surveillance initially focused on women with risky behavioral characteristics in order to identify women at greatest risk of HIV acquisition.5 These approaches, however, did not always succeed,6–8 leading to a greater appreciation of the complexity of HIV risk among women in the U.S. Disparities in HIV infection are no longer viewed as driven by individual behaviors alone.9 Instead, place characteristics, such as poverty, violent crime, social disorder, incarceration rates, and male-to-female sex ratios are thought to be powerful drivers of HIV among U.S. black adults.10–13 This appreciation has led to newer recruitment approaches that reflect the relationship between HIV risk and environmental and network characteristics. HIV surveillance evaluations, such as the Center for Disease Control and Prevention (CDC)'s National HIV Behavioral Surveillance among heterosexuals (NHBS), as well as HIV clinical research such as the HIV Prevention Trials Network (HPTN) 064 and the HIV Vaccine Trials Network (HVTN) 903 studies, recruited individuals from “hot spots” (i.e., geographic areas with higher HIV prevalence), using sampling methods designed to recruit individuals at higher risk of HIV acquisition.14,15 HPTN 064 used venue-based sampling (VBS),14 and HVTN 903 used a combination of VBS and network recruitment methods15 to recruit women into longitudinal cohorts to estimate HIV incidence. NHBS 2010 used respondent-driven sampling (RDS) to survey men and women living in metropolitan areas with high HIV prevalence and poverty who reported having heterosexual sex in the past 12 months.16 These approaches to recruitment have succeeded in identifying women in the U.S. at high risk of HIV acquisition, as evidenced by the HIV incidence findings of HPTN 064 and HVTN 903 of 0.32%14 and 0.31%15 respectively, nearly five times the estimate of HIV incidence in the general U.S. population of similarly aged black women.17 These approaches have also uncovered the unexpectedly high prevalence of newly diagnosed HIV among black women in New York City, as reported by Reilly et al. in this issue of the Journal of Women's Health.18 NHBS researchers used RDS to recruit a cross-sectional cohort of 523 men and women who were 18–60 years old, resided in New York City, and who reported opposite-sex vaginal or anal sex in the prior 12 months. In this substudy of 153 black women from New York City who did not self-report a history of HIV infection, 10% of these women were newly diagnosed with HIV. Access to health care and HIV testing was good, with over 80% of participants reporting health insurance, a recent healthcare visit and prior HIV testing. Half of those newly diagnosed, however, had never had an HIV test before. Prior injection drug use (IDU) was identified as the only significant factor associated with HIV infection in multivariate analyses.18 The prevalence rate for newly diagnosed HIV of 10% is remarkably high and contrasts sharply with both HPTN 064, which found a 1.5% prevalence14 using similar criteria, and the 2010 NHBS, which found an overall HIV prevalence of 1.1 % among women from 21 metropolitan areas in the U.S.16 Why do these prevalence rates have such striking differences? Differences in study design and in recruitment methods may explain some of the observed differences. Cross-sectional and longitudinal designs are subject to different types of participant selection bias; highest-risk individuals may be willing to participant in a one-time interview but may be difficult to enroll and follow over time. Recruitment approaches, by necessity, depend on the desired target population and study objectives. VBS may be a particularly relevant method for reaching populations associated with a specific geographic place, such as a zip code.19 RDS is gaining popularity as a surveillance tool for “hard-to-reach” populations20; however, the generalizability of RDS and its suitability for surveillance estimates are under debate.21–23 The feasibility and generalizability of RDS may depend on the density of social and sexual networks, how seeds are selected and identified, and sample variability.21–25 Older age and former IDU also explain the difference in the prevalence of newly diagnosed HIV among the studies. Just over half (54%) of the participants in the Reilly study were over 40 years old, versus 20% in HPTN 064; of note, older age was associated with newly diagnosed prevalent HIV in HPTN 064.14 In the Reilly study, 18% had ever injected drugs, versus 3.9% in HPTN 064.18 Unlike the overall NHBS study, the Reilly substudy did not exclude individuals reporting prior IDU and therefore may have mixed IDU and heterosexual risk.16 HPTN 064 and HVTN 903 both included male sexual partner risks as possible eligibility criteria, which may have enriched the “heterosexual” nature of the sample.14,15 As the authors note, the selected seeds may have led to an oversampling of networks with current or former IDU members. It is also possible that former IDU is an underrecognized or emerging risk factor among U.S. women. Former IDU may connect women to higher risk sexual networks or be associated with different levels of behavioral risk, adding to the questions about how best to identify women in the U.S. who are at highest risk of HIV acquisition. Regardless of differences in study populations and design, the results of HPTN, HVTN, and NHBS all underscore the extent of ongoing and undiagnosed HIV infections among U.S. women and highlight the need for continued HIV prevention and testing in this population. In the Reilly et al. study, black women in New York City with new HIV diagnoses reported low HIV testing rates, despite good access to health care. Even with the rollout of universal health care, significant barriers to HIV testing still exist, such as distrust of the medical system, perceived lack of risk, and stigma associated with HIV testing and diagnosis. These barriers may be even steeper for women of color and for women with former or current stigmatized behaviors, such as substance use. Moreover, older women may not be seen as a high-risk group by providers and as a result may not be approached for testing. There are many pieces to the puzzle of the HIV epidemic in U.S. women. The results of these studies collectively suggest that HIV risk among U.S. women is not only complex, but also dynamic. Moving forward, a combination of strategies integrating individual, network, and environmental factors will be required not only to monitor the HIV epidemic among women, but also to ensure that prevention technologies reach those at greatest risk.

Objectives. We determined the prevalence of recent emotional, physical, and sexual violence against women and their associations with HIV-related risk factors in women living in the United States. Methods. We performed an assessment of women ages 18 to 44 years with a history of unprotected sex and 1 or more personal or partner HIV risk factors in the past 6 months from 2009 to 2010. We used multivariable logistic regression to examine the association of experiencing violence. Results. Among 2099 women, the prevalence of emotional abuse, physical violence, and sexual violence in the previous 6 months was 31%, 19%, and 7%, respectively. Nonmarried status, food insecurity, childhood abuse, depression symptomology, and posttraumatic stress disorder were significantly associated with multiple types of violence. All types of violence were associated with at least 3 different partner or personal HIV risk behaviors, including unprotected anal sex, previous sexually transmitted infection diagnosis, sex work, or partner substance abuse. Conclusions. Our data suggested that personal and partner HIV risk behaviors, mental illness, and specific forms of violence frequently co-occurred in the lives of impoverished women. We shed light on factors purported to contribute to a syndemic in this population. HIV prevention programs in similar populations should address these co-occurring issues in a comprehensive manner.

Ecologic and cross-sectional multilevel analyses suggest that characteristics of the places where people live influence their vulnerability to HIV and other sexually-transmitted infections (STIs). Using data from a predominately substance-misusing cohort of African-American adults relocating from US public housing complexes, this multilevel longitudinal study tested the hypothesis that participants who experienced greater post-relocation improvements in economic disadvantage, violent crime, and male:female sex ratios would experience greater reductions in perceived partner risk and in the odds of having a partner who had another partner (i.e., indirect concurrency). Baseline data were collected from 172 public housing residents before relocations occurred; three waves of post-relocation data were collected every nine months. Participants who experienced greater improvements in community violence and in economic conditions experienced greater reductions in partner risk. Reduced community violence was associated with reduced indirect concurrency. Structural interventions that decrease exposure to violence and economic disadvantage may reduce vulnerability to HIV/STIs.

Although studies have consistently demonstrated that women at high risk for HIV and non-HIV sexually transmitted infections (STIs) tend to underestimate their individual risk, little is known about how women at risk perceive their community’s HIV/STI risk. We explored perceptions of community HIV/ STI risk among U.S. women living in areas with high poverty and HIV prevalence rates as part of a qualitative substudy of the Women’s HIV SeroIncidence Study. Semi-structured focus groups were conducted. Data were coded and analyzed using the constant comparative method. Participants expressed the perception that their communities were at elevated HIV/STI risk, mostly due to contextual and structural factors such as lack of access to health care and education. Findings suggest that HIV prevention messages that target U.S. women at high risk for HIV may be strengthened by addressing the high perceived community HIV/ STI risk driven by structural factors.

Purpose Neighborhood characteristics shape sexual risk in HIV-uninfected adults in the United States (US). We assess relationships between census tract characteristics and sexual risk behaviors in a predominantly HIV-infected cohort of women living in the Southern US. Methods This cross-sectional multilevel analysis included data from 737 HIV-infected and HIV-uninfected women enrolled in the Women's Interagency HIV Study. Administrative data captured characteristics of census tracts where women lived; participant-level data were gathered via survey. We used principal components analysis to condense tract-level variables into components: social disorder (e.g., violent crime rate), and social disadvantage (e.g., alcohol outlet density). We used hierarchical generalized linear models to assess relationships between tract-level characteristics and condomless vaginal intercourse, anal intercourse, and condomless anal intercourse. Results Greater social disorder was associated with less anal intercourse (OR = 0.63, 95% CI = 0.43–0.94) and condomless anal intercourse (OR = 0.49, 95% CI = 0.30–0.80), regardless of HIV status. There were no statistically significant additive or multiplicative interactions between tract characteristics and HIV status. Conclusions Neighborhood characteristics are associated with sexual risk behaviors among women living in the Southern US, these relationships do not vary by HIV status. Future studies should establish temporality and explore the causal pathways through which neighborhoods influence sexual risk.

Background Although prison provides the opportunity for HIV diagnosis and access to in-prison care, following release, many HIV-infected inmates experience clinical setbacks, including nonadherence to antiretrovirals, elevations in viral load, and HIV disease progression. HIV-infected former inmates face numerous barriers to successful community reentry and to accessing healthcare. However, little is known about the outcome expectations of HIV-infected inmates for release, how their post-release lives align with pre-release expectations, and how these processes influence engagement in HIV care following release from prison. Methods We conducted semi-structured interviews (24 pre- and 13 post-release) with HIV-infected inmates enrolled in a randomized controlled trial of a case management intervention to enhance post-release linkage to care. Two researchers independently coded data using a common codebook. Intercoder reliability was strong (kappa = 0.86). We analyzed data using Grounded Theory methodology and Applied Thematic Analysis. We collected and compared baseline sociodemographic and behavioral characteristics of all cohort participants who did and did not participate in the qualitative interviews using Fisher’s Exact Tests for categorical measures and Wilcoxon rank-sum tests for continuous measures. Results Most participants were heterosexual, middle-aged, single, African American men and women with histories of substance use. Substudy participants were more likely to anticipate living with family/friends and needing income assistance post-release. Most were taking antiretrovirals prior to release and anticipated needing help securing health benefits and medications post-release. Before release, most participants felt confident they would be able to manage their HIV. However, upon release, many experienced intermittent or prolonged periods of antiretroviral nonadherence, largely due to substance use relapse or delays in care initiation. Substance use was precipitated by stressful life experiences, including stigma, and contact with drug-using social networks. As informed by the Social Cognitive Theory and HIV Stigma Framework, findings illustrate the reciprocal relationships among substance use, experiences of stigma, pre- and post-release environments, and skills needed to engage in HIV care. Conclusion These findings underscore the need for comprehensive evidence-based interventions to prepare inmates to transition from incarceration to freedom, particularly those that strengthen linkage to HIV care and focus on realities of reentry, including stigma, meeting basic needs, preventing substance abuse, and identifying community resources.

Women at high-risk for HIV acquisition often face challenges that hinder their retention in HIV prevention trials. These same challenges may contribute to missed clinical care visits among HIV-infected women. This article, informed by the Gelberg-Andersen Behavioral Model for Vulnerable Populations, identifies factors associated with missed study visits and describes the multifaceted retention strategies used by study sites. HPTN 064 was a multisite, longitudinal HIV seroincidence study in 10 US communities. Eligible women were aged 18-44 years, resided in a census tract/zipcode with high poverty and HIV prevalence, and self-reported ≥1 personal or sex partner behavior related to HIV acquisition. Multivariate analyses of predisposing (e.g., substance use) and enabling (e.g., unmet health care needs) characteristics, and study attributes (i.e., recruitment venue, time of enrollment) identified factors associated with missed study visits. Retention strategies included: community engagement; interpersonal relationship building; reduction of external barriers; staff capacity building; and external tracing. Visit completion was 93% and 94% at 6 and 12 months. Unstable housing and later date of enrollment were associated with increased likelihood of missed study visits. Black race, recruitment from an outdoor venue, and financial responsibility for children were associated with greater likelihood of attendance. Multifaceted retention strategies may reduce missed study visits. Knowledge of factors associated with missed visits may help to focus efforts.

We examined parameters of sexual partnerships, including respondents' participation in concurrency, belief that their partner had concurrent partnerships (partners' concurrency), and partnership intervals, among the 2099 women in HIV Prevention Trials Network 064, a study of women at high risk for HIV infection, in 10 U.S. communities.We analyzed baseline survey responses about partnership dates to determine prevalence of participants' and partners' concurrency, intervals between partnerships, knowledge of whether recent partners had undergone HIV testing, and intercourse frequency during the preceding 6 months.Prevalence of participants' and partners' concurrency was 40% and 36%, respectively; 24% respondents had both concurrent partnerships and nonmonogamous partners. Among women with1 partner and no concurrent partnerships themselves, the median gap between partners was 1 month. Multiple episodes of unprotected vaginal intercourse with ≥2 of their most recent partners was reported by 60% of women who had both concurrent partnerships and nonmonogamous partners, 50% with only concurrent partners and no partners' concurrency, and 33% with only partners' concurrency versus 14% of women with neither type of concurrency (P0.0001). Women who had any involvement with concurrency were also more likely than women with no concurrency involvement to report lack of awareness of whether recent partners had undergone HIV testing (participants' concurrency 41%, partners' concurrency 40%, both participants' and partners' concurrency 48%, neither 17%; P0.0001).These network patterns and short gaps between partnerships may create substantial opportunities for HIV transmission in this sample of women at high risk for HIV infection.

Background: The challenge of identifying and recruiting U.S. women at elevated risk for HIV acquisition impedes prevention studies and services. HIV Prevention Trials Network (HPTN) 064 was a U.S. multisite, longitudinal cohort study designed to estimate HIV incidence among women living in communities with prevalent HIV and poverty. Venue-based sampling (VBS) methodologies and participant and venue characteristics are described. Methods: Eligible women were recruited from 10 U.S. communities with prevalent HIV and poverty using VBS. Participant eligibility criteria included age 18–44 years, residing in a designated census tract/zip code, and self-report of at least one high-risk personal and/or male sexual partner characteristic associated with HIV acquisition (e.g., incarceration history). Ethnography was conducted to finalize recruitment areas and venues. Results: Eight thousand twenty-nine women were screened and 2,099 women were enrolled (88% black, median age 29 years) over 14 months. The majority of participants were recruited from outdoor venues (58%), retail spaces (18%), and social service organizations (13%). The proportion of women recruited per venue category varied by site. Most participants (73%) had both individual and partner characteristics that qualified them for the study; 14% were eligible based on partner risk only. Conclusion: VBS is a feasible and effective approach to rapidly recruit a population of women at enhanced risk for HIV in the United States. Such a recruitment approach is needed in order to engage women most at risk and requires strong community engagement.

Cross-sectional and ecologic studies suggest that place characteristics influence sexual behaviors and sexually transmitted infections (STIs). Using data from a predominately substance-misusing cohort of African American adults relocating from US public housing complexes, this multilevel longitudinal study tested the hypothesis that participants who experienced greater postrelocation improvements in neighborhood conditions (i.e., socioeconomic disadvantage, social disorder, STI prevalence, and male/female sex ratios) would have reduced the odds of testing positive for an STI over time.Baseline data were collected in 2009 from 172 public housing residents before relocations occurred; 3 waves of postrelocation data were collected every 9 months thereafter. Polymerase chain reaction methods were used to test participants' urine for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. Individual-level characteristics were assessed via survey. Administrative data described the census tracts where participants lived at each wave (e.g., sex ratios, violent crime rates, and poverty rates). Hypotheses were tested using multilevel models.Participants experienced improvements in all tract-level conditions studied and reductions in STIs over time (baseline: 29% tested STI positive; wave 4: 16% tested positive). Analyses identified a borderline statistically significant relationship between moving to tracts with more equitable sex ratios and reduced odds of testing positive for an STI (odds ratio, 0.16; 95% confidence interval, 0.02-1.01). Changes in other neighborhood conditions were not associated with this outcome.Consonant with past research, our findings suggest that moving to areas with more equitable sex ratios reduces the risk of STI infection. Future research should study the extent to which this relationship is mediated by changes in sexual network dynamics.