Dissertation (Ph.D.).--University of Texas Graduate School of Biomedical Sciences at San Antonio, 2008. / Vita. Includes bibliographical references.

Despite increased involvement in the criminal justice system among populations of migrants, people who inject drugs, and drug-involved men in community corrections, few studies investigate associations between involvement in the criminal justice system and sexual and injection drug risks among these key-affected populations and their intimate partners. To address these gaps the following dissertation study investigated the association between exposures to the criminal justice system and sexual and injection drug risks among three key affected populations: 1) male labor migrants in Almaty, Kazakhstan, 2) people who inject drugs and their intimate partners in Almaty, Kazakhstan, and 3) drug-involved men in community corrections in New York City, NY in the United States. Using the three-paper model, the following dissertation sheds new insights into how exposures to the risk environment shape sexual and injection HIV risks to inform HIV prevention research and practice with populations disproportionately involved in criminal justice systems.

Background: Though there continues to be a significant amount of research aimed at understanding factors associated with participating in sexual risk behavior in populations of YBMSM, there has been far less research concerned with understanding how psychological distress may influence sexual risk behaviors and how emotional bond formation may affect the relationship between psychological distress and sexual risk behavior. This study aims to better understand the relationship between psychological distress and sexual risk behavior as well as the moderating effect of adult attachment insecurity on this relationship. Methods: Three data collection strategies were utilized to address the study aims: 1) cross-sectional (n = 228), 2) eight-week structured diary (n = 153), and 3) semi-structured interview (n = 30). The cross-sectional survey provided measurement information on adult attachment style using a modified version of the Experiences in Close Relationships Scale (ECR) that consists of the attachment avoidance and anxiety subscales, the Brief Symptoms Inventory (BSI) and the Kessler-10 (K10). Sexual risk was measured by assessing unprotected anal intercourse (UAI) and serodiscordant UAI in the last two months. The eight-week structured diary utilized weekly reports of UAI encounter vs. no UAI encounter, and serodiscordant UAI encounter vs. no serodiscordant UAI encounter. The K10 and the Profile of Moods (POMS) anxiety and depression subscales measured psychological distress. The semi-structured interview assessed childhood attachment. Regression analyses were used to analyze the cross-sectional data. Random effects and population average regression models were used to analyze the structured diary data. A thematic inductive analysis technique was utilized to analyze the qualitative data. Results: Overall, participants reported slightly elevated mean scores on the attachment anxiety subscale while scores on the attachment avoidance subscale remained low. Participants reported an average of two UAI partners in the last month and an average of 1.3 UAI encounters over the eight-week diary period. Psychological distress scores were slightly elevated in the cross-sectional survey and depression scores were elevated in the diary component. For Aim 1, men higher on attachment insecurity (anxiety and avoidance) had higher levels of general psychological distress, depression, and anxiety in comparison to men who were more secure. The qualitative data supported the quantitative findings and showed that subjective appraisal of traumatic events and sexual orientation disclosure may mediate the relationship between childhood attachment and adult mental health. For Aim 2, the quantitative findings suggested that attachment insecurity was not related to sexual risk behavior. However, the qualitative component suggested that participants who were anxious used sex as a means to try to create an emotional bond, while participants who were avoidant used sex as a means to feel good without wanting to create an emotional bond. Both anxious and avoidant men seemed to participate in more concurrent sexual relationships which could increase their likelihood of HIV/STI transmission. For Aim 3, men who were more depressed and had higher levels of general psychological distress were more likely to report a serodiscordant UAI encounter in a given week. The qualitative data supported the quantitative findings and suggested that men might use sex as a means of escape their negative mood. This model of "escapism" could have lead to participation in sexual practices that increased men's risk of HIV/STI transmission. For Aim 4, adult attachment insecurity did not moderate the relationship between psychological distress and sexual risk. The qualitative data suggested that secure attachment in childhood was important to adequately coping with stressful situations, which in turn promoted overall well-being. Conclusion: Study findings suggest that understanding adult attachment may lead to a better understanding of psychological distress and sexual risk behavior among YBMSM. The results highlight the importance of considering childhood and young adult emotional bond formation in the development of HIV/STI prevention intervention activities aimed at addressing the heightened rates of sexual risk behavior among YBMSM. This research could have valuable implications for the development of HIV/STI and mental health prevention interventions aimed at reducing sexual risk behaviors and promoting well-being in populations of YBMSM

There are important disparities between how HIV transmission, prevention, and mitigation are addressed within sub-Saharan Africa (SSA) and how they are understood by the international aid agencies that design and implement interventions to combat AIDS in this region. Contending that local responses to the AIDS epidemic hinge on a religious framework, this dissertation examines the relationship between religion and HIV risk at both the individual and collective levels in the setting of rural Malawi - a religiously diverse country with high levels of both religious participation and HIV prevalence. This dissertation advances the Durkheimian idea that participation in harmful behaviors is reduced in places where particular religions or religious rituals are widely practiced. Specifically, it addresses the associations between religion and (1) HIV prevention, (2) actual HIV status, and (3) perceived obligations to support families affected by AIDS. The relationships are assessed by employing multiple methodologies and data sources including participant observation data from religious services, in-depth interviews with religious leaders and lay people, and large-scale survey data. This dissertation provides the first empirical assessment of what religious leaders in SSA say and do about HIV in their communities and shows that many have assumed an activist role in combating the epidemic. The relevant practices religious leaders engage in include: preaching explicitly about AIDS on a regular basis, privately advising members to use condoms, actively policing the sexual behavior of their members -- visiting those suspected to be at risk of contracting the disease and to confront them about their sexual behavior, and advising divorce as a strategy for HIV prevention in cases where a member is likely to be infected by an unfaithful spouse. By synthesizing insights from demographic studies of contextual effects on sexual behavior with the notion of "moral communities" from the sociology of religion, this dissertation emphasizes the importance of conceptualizing religion as a supra-individual phenomenon with important implications for the health of populations.

Background: HIV transmission is greatly reduced when antiretroviral treatment (ART) suppresses an infected person’s HIV viral load. It is unclear, however, whether the contextual risk of incident HIV is optimally reduced by widespread individual-level suppression of HIV viral load alone or in combination with other HIV prevention services. HIV service coverage and community norms can influence risk in small area geographies; and contextual factors, like gender inequality and stigma, may foster environments conducive to HIV transmission. Yet, the relationship between places with high HIV levels and the clustering of area risk factors is unknown. The goal of this dissertation is to learn if and how a geographically focused combination implementation strategy could reduce population-level HIV risk. Analyses explored whether small area risk profiles explain area differences in HIV. The guiding hypothesis is that in high HIV prevalence settings, low HIV service uptake in a geographically defined area increases the prevalence of high HIV viremia, leading to greater HIV transmission and incident HIV. Methods: A systematic review was conducted to examine the association between population-level measures of HIV viral load and incident HIV infection in generalized and concentrated epidemics. Publications were English, peer-reviewed articles published from January 1, 1995 through February 15, 2019 that explicitly defined HIV viral load and assessed outcomes of HIV recency, incidence, seroconversion, or new diagnosis. Studies sampled general or key populations through population-based surveillance registries, household-based enumeration, cluster sampling, or respondent driven sampling. Descriptive statistics summarized review findings. The Swaziland HIV Incidence Measurement Survey (SHIMS) data were used for the remaining analyses. Using a two-stage cluster-based design, a nationally representative, household-based sample of adults, ages 18-49 years was enrolled from December 2010 to June 2011 in Eswatini. Consenting adults completed an interview and received home-based rapid HIV testing and counseling. All seropositive samples were tested for HIV viral load using the COBAS AmpliPrep/Taqman HIV-1 Test, v 2.0. Adults testing HIV-seronegative were enrolled in a prospective cohort for the direct observation of HIV seroconversion, completing an interview and home-based rapid HIV testing six months later. Multi-level latent class modeling was performed to identify statistically significant combinations of HIV risk factors and to classify the combinations into small area risk profiles. In the cross-sectional sample, linear regression with robust standard errors assessed the correlation between area profiles and places with high levels of uncontrolled HIV infection, or HIV core areas, measured by the area prevalence of detectable virus (≥20 copies/milliliter) among HIV-positive adults and among all adults, regardless of HIV status. In the prospective cohort, generalized linear regression of longitudinal data assessed the association between area profiles and places prone to new HIV infections (i.e., HIV susceptible areas), measured by area-level HIV seroconversions. Results: The systematic review found an evidence base primarily of lower quality studies and inconsistent HIV viral exposure measurement. Overall findings supported a relationship between increasing levels of suppressed HIV in HIV-infected populations and fewer new infections over time. Better quality studies consistently showed higher population viremia (i.e. HIV viral quantity among all persons, regardless of HIV status) associated with HIV incidence in high prevalence populations; population viral load (i.e., HIV viral quantity among only HIV-positive persons) did not show an association with incident HIV in high prevalence, general populations and was inconsistent in key populations. To determine whether area risk profiles can pinpoint HIV core areas, latent class modeling was used to categorize 18,172 adults into one of six HIV risk types. The risk typology, classified through unique combinations of HIV service uptake and sexual risk behaviors, conveyed an adult’s propensity for HIV transmission and/or acquisition risk. The model next identified the area-level composite prevalences of HIV risk types; estimated the three most frequent, unique composite combinations; and categorized them into area risk profiles characterizing HIV risk: low-moderate acquisition risk, moderate acquisition/transmission risk, and high acquisition/transmission risk. The high acquisition/transmission areas comprised the largest proportions of highest risk transmission and acquisition types. The prevalence of detectable viremia progressively increased from low-moderate acquisition, moderate acquisition/transmission, and high acquisition/transmission profiles [17.7%, 25.4%, and 35.1%, respectively]. When compared with low-moderate acquisition areas, the prevalence of detectable viremia was 7.4% [p<.001] higher in moderate acquisition/transmission areas and 17.1% [p<.001] higher in high acquisition/transmission areas. The prevalence of detectable viral load significantly decreased from low-moderate acquisition to moderate acquisition/transmission areas [76.6% versus 68.7%, p<.001], and was significantly higher in high acquisition/transmission areas by 7.3% [p<.001], when compared with low-moderate acquisition areas. To determine whether area risk profiles can predict HIV susceptible areas, a total of 18,172 adults were surveyed of which 4396 [24%] had detectable viremia. 11,880 [96%; n=12,357] HIV-seronegative adults enrolled in the prospective cohort and 11,155 [94%] of them completed an endline visit. Four area profiles were identified, defined by unique patterns in prevalence of HIV viremia and of sexual risk behaviors. The proportion of HIV susceptible areas progressively increased from Profiles A, B, C, and D [14.3%, 21.8%, 24.6%, and 30.8%, respectively]. HIV susceptible areas were more than twice as likely to occur in Profile D than Profile A environments [RR 2.13, 95% confidence interval (CI) (1.13, 4.00); p=0.02]. Profile D areas had prevalences of unknown partner HIV status and detectable viremia at 28% and 24%, respectively. In contrast, Profile A areas had prevalences of only 8% with unknown HIV status and 31% with detectable viremia. Conclusion: This dissertation shows that geographic risk profiles can explain differences in population-level HIV outcomes. Risk factors spatially cluster in predictable, meaningful combinations that can inform an area typology of HIV risk. The co-location of adults predisposed to greater HIV risk may heighten levels of uncontrolled HIV infection, thereby creating potential area sources of ongoing transmission; however, the concurrent levels of other risk factors may have more influence in reducing population-level incidence than previously considered. A composite indicator of contextual HIV risk may reveal places core to HIV transmission and susceptible to HIV acquisition. Such area profiles may help identify the combination of locally specific risk factors that readily promulgate HIV and better inform the design of place-based HIV intervention packages to enhance current strategies towards global HIV control.

Refugees are not a new phenomenon and their plight has been felt the world over. Africa continues to see large numbers of people displaced through armed conflict, producing more refugees on the worlds&rsquo / most poverty stricken continent than any other.<br /> The implications of these displacements of people dislocated from their places of habitual residence create much concern, particularly in the wake of the HIV/AIDS pandemic. Such dislocations and displacements imply separation from family and communities, including socio-economic benefits that accrue to them. There is an apparent problem of accessing health services, educational services, sources of livelihood and protection from sexual and emotional abuse. Refugee children and women are said to be the most vulnerable, although until recently adolescents in armed conflict were not considered as a<br /> special group of children requiring special attention. The main objective of this research was to investigate levels of risk for HIV among refugee adolescents in Zambia and to determine how location relates to risk. Of particular interest was the difference in risk experienced in rural and urban areas. The researcher&rsquo / s hypothesis was that refugee adolescents in rural camps of Zambia are at greater risk because they lack adequate sources of income, health, and education in comparison to urban areas. The research was located within two theoretical underpinnings namely the social cognitive theory and the AIDS Risk Reduction Model (ARRM). The theory posits that a reciprocal relationship exists between environmental contexts, personal factors and behavior. The model explains how people change behavior that reduces risk for HIV by changing perceptions on sexual activity and when they enact the knowledge obtained from HIV preventive programmes. The methodology was located within both the qualitative and quantitative research<br /> approaches. Qualitative because firstly, the research is a comparative case study and secondly, it is the first time such a study is being conducted. The researcher also made use of the quantitative through the survey and secondary HIV/AIDS statistical data.

In the context of decreasing mortality and increasing prevalence, prevention of HIV-transmission represents a public health priority. In the United States, the majority of infections are sexually-acquired, with men who have sex with men and minorities disproportionately affected. Although a number of promising biomedical prevention approaches have emerged over the past decade, a further 20 years could be needed before a suitable product becomes widely available. Evidence from vaccine and microbicide trials has shown that success in one population may not be replicated in another. To understand surprising or unexpected results, investigators need chronologically concordant evidence of both study product adherence and viral exposure. Since exposure to HIV cannot yet be independently verified, in seeking to measure this variable, investigators target the sexual behaviors through which it takes place deriving data for these surrogate measures from study participants' voluntary self-reports. Likely sources of reporting bias and efforts to minimize this phenomenon in the context of HIV-prevention research are critically reviewed in Chapter 1. Research describing the role of cognitive and affective functioning in the preparation of responses to potentially threatening questions is examined. Studies investigating techniques such as the use of colloquial language to facilitate comprehension, or variation in the length of the reference period to enhance recall are explored. Research comparing the effect of mode of administration on the amount of proscribed behavior reported - widely believed to correlate with validity - is reviewed. Contextual factors facilitating versus inhibiting disclosure of sensitive information are examined. Finally, risk-behavior measurement approaches used in selected HIV-prevention trials are inspected. Thereafter, the dissertation focuses on the properties of risk-assessment items, formulated specifically to elicit Global recall over six months, or Event-Specific (episodic) memory for selected recent episodes of limited duration, to capture sexual behaviors or temporally related activities. The capacity of the different questionnaire item formats to elicit responses with sufficient construct validity to serve as proxies for HIV-exposure is examined. Data for these studies are drawn from a large randomized controlled trial of a behavioral intervention to prevent HIV-transmission among men who have sex with men. Using a subset of 1295 cases and controls, models with good discriminant validity for HIV are derived separately for the Global and Event-Specific items. Thereafter, selected items from the two formats are combined to produce a single model with excellent discriminant validity, suggesting that these items can adequately represent true HIV-exposure. Next, a preliminary investigation of the contribution of psychosocial items to the predictive model based on exposure measures is undertaken. Specifically, interaction with exposure measures and the increase in discriminant validity obtained using data derived from constructs of partner type/relationship status, substance use, depressive symptoms and perceived self-efficacy is examined first in stratified analysis and then in logistic regression analysis using the case-control data. Effect-modification is observed for perceived relationship status and non-injection drug use. Evaluation of psychosocial items continues in a cohort study with prospective analysis of follow-up data from all trial participants who returned for at least one follow-up visit. Informed by the case-control study, a series of items representing psychosocial constructs known for their association with HIV-infection are tested for main effects and effect-modification. Evidence of the interaction observed in stratified analyses and confirmed in ordinary logistic regression persists in separate, topic-specific GEE analyses with assorted exposure measures, but abates in repeated measures analyses drawing on all available psychosocial items. Lastly, a single lagged variable indicating primary relationship status of the most recent partner (with respect to the preceding study visit) provides a significant addition to the model. Significant main effects for all except depressive symptoms and perceived self-efficacy and the increase in discriminant validity obtained for the multivariable model versus the `exposure-only' model are sufficient to warrant continued use of these risk-assessment items. Despite good predictive validity demonstrated for the sexual risk-behavior and psychosocial items, some inconsistent reporting between the Global and Event-specific formats is evident. Likely sources of this reporting bias are considered in light of the literature, and strengths and limitations of the overall study are discussed in the closing chapter.

Black South African men who have sex with men (MSM) face a set of adverse circumstances, including economic hardship and stigmatization, that combine to put them at an elevated risk for hazardous substance use and HIV infection. This creates a context where substance use is normative and high-risk sexual behavior is often engaged in covertly and under the influence of intoxicating substances. The overarching objective of this dissertation was to explore determinants of hazardous drinking and HIV risk behavior among black South African MSM with a particular focus on the role of social networks. In order to achieve this, I used data drawn from the study, “HIV and Sexual Risk in African MSM in South African Townships” (R01-MH083557; PI: Sandfort, PhD). First, I conducted a systematic literature review to identify studies that used social network analysis to evaluate alcohol use among adults in order to answer the question: how have social network characteristics been shown to influence adults’ drinking behaviors, both in terms of characteristics of their network structures and characteristics of their network ties? Results of the review demonstrated that characteristics of one’s peers as well as social network structure influenced egos’ alcohol consumption in a variety of ways and across settings. Second, I described drug and alcohol use among black South African MSM and identified determinants of hazardous drinking, a highly prevalent form of alcohol use identified in the sample. The results showed that hazardous drinking was highly prevalent and multiple indicators of social vulnerability were identified as independent determinants of hazardous drinking. Third, I assessed the relationship between substance use and sexual risk behavior and explored the moderating effects of psychosocial factors. The results showed that there was not a main effect between substance use and sexual risk behavior; however, among men with high intentions to engage in safer sex, substance use was associated with increased risky sexual behavior. Overall, this dissertation increased our understanding of social networks, substance use and HIV risk behavior among black South African MSM. Our results suggest the importance of using pre-existing social networks to deliver potential interventions. The results also suggest that the most vulnerable members of this community are at increased risk of hazardous drinking. Lastly, efforts to reduce HIV risk behavior should focus on both increasing safer sex intentions and negating the impact of substance use on sexual risk behavior. Taken together, these studies provide insight for developing potential interventions, including intervention that use social network data to facilitate behavioral change, as well as undertaking further research among a critical population.

Latino men who have sex with men (MSM) in the United States experience a disproportionate and growing HIV burden. In spite of germinal studies and recent advances reported in the scientific literature, there is a noteworthy gap in our understanding of the factors that influence HIV transmission and acquisition among Latino MSM. The goal of this dissertation is to explore how cultural, spatial, and syndemic contexts influence two HIV-related risk behaviors among Latino MSM: serodiscordant condomless anal intercourse (SDCAI) and number of male causal partners. Specifically, I aimed to assess the how acculturation, neighborhood characteristics, and co-occurring epidemics may each contribute to HIV-related risk among Latino MSM. For this project, I utilized data from the NYCM2M study (R01 HD059729; PI: B. Koblin), a cross-sectional study of the relations among neighborhood environmental characteristics, sexual risk behaviors, anxiety and depression, and alcohol and substance use among urban MSM. First, I examined the association between indices of acculturation and the two HIV-related risk behavior outcomes, in addition to assessing if acculturation moderates the influence of sexual minority stressors and peer condom use norms on those same outcomes. The results indicated that relationships between the two sexual minority stressors and SDCAI were strongest among two groups: English-speaking and foreign-born Latino MSM, groups considered to be high and low, respectively, on acculturation. Second, I examined the ethnicity- and gay-related neighborhood correlates of the HIV-related risk behavior outcomes. The results showed that living in areas with a higher proportion of men reporting experiences of ethnicity-based discrimination and higher levels of gay community connectedness were both associated with an increased likelihood of engaging with 5 or more casual sexual partners, while living in an area with a higher foreign-born population was associated with a lower likelihood of the same. Third, I examined both established and population-relevant syndemic conditions to assess the association between syndemic burden and the HIV-related risk behavior outcomes among Latino MSM, and assessed if outness moderated these potential relationships. The results indicated a significant, positive association between the number of syndemic conditions and SDCAI, but, upon testing for moderation, this relationship only existed among men with high levels of outness about their sexual orientation. The results also showed that having any syndemic conditions, regardless of the number, was associated with having more casual sexual partners. Overall, this dissertation highlights the importance of studying HIV-related risk behaviors through multiple contextual lenses among Latino MSM. Specifically, the results suggest a strong need to attend to how cultural factors, spatial environments, and syndemic factors may shape HIV burden among Latino MSM. Taken together, these studies provide evidence for the development of multi-level, multicomponent HIV-reducing interventions that specifically target the differing needs among subgroups of Latino MSM, rather than treating them as a single, monolithic group for study and intervention.

Since 1988 when the first HIV positive drug user was identified in Poland, for close to two decades, the predominant route of HIV transmission has been through injecting drug use. In mid 2000s, Polish officials reported that injecting drug use no longer contributed to incrasing HIV incidence. The consequences of such a statement are that many of the structural and personal risks associated with HIV infection go unaddressed, that drug users are neglected by HIV prevention efforts, that HIV treatment is not made available to drug users and that the policy environment does not adequately support effective public health initiatives. This case study is based on documentation, archival records, interviews, participant observation, and physical artifacts shows that these assertions were made, and continue to be repeated, in a highly political context. Poland is a post-socialist state with strong neoliberal leanings, and it is highly invested in successful integration with the European Union. Powerful Catholic Church serves as an important backdrop. While people considered "at risk" now have more freedom to conduct their lives, they also have a set of neoliberal expectations and religious pressures placed on them. Country's geographic location adds to this complexity - situated between "Old Europe" where HIV problem has been successfully contained and the former Soviet Union, where the HIV incidence among drug users is the highest in the world, Poland attempts to align itself with the success of the West. Furthermore, examination of the available data suggests that the assertions made by Polish officials omit numerous variables. My research shows that even though Polish leadership in the area of HIV and drug policy wishes to resemble Western Europe, Poland does not meet international standards for the prevention of HIV transmission. The interviews I conducted, as well as the review of the literature on drug and HIV policies and programs suggest that these services are scattered, often unavailable, and that their number is stagnating, at best, and in some cases, even decreasing. This maybe a direct result of lack of engagement of drug users in their design. Excluded from the discussion of risk, drug users are thus not the focus of prevention efforts. Based on gathered data, there are seven crucial issues that require immediate action if Poland is to manage HIV prevention and care for people who use drugs in a manner consistent with the international standards. The areas requiring action are: a change in the drug policy from the current very punitive approach, expansion of needle and syringe programs and other harm reduction services, improved data collection and an increase in the availability of HIV testing, scaled-up substitution treatment, improved quality of other forms of drug treatment, greater investment in civil society organizations, improved access to HIV treatment, and educational and training efforts that encourage greater attention to HIV related matters across disciplines.