Jacky M. Jennings

Context Intimate partner violence (IPV) screening remains controversial. Major medical organizations mandate screening, whereas the U.S. Preventive Services Task Force (USPSTF) cautions that there is insufficient evidence to recommend for or against screening. An effective IPV screening program must include a screening tool with sound psychometric properties. A systematic review was conducted to summarize IPV screening tools tested in healthcare settings, providing a discussion of existing psychometric data and an assessment of study quality. Evidence acquisition From the end of 2007 through 2008, three published literature databases were searched from their start through December 2007; this search was augmented with a bibliography search and expert consultation. Eligible studies included English-language publications describing the psychometric testing of an IPV screening tool in a healthcare setting. Study quality was judged using USPSTF criteria for diagnostic studies. Evidence synthesis Of 210 potentially eligible studies, 33 met inclusion criteria. The most studied tools were the Hurt, Insult, Threaten, and Scream (HITS, sensitivity 30%–100%, specificity 86%–99%); the Woman Abuse Screening Tool (WAST, sensitivity 47%, specificity 96%); the Partner Violence Screen (PVS, sensitivity 35%–71%, specificity 80%–94%); and the Abuse Assessment Screen (AAS, sensitivity 93%–94%, specificity 55%–99%). Internal reliability (HITS, WAST); test–retest reliability (AAS); concurrent validity (HITS, WAST); discriminant validity (WAST); and predictive validity (PVS) were also assessed. Overall study quality was fair to good. Conclusions No single IPV screening tool had well-established psychometric properties. Even the most common tools were evaluated in only a small number of studies. Sensitivities and specificities varied widely within and between screening tools. Further testing and validation are critically needed. Intimate partner violence (IPV) screening remains controversial. Major medical organizations mandate screening, whereas the U.S. Preventive Services Task Force (USPSTF) cautions that there is insufficient evidence to recommend for or against screening. An effective IPV screening program must include a screening tool with sound psychometric properties. A systematic review was conducted to summarize IPV screening tools tested in healthcare settings, providing a discussion of existing psychometric data and an assessment of study quality. From the end of 2007 through 2008, three published literature databases were searched from their start through December 2007; this search was augmented with a bibliography search and expert consultation. Eligible studies included English-language publications describing the psychometric testing of an IPV screening tool in a healthcare setting. Study quality was judged using USPSTF criteria for diagnostic studies. Of 210 potentially eligible studies, 33 met inclusion criteria. The most studied tools were the Hurt, Insult, Threaten, and Scream (HITS, sensitivity 30%–100%, specificity 86%–99%); the Woman Abuse Screening Tool (WAST, sensitivity 47%, specificity 96%); the Partner Violence Screen (PVS, sensitivity 35%–71%, specificity 80%–94%); and the Abuse Assessment Screen (AAS, sensitivity 93%–94%, specificity 55%–99%). Internal reliability (HITS, WAST); test–retest reliability (AAS); concurrent validity (HITS, WAST); discriminant validity (WAST); and predictive validity (PVS) were also assessed. Overall study quality was fair to good. No single IPV screening tool had well-established psychometric properties. Even the most common tools were evaluated in only a small number of studies. Sensitivities and specificities varied widely within and between screening tools. Further testing and validation are critically needed.

Disease variation can be substantial even in conditions with a single gene etiology such as cystic fibrosis (CF). Simultaneously studying the effects of genes and environment may provide insight into the causes of variation.To determine whether secondhand smoke exposure is associated with lung function and other outcomes in individuals with CF, whether socioeconomic status affects the relationship between secondhand smoke exposure and lung disease severity, and whether specific gene-environment interactions influence the effect of secondhand smoke exposure on lung function.Retrospective assessment of lung function, stratified by environmental and genetic factors. Data were collected by the US Cystic Fibrosis Twin and Sibling Study with missing data supplemented by the Cystic Fibrosis Foundation Data Registry. All participants were diagnosed with CF, were recruited between October 2000 and October 2006, and were primarily from the United States.Disease-specific cross-sectional and longitudinal measures of lung function.Of 812 participants with data on secondhand smoke in the home, 188 (23.2%) were exposed. Of 780 participants with data on active maternal smoking during gestation, 129 (16.5%) were exposed. Secondhand smoke exposure in the home was associated with significantly lower cross-sectional (9.8 percentile point decrease; P < .001) and longitudinal lung function (6.1 percentile point decrease; P = .007) compared with those not exposed. Regression analysis demonstrated that socioeconomic status did not confound the adverse effect of secondhand smoke exposure on lung function. Interaction between gene variants and secondhand smoke exposure resulted in significant percentile point decreases in lung function, namely in CFTR non-DeltaF508 homozygotes (12.8 percentile point decrease; P = .001), TGFbeta1-509 TT homozygotes (22.7 percentile point decrease; P = .006), and TGFbeta1 codon 10 CC homozygotes (20.3 percentile point decrease; P = .005).Any exposure to secondhand smoke adversely affects both cross-sectional and longitudinal measures of lung function in individuals with CF. Variations in the gene that causes CF (CFTR) and a CF-modifier gene (TGFbeta1) amplify the negative effects of secondhand smoke exposure.

It is often assumed that local sexual networks play a dominant role in HIV spread in sub-Saharan Africa. The aim of this study was to determine the extent to which continued HIV transmission in rural communities--home to two-thirds of the African population--is driven by intra-community sexual networks versus viral introductions from outside of communities.We analyzed the spatial dynamics of HIV transmission in rural Rakai District, Uganda, using data from a cohort of 14,594 individuals within 46 communities. We applied spatial clustering statistics, viral phylogenetics, and probabilistic transmission models to quantify the relative contribution of viral introductions into communities versus community- and household-based transmission to HIV incidence. Individuals living in households with HIV-incident (n = 189) or HIV-prevalent (n = 1,597) persons were 3.2 (95% CI: 2.7-3.7) times more likely to be HIV infected themselves compared to the population in general, but spatial clustering outside of households was relatively weak and was confined to distances <500 m. Phylogenetic analyses of gag and env genes suggest that chains of transmission frequently cross community boundaries. A total of 95 phylogenetic clusters were identified, of which 44% (42/95) were two individuals sharing a household. Among the remaining clusters, 72% (38/53) crossed community boundaries. Using the locations of self-reported sexual partners, we estimate that 39% (95% CI: 34%-42%) of new viral transmissions occur within stable household partnerships, and that among those infected by extra-household sexual partners, 62% (95% CI: 55%-70%) are infected by sexual partners from outside their community. These results rely on the representativeness of the sample and the quality of self-reported partnership data and may not reflect HIV transmission patterns outside of Rakai.Our findings suggest that HIV introductions into communities are common and account for a significant proportion of new HIV infections acquired outside of households in rural Uganda, though the extent to which this is true elsewhere in Africa remains unknown. Our results also suggest that HIV prevention efforts should be implemented at spatial scales broader than the community and should target key populations likely responsible for introductions into communities.

Objective Glial fibrillary acidic protein (GFAP) is specific to astrocytes in the central nervous system. We hypothesized that serum GFAP would be increased in neonates with hypoxic-ischemic encephalopathy (HIE) treated with whole-body cooling. Study Design We measured GFAP at birth and daily for up to 7 days for neonates in the intensive care unit. We compared neonates with HIE treated with whole-body cooling to gestational age–matched controls without neurological injury and neonates with HIE by brain abnormalities on magnetic resonance imaging (MRI). Results Neonates with HIE had increased GFAP levels compared with controls. Neonates with HIE and abnormal brain imaging had elevated GFAP levels compared with neonates with HIE and normal imaging. Conclusion Serum GFAP levels during the first week of life were increased in neonates with HIE and were predictive of brain injury on MRI. Biomarkers such as GFAP could help triage neonates with HIE to treatment, measure treatment efficacy, and provide prognostic information. Glial fibrillary acidic protein (GFAP) is specific to astrocytes in the central nervous system. We hypothesized that serum GFAP would be increased in neonates with hypoxic-ischemic encephalopathy (HIE) treated with whole-body cooling. We measured GFAP at birth and daily for up to 7 days for neonates in the intensive care unit. We compared neonates with HIE treated with whole-body cooling to gestational age–matched controls without neurological injury and neonates with HIE by brain abnormalities on magnetic resonance imaging (MRI). Neonates with HIE had increased GFAP levels compared with controls. Neonates with HIE and abnormal brain imaging had elevated GFAP levels compared with neonates with HIE and normal imaging. Serum GFAP levels during the first week of life were increased in neonates with HIE and were predictive of brain injury on MRI. Biomarkers such as GFAP could help triage neonates with HIE to treatment, measure treatment efficacy, and provide prognostic information.

Neonates with hypoxic–ischemic encephalopathy (HIE) are at risk of cerebral blood flow dysregulation. Our objective was to describe the relationship between autoregulation and neurologic injury in HIE. Neonates with HIE had autoregulation monitoring with the hemoglobin volume index (HVx) during therapeutic hypothermia, rewarming, and the first 6 h of normothermia. The 5-mm Hg range of mean arterial blood pressure (MAP) with best vasoreactivity (MAPOPT) was identified. The percentage of time spent with MAP below MAPOPT and deviation in MAP from MAPOPT were measured. Neonates received brain magnetic resonance imaging (MRI) 3–7 d after treatment. MRIs were coded as no, mild, or moderate/severe injury in five regions. HVx identified MAPOPT in 79% (19/24), 77% (17/22), and 86% (18/21) of the neonates during hypothermia, rewarming, and normothermia, respectively. Neonates with moderate/severe injury in paracentral gyri, white matter, basal ganglia, and thalamus spent a greater proportion of time with MAP below MAPOPT during rewarming than neonates with no or mild injury. Neonates with moderate/severe injury in paracentral gyri, basal ganglia, and thalamus had greater MAP deviation below MAPOPT during rewarming than neonates without injury. Maintaining MAP within or above MAPOPT may reduce the risk of neurologic injuries in neonatal HIE.

Geographic approaches to sexually transmitted infection (STI) research frequently seek to identify areas where outreach STI testing may most effectively interrupt continued transmission of STIs. Many of the studies are limited, however, in that they fail to control for racial/ethnic composition of the high prevalence areas. These studies thus may be merely identifying the broader sexual networks of the high morbidity population and not the high transmission networks within them. Cluster detection analysis may be an appropriate approach to identify critical STI disease transmission locations. This study determined whether statistically significant geographic clusters of high prevalence gonorrhea cases can be located after controlling for race/ethnicity. Using a spatial scan statistic, the authors analyzed reported cases of gonorrhea (n = 32,454) in Baltimore City, Maryland, from 1994 to 1999 geocoded to the primary address and aggregated to census block groups (n = 709). They adjusted for the underlying distribution of the population aged 15-39 years and percent African American per census block group. The results identified eight significant clusters of high STI prevalence areas, reinforcing the inference that risks for gonorrhea are associated with definable sociogeographic spaces. The areas identified may be critical to control STIs and may provide important direction for further study and targeted interventions.

Important barriers to STD testing may include individuals' perceptions of STD-related stigma (negative societal attitudes toward STD infection) and expectations of STD-related shame (negative personal feelings) that would result from a positive STD test. Obtaining a clear understanding of the relationship between STD-related stigma, STD-related shame and STD testing may help inform programs and policies aimed at reducing STD transmission.Measures derived from previously published scales were used to assess perceived STD-related stigma, anticipated STD-related shame and receipt of an STD test in the past year in an urban, household sample of 594 sexually active 15-24-year-olds interviewed in 2004-2007. Logistic regression was used to examine associations between recent STD testing and perceived stigma, shame and other participant characteristics.Thirty-seven percent of males and 70% of females reporting having had an STD test in the past year; the largest proportions of tests (42% among males and 59% among females) had occurred in the context of a routine health care visit, not because adolescents had had disease symptoms or were concerned about exposure to infection. For both males and females, the level of STD-related stigma was negatively associated with the odds of having been tested (odds ratio, 0.5 for each). STD-related shame was not related to STD testing.Adolescents who view STDs as stigmatizing have a reduced likelihood of being screened, but it is unclear whether this relationship reflects their care seeking or providers' practice of offering STD screening at a routine health visit.

Objectives: To estimate whether home visitation beginning after childbirth was associated with changes in average rates of mothers' intimate partner violence (IPV) victimization and perpetration as well as rates of specific IPV types (physical assault, verbal abuse, sexual assault, and injury) during the 3 years of program implementation and during 3 years of long-term follow-up.Design: Randomized controlled trial.Setting:

Violent crime such as homicide causes significant excess morbidity and mortality in US urban areas. A health impact assessment (HIA) identified zoning policy related to alcohol outlets as one way to decrease violent crime. The objectives were to determine the relationship between alcohol outlets including off-premise alcohol outlets and violent crime in one urban area to provide local public health evidence to inform a zoning code rewrite. An ecologic analysis of census tracts in Baltimore City was conducted from 2011 to 2012. The data included violent crimes (n = 51,942) from 2006 to 2010, licensed alcohol outlets establishments (n = 1,327) from 2005 to 2006, and data on neighborhood disadvantage, percent minority, percent occupancy, and drug arrests from 2005 to 2009. Negative binomial regression models were used to determine the relationship between the counts of alcohol outlets and violent crimes controlling for other factors. Spatial correlation was assessed and regression inference adjusted accordingly. Each one-unit increase in the number of alcohol outlets was associated with a 2.2 % increase in the count of violent crimes adjusting for neighborhood disadvantage, percent minority, percent occupancy, drug arrests, and spatial dependence (IRR = 1.022, 95 % CI = 1.015, 1.028). Off-premise alcohol outlets were significantly associated with violent crime in the adjusted model (IRR = 1.048, 95 % CI = 1.035, 1.061). Generating Baltimore-specific estimates of the relationship between alcohol outlets and violent crime has been central to supporting the incorporation of alcohol outlet policies in the zoning code rewrite being conducted in Baltimore City.

Neurodevelopmental disabilities persist in survivors of neonatal hypoxic-ischemic encephalopathy (HIE) despite treatment with therapeutic hypothermia. Cerebrovascular autoregulation, the mechanism that maintains cerebral perfusion during changes in blood pressure, may influence outcomes. Our objective was to describe the relationship between acute autoregulatory vasoreactivity during treatment and neurodevelopmental outcomes at 2 years of age.In a pilot study of 28 neonates with HIE, we measured cerebral autoregulatory vasoreactivity with the hemoglobin volume index (HVx) during therapeutic hypothermia, rewarming, and the first 6 h of normothermia. The HVx, which is derived from near-infrared spectroscopy, was used to identify the individual optimal mean arterial blood pressure (MAPOPT) at which autoregulatory vasoreactivity is greatest. Cognitive and motor neurodevelopmental evaluations were completed in 19 children at 21-32 months of age. MAPOPT, blood pressure in relation to MAPOPT, blood pressure below gestational age + 5 (ga + 5), and regional cerebral oximetry (rSO2) were compared to the neurodevelopmental outcomes.Nineteen children who had HIE and were treated with therapeutic hypothermia performed in the average range on cognitive and motor evaluations at 21-32 months of age, although the mean performance was lower than that of published normative samples. Children with impairments at the 2-year evaluation had higher MAPOPT values, spent more time with blood pressure below MAPOPT, and had greater blood pressure deviation below MAPOPT during rewarming in the neonatal period than those without impairments. Greater blood pressure deviation above MAPOPT during rewarming was associated with less disability and higher cognitive scores. No association was observed between rSO2 or blood pressure below ga + 5 and neurodevelopmental outcomes.In this pilot cohort, motor and cognitive impairments at 21-32 months of age were associated with greater blood pressure deviation below MAPOPT during rewarming following therapeutic hypothermia, but not with rSO2 or blood pressure below ga + 5. This suggests that identifying individual neonates' MAPOPT is superior to using hemodynamic goals based on gestational age or rSO2 in the acute management of neonatal HIE.

Background: Therapeutic hypothermia provides incomplete neuroprotection for neonatal hypoxic-ischemic encephalopathy (HIE). We examined whether hemodynamic goals that support autoregulation are associated with decreased brain injury and whether these relationships are affected by birth asphyxia or vary by anatomic region. Methods: Neonates cooled for HIE received near-infrared spectroscopy autoregulation monitoring to identify the mean arterial blood pressure with optimized autoregulatory function (MAPOPT). Blood pressure deviation from MAPOPT was correlated with brain injury on MRI after adjusting for the effects of arterial carbon dioxide, vasopressors, seizures, and birth asphyxia severity. Results: Blood pressure deviation from MAPOPT related to neurologic injury in several regions independent of birth asphyxia severity. Greater duration and deviation of blood pressure below MAPOPT were associated with greater injury in the paracentral gyri and white matter. Blood pressure within MAPOPT related to lesser injury in the white matter, putamen and globus pallidus, and brain stem. Finally, blood pressures that exceeded MAPOPT were associated with reduced injury in the paracentral gyri. Conclusions: Blood pressure deviation from optimal autoregulatory vasoreactivity was associated with MRI markers of brain injury that, in many regions, were independent of the initial birth asphyxia. Targeting hemodynamic ranges to optimize autoregulation has potential as an adjunctive therapy to hypothermia for HIE.

Improved survival after cardiac arrest has placed greater emphasis on neurologic resuscitation. The purpose of this pilot study was to evaluate the relationship between cerebrovascular autoregulation and neurologic outcomes after pediatric cardiac arrest.Children resuscitated from cardiac arrest had autoregulation monitoring during the first 72h after return of circulation with an index derived from near-infrared spectroscopy in a pilot study. The range of mean arterial blood pressure (MAP) with optimal vasoreactivity (MAPOPT) was identified. The area under the curve (AUC) of the time spent with MAP below MAPOPT and MAP deviation below MAPOPT was calculated. Neurologic outcome measures included placement of a new tracheostomy or gastrostomy, death from a primary neurologic etiology (brain death or withdrawal of support for neurologic futility), and change in the Pediatric Cerebral Performance Category score (ΔPCPC).Thirty-six children were monitored. Among children who did not require extracorporeal membrane oxygenation (ECMO), children who received a tracheostomy/gastrostomy had greater AUC during the second 24h after resuscitation than those who did not (P=0.04; n=19). Children without ECMO who died from a neurologic etiology had greater AUC during the first 48h than did those who lived or died from cardiovascular failure (P=0.04; n=19). AUC below MAPOPT was not associated with ΔPCPC when children with or without ECMO were analyzed separately.Deviation from the blood pressure with optimal autoregulatory vasoreactivity may predict poor neurologic outcomes after pediatric cardiac arrest. This experimental autoregulation monitoring technique may help individualize blood pressure management goals after resuscitation.

Purpose To explore perceptions of facilitators/barriers to sexual and reproductive health (SRH) care use among an urban sample of African-American and Hispanic young men aged 15–24 years, including sexual minorities. Methods Focus groups were conducted between April 2013 and May 2014 in one mid-Atlantic U.S. city. Young men aged 15–24 years were recruited from eight community settings to participate in 12 groups. Moderator guide explored facilitators/barriers to SRH care use. A brief pregroup self-administered survey assessed participants' sociodemographics and SRH information sources. Content analysis was conducted, and three investigators independently verified the themes that emerged. Results Participants included 70 males: 70% were aged 15–19 years, 66% African-American, 34% Hispanic, 83% heterosexual, and 16% gay/bisexual. Results indicated young men's perceptions of facilitators/barriers to their SRH care use come from multiple levels of their socioecology, including cultural, structural, social, and personal contexts, and dynamic inter-relationships existed across contexts. A health care culture focused on women's health and traditional masculinity scripts provided an overall background. Structural level concerns included cost, long visits, and confidentiality; social level concerns included stigma of being seen by community members and needs regarding health care provider interactions; and personal level concerns included self-risk assessments on decisions to seek care and fears/anxieties about sexually transmitted infection/HIV testing. Young men also discussed SRH care help-seeking sometimes involved family and/or other social network members and needs related to patient-provider interactions about SRH care. Conclusions Study findings provide a foundation for better understanding young men's SRH care use and considering ways to engage them in care.

OBJECTIVES: To measure associations between residential moves because of unaffordable housing costs and disruptions in access to the Supplemental Nutrition Assistance Program; the Special Supplemental Nutrition Program for Women, Infants, and Children; and Medicaid in a health care-based sample of families with young children. METHODS: We used cross-sectional survey data on social safety net-eligible caregivers and children recruited into the Children’s HealthWatch study from emergency departments and primary care clinics in Baltimore and Philadelphia (2011–2019). Children’s HealthWatch measured residential moves (cost-driven and noncost-driven) in the past year and disruptions in safety net access. We used logistic regression to estimate associations between each type of move and disrupted access to social safety nets. RESULTS: Across 9344 children, cost-driven residential moves were associated with higher odds of disrupted access to at least 1 safety net program (Supplemental Nutrition Assistance Program; the Special Supplemental Nutrition Program for Women, Infants, and Children; or Medicaid; adjusted odds ratio 1.44; 95% confidence interval 1.16–1.80), as well as higher odds of disruption to each program separately. Noncost-driven moves were also associated with disruptions to at least 1 safety net program, but less strongly so (adjusted odds ratio 1.14; confidence interval 1.01–1.29; P value for comparison with cost-driven = .045). CONCLUSIONS: Residential moves, particularly cost-driven moves, are associated with social safety net benefit disruptions. The association between these events suggests a need for action to ensure consistent safety net access among children facing cost-driven moves and vice versa (ie, access to housing supports for children with disrupted safety net access).

Spatial distribution of repeat and singly occurring gonorrhea in Baltimore, Maryland, was examined to identify clusters of core transmitters. Gonorrhea reported between 2001 and 2002 was geocoded and mapped. Those with more than one gonorrhea infection separated by more than 14 days during the 2-year period were considered repeaters. Other cases were treated as isolated events. Six definitions of core transmission were examined by census tracts with the highest quintiles of 1) cases for 2001, 2) cases for 2002, 3) rates for 2001, 4) rates for 2002, 5) counts of repeaters over the 2-year period, and 6) proportion of total cases that were repeaters. Of the 6,108 gonorrhea cases analyzed, 9% were repeaters. Repeaters were more likely to be female and younger. Core areas identified by definitions based on overall disease burden agreed well with each other but had poor agreement with definitions based upon repeat infections. Repeaters clustered to a greater extent at smaller distances than did singly occurring gonorrhea cases. Repeat gonorrhea infections are prevalent in Baltimore and likely represent behavior consistent with core transmission. Census tracts of core transmission defined by geographic distribution of repeat infections may indicate foci of highest risk sexual behaviors and high transmission.

Abstract Background: There are no guidelines and multiple devices available now for closure of PDA. Objective: We sought to determine which devices are used and their outcomes. Methods: Prospectively collected data on closure of PDA at 12 US catheterization labs was entered into the MAGIC data registry between November 2005 and September 2008. Results: PDA closure was accomplished in 357 of 359 attempted closures during the study period. Mean age, weight, and minimum ductal diameter were 4.3 ± 6.8 years, 18.7 ± 18.4 kg, and 2.1 ± 1.4 mm, respectively. Devices used were Gianturco coils (161/359), Amplatzer Duct Occluder (ADO, 174/359), Flipper coils (18/359), and other devices (6/359). Gianturco coils had the least fluoroscopy and contrast exposure (8.7 ± 7.5 min, P = 0.00001, 2.6 ± 1.4 cm 3 kg −1 , P = 0.00001). Immediate angiographic success rates were 96.9% (156/161) for Gianturco coils, 89.7% (156/174) for the ADO, 100% (18/18) for Flipper coils, and 66.7% (4/6) for other devices. Major complication rates were 0.6% for Gianturco coils (1/161), 1.7% for ADO (3/174), and 83.3% for other devices (4/6). Minor complication rates by device were 1.9% for Gianturco coils (3/161), 2.3% for ADO (4/174), and 16.7% (1/6) for other devices. Conclusions: Gianturco coils, the ADO and Flipper coils were immediately successful with low complication profiles. The ADO and Gianturco coils were the predominate devices. The ADO was the device of choice for PDA &gt; 3 mm with good success. In PDA &lt; 3 mm, the Gianturco coil is as effective and safe as the ADO with less cost, less radiation, and less contrast exposure. © 2010 Wiley‐Liss, Inc.

To estimate the diagnostic accuracy of electronic fetal heart rate abnormalities in the identification of neonates with encephalopathy treated with whole-body hypothermia.Between January 1, 2007, and July 1, 2013, there were 39 neonates born at two hospitals within our system treated with whole-body hypothermia within 6 hours of birth. Neurologically normal control neonates were matched to each case by gestational age and mode of delivery in a two-to-one fashion. The last hour of electronic fetal heart rate monitoring before delivery was evaluated by three obstetricians blinded to outcome.The differences in tracing category were not significantly different (neonates in the case group 10.3% I, 76.9% II, 12.8% III; neonates in the control group 9.0% I, 89.7% II, 1.3% III; P=.18). Bivariate analysis showed neonates in the case group had significantly increased late decelerations, total deceleration area 30 (debt 30) and 60 minutes (debt 60) before delivery and were more likely to be nonreactive. Multivariable logistic regression showed neonates in the case group had a significant decrease in early decelerations (P=.03) and a significant increase in debt 30 (.01) and debt 60 (P=.005). The area under the receiver operating characteristic curve, sensitivity, and specificity were 0.72, 23.1%, and 94.9% for early decelerations; 0.66, 33.3%, and 87.2% for debt 30, and 0.68, 35.9%, and 89.7% for debt 60, respectively.Abnormalities during the last hour of fetal heart rate monitoring before delivery are poorly predictive of neonatal hypoxic-ischemic encephalopathy qualifying for whole-body hypothermia treatment within 6 hours of birth. LEVEL OF EVIEDENCE: II.

Neurologic morbidity remains high in neonates with perinatal hypoxic-ischemic injury despite therapeutic hypothermia. DTI provides qualitative and quantitative information about the microstructure of the brain, and a near-infrared spectroscopy index can assess cerebrovascular autoregulation. We hypothesized that lower ADC values would correlate with worse autoregulatory function.Thirty-one neonates with hypoxic-ischemic injury were enrolled. ADC scalars were measured in 27 neonates (age range, 4-15 days) in the anterior and posterior centrum semiovale, basal ganglia, thalamus, posterior limb of the internal capsule, pons, and middle cerebellar peduncle on MRI obtained after completion of therapeutic hypothermia. The blood pressure range of each neonate with the most robust autoregulation was identified by using a near-infrared spectroscopy index. Autoregulatory function was measured by blood pressure deviation below the range with optimal autoregulation.In neonates who had MRI on day of life ≥10, lower ADC scalars in the posterior centrum semiovale (r = -0.87, P = .003, n = 9) and the posterior limb of the internal capsule (r = -0.68, P = .04, n = 9) correlated with blood pressure deviation below the range with optimal autoregulation during hypothermia. Lower ADC scalars in the basal ganglia correlated with worse autoregulation during rewarming (r = -0.71, P = .05, n = 8).Blood pressure deviation from the optimal autoregulatory range may be an early biomarker of injury in the posterior centrum semiovale, posterior limb of the internal capsule, and basal ganglia. Optimizing blood pressure to support autoregulation may decrease the risk of brain injury in cooled neonates with hypoxic-ischemic injury.

This research examined whether publicly funded drug treatment centers (DTCs) were associated with violent crime in excess of the violence happening around other commercial businesses.Violent crime data and locations of community entities were geocoded and mapped. DTCs and other retail outlets were matched based on a Neighborhood Disadvantage score at the census tract level. Street network buffers ranging from 100 to 1,400 feet were placed around each location. Negative binomial regression models were used to estimate the relationship between the count of violent crimes and the distance from each business type.Compared with the mean count of violent crime around drug treatment centers, the mean count of violent crime (M = 2.87) was significantly higher around liquor stores (M = 3.98; t test; p < .01) and corner stores (M = 3.78; t test; p < .01), and there was no statistically significant difference between the count around convenience stores (M = 2.65; t test; p = .32). In the adjusted negative binomial regression models, there was a negative and significant relationship between the count of violent crime and the distance from drug treatment centers (β = -.069, p < .01), liquor stores (β = -.081, p < .01), corner stores (β = -.116, p < .01), and convenience stores (β = -.154, p < .01).Violent crime associated with drug treatment centers is similar to that associated with liquor stores and is less frequent than that associated with convenience stores and corner stores.

Background While there are overwhelming data supporting the association between alcohol outlet density and violent crime, there remain conflicting findings about whether on‐ or off‐premise outlets have a stronger association. This inconsistency may be in part a result of the methods used to calculate alcohol outlet density and violent crime. This analysis uses routine activity theory and spatial access methods to study the association between access to alcohol outlets and violent crime, including type of outlet and type of crime in Baltimore, MD. Methods The data in this analysis include alcohol outlets from 2016 ( n = 1,204), violent crimes from 2012 to 2016 ( n = 51,006), and markers of social disorganization, including owner‐occupied housing, median annual household income, drug arrests, and population density. The analysis used linear regression to determine the association between access to alcohol outlets and violent crime exposure. Results Each 10% increase in alcohol outlet access was associated with a 4.2% increase in violent crime exposure ( β = 0.43, 95% CI 0.33, 0.52, p &lt; 0.001). A 10% increase in access to off‐premise outlets (4.4%, β = 0.45, 95% CI 0.33, 0.57, p &lt; 0.001) and LBD ‐7 outlets (combined off‐ and on‐premise outlets; 4.2%, β = 0.43, 95% CI 0.33, 0.52, p &lt; 0.001) had a greater association with violent crime than on‐premise outlets (3.0%, β = 0.31, 95% CI 0.20, 0.41, p &lt; 0.001). Conclusions Access to outlets that allow for off‐site consumption had a greater association with violent crime than outlets that only permit on‐site consumption. The lack of effective measures to keep order in and around off‐premise outlets could attract or multiply violent crime.

Eviction affects a substantial share of U.S. children, but its effects on child health are largely unknown. Our objectives were to examine how eviction relates to 1) children's health and sociodemographic characteristics at birth, 2) neighborhood poverty and food security at age 5, and 3) obesity in later childhood and adolescence. We analyzed data from the Fragile Families and Child Wellbeing Study, a longitudinal cohort of children born in 20 large U.S. cities. Children who lived in rental housing with known eviction histories and measured outcomes were included. We compared maternal and infant health and sociodemographic characteristics at the time of the child's birth. We then characterized the associations between eviction and neighborhood poverty and food security at age 5 and obesity at ages 5, 9, and 15 using log binomial regression with inverse probability of treatment and censoring weights. Of the 2556 children included in objective 1, 164 (6%) experienced eviction before age 5. Children who experienced eviction had lower household income and maternal education and were more likely to be born to mothers who were unmarried, smoked during pregnancy, and had mental health problems. Evicted and non-evicted children were equally likely to experience high neighborhood poverty at age 5 (prevalence ratio (PR) = 1.03, 95% CI 0.82, 1.29) but had an increased prevalence of low food security (PR = 2.16, 95% CI 1.46, 3.19). Obesity prevalence did not differ at age 5 (PR = 1.01; 95% CI 0.58, 1.75), 9 (PR = 1.08; 95% CI 0.715, 1.55); or 15 (PR = 1.05; 95% CI 0.51, 2.18). In conclusion, children who went on to experience eviction showed signs of poor health and socioeconomic disadvantage already at birth. Eviction in early childhood was not associated with children's likelihood of neighborhood poverty, suggesting that eviction may not qualitatively change children's neighborhood conditions in this disadvantaged sample. Though we saw evidence supporting an association with low child food security at age 5, we did not find eviction to be associated with obesity in later childhood and adolescence.

Introduction: Housing insecurity is increasingly commonplace among disadvantaged women and children. We measured the individual- and population-level impact of severe housing insecurity during pregnancy on adverse birth and infant outcomes. Methods: We analyzed data from 3428 mother-infant dyads enrolled in the Fragile Families and Child Wellbeing Study, a prospective cohort study representing births in 20 large U.S. cities from 1998 to 2000. Severe housing insecurity was defined as threatened eviction or homelessness during pregnancy. Outcomes included low birth weight and/or preterm birth, admission to a neonatal intensive care unit (NICU) or stepdown facility, extended hospitalization after delivery, and infant health and temperament. We estimated exposure-outcome associations with risk ratios adjusted for pre-pregnancy maternal sociodemographic and heath factors and calculated a population attributable fraction (PAF) of outcomes attributable to severe housing insecurity. Results: We found statistically significant associations between severe housing insecurity during pregnancy and low birth weight and/or preterm birth (risk ratio (RR] 1.73, 95% confidence interval (CI) 1.28, 2.32), NICU or stepdown stay (RR 1.64, CI 1.17, 2.31), and extended hospitalization (RR 1.66, CI 1.28, 2.16). Associations between housing insecurity and infant fair or poor health (RR 2.62, CI 0.91, 7.48) and poor temperament (RR 1.52, CI 0.98, 2.34) were not statistically significant. PAF estimates ranged from 0.9-2.7%, suggesting that up to three percent of adverse birth and infant outcomes could be avoided by eliminating severe housing insecurity among low-income, pregnant women in US cities. Conclusions: Results suggest that housing insecurity during pregnancy shapes neonatal and infant health in disadvantaged urban families.

Knowledge of the geographic and temporal clustering of drug activity can inform where health and social services are needed and can provide insight on the potential impact of local policies on drug activity. This ecologic study assessed the spatial and temporal distribution of drug activity in Baltimore, Maryland, prior to and following the implementation of a large urban redevelopment project in East Baltimore, which began in 2003. Drug activity was measured by narcotic calls for service at the neighborhood level. A space-time scan statistic approach was used to identify statistically significant clusters of narcotic calls for service across space and time, using a discrete Poisson model. After adjusting for economic deprivation and housing vacancy, clusters of narcotic calls for service were identified among neighborhoods located in Southeast, Northeast, Northwest, and West Baltimore from 2001 to 2010. Clusters of narcotic calls for service were identified among neighborhoods located in East Baltimore from 2001 to 2003, indicating a decrease in narcotic calls thereafter. A large proportion of clusters occurred among neighborhoods located in North and Northeast Baltimore after 2003, which indicated a potential spike during this time frame. These findings suggest potential displacement of drug activity coinciding with the initiation of urban redevelopment in East Baltimore. Space-time scan statistics should be used in future research to describe the potential implications of local policies on drug activity.

Sexually transmitted infection (STI) transmission models propose that incident STIs are related to exposure to infected sex partners. The objective of this study was to determine whether the prevalence of STIs among the available pool of sex partners in a neighborhood, measured indirectly, is an independent determinant of a current incident STI. The target population comprised 58,299 English-speaking, sexually active 15- to 24-year-olds in 486 census block groups (CBGs) in Baltimore, MD. A sample of 65 CBGs was selected using a stratified, systematic, probability-proportional-to-size strategy and 13,873 households were randomly selected. From 2004 through 2007, research assistants administered an audio computer-assisted interview survey and collected biologic samples for gonorrhea and chlamydia testing. The final sample size included 575 participants from 63 CBGs. Additional data provided gonorrhea prevalence from 2004 through 2005 per 15- to 49-year-old persons per 100,000 per CBG. After adjustment for individual-level STI risk factors in a multilevel probability model, adolescents and young adults living in high (vs. low) prevalence STI areas were 4.73 times (95% confidence interval [CI]: 3.65–6.15) more likely to have a current incident STI. To inform prevention programs, future research should focus on identifying mechanisms through which context causes changes in local sexual networks and their STI prevalence.

We hypothesized that neighborhoods with drug markets, as compared to those without, have a greater concentration of infected sex partners, i.e. core transmitters, and that in these areas, there is an increased risk environment for STIs. This study determined if neighborhood drug markets were associated with a high-risk sex partnership and, separately, with a current bacterial STI (chlamydia and/or gonorrhea) after controlling for individual demographic and sexual risk factors among a household sample of young people in Baltimore City, MD. Analyses also tested whether links were independent of neighborhood socioeconomic status. Data for this study were collected from a household study, systematic social observations and police arrest, public health STI surveillance and U.S. census data. Nonlinear multilevel models showed that living in neighborhoods with household survey-reported drug markets increased the likelihood of having a high-risk sex partnership after controlling for individual-level demographic factors and illicit drug use and neighborhood socioeconomic status. Further, living in neighborhoods with survey-reported drug markets increased the likelihood of having a current bacterial STI after controlling for individual-level demographic and sexual risk factors and neighborhood socioeconomic status. The results suggest that local conditions in neighborhoods with drug markets may play an important role in setting-up risk environments for high-risk sex partnerships and bacterial STIs. Patterns observed appeared dependent on the type of drug market indicator used. Future studies should explore how conditions in areas with local drug markets may alter sexual networks structures and whether specific types of drug markets are particularly important in determining STI risk.

To compare longitudinal adolescent and adult reproductive outcomes after pelvic inflammatory disease (PID).Secondary analysis of longitudinal data from the Pelvic Inflammatory Disease Evaluation and Clinical Health study.A large multicenter randomized clinical trial assessing PID treatment strategies in the United States.Eight hundred thirty-one female patients aged 14 to 38 years with a diagnosis of PID.Adverse longitudinal outcomes were compared in adolescents (≤19 years) and adults (>19 years).Primary outcome measures included recurrent sexually transmitted infection at 30 days, recurrent PID, chronic abdominal pain, infertility, pregnancy, and times to recurrent PID and pregnancy. Cox proportional hazards modeling was used to examine the effect of young age on times to pregnancy and recurrent PID.Adolescents were more likely than adults to have positive results of sexually transmitted infection testing at baseline and at 30 days. There were no significant group differences in chronic abdominal pain, infertility, and recurrent PID at 35 or 84 months, but adolescents were more likely to have a pregnancy at both time points. Adjusted hazard ratios (95% confidence intervals) also demonstrated that adolescents had shorter times to pregnancy (1.48 [1.18-1.87]) and recurrent pelvic inflammatory disease (1.54 [1.03-2.30]).Adolescents may require a different approach to clinical care and follow-up after PID to prevent recurrent sexually transmitted infections, recurrent PID, and unwanted pregnancies.

Periventricular white matter injury (PWMI), a precursor of cerebral palsy, traditionally is not diagnosed until 6 weeks of life by head ultrasound scanning. We sought to determine whether early neonatal glial fibrillary acidic protein (GFAP) levels could identify PWMI in low birthweight (<2500 g) infants.Each case with PWMI on head ultrasound scanning at 6 weeks of life from April 2009 to April 2011 was matched by gestational age and mode of delivery to 2 subsequent neonates with a normal head ultrasound scan. GFAP was measured in cord blood at birth, at neonatal intensive care unit admission, and on days 1-4 of life.During this 2-year period, 21 cases with PWMI with gestational age 27.4 ± 3.3 weeks were compared with 42 control infants. The incidence of cesarean delivery was 61.9% in both groups. GFAP was not significantly different in cord blood or at neonatal intensive care unit admission but was significantly elevated on day 1 (median, 5-95%; 0, 0-0.98 ng/mL cases; 0, 0-0.06 ng/mL control infants; P = .03), day 2 (0, 0-1.21 ng/mL; 0, 0-0.05 ng/mL, respectively; P = .02), day 3 (0.05, 0-0.33 ng/mL; 0, 0-0.04 ng/mL, respectively; P = .004), and day 4 (0.02, 0-1.03 ng/mL; 0, 0-0.05 ng/mL, respectively; P < .001). The odds of the development of PWMI significantly increased with increasing levels of GFAP from day 1-4 of life when adjustment was made for preeclampsia, antenatal steroid administration, and neonatal chronic lung disease.The ability to predict PWMI with a blood test for GFAP shortly after birth opens the possibility for rapid identification of infants for early intervention and provides a benchmark for the qualification of new therapies to improve neurodevelopmental outcomes.

Despite a growing literature assessing pregnancy desires among HIV-infected women enrolled in clinical care, little attention has been paid to HIV-infected youth for whom pregnancy is a very relevant issue. In urban areas with high rates of teen pregnancy and HIV infection, further understanding of childbearing motivations and relationship dynamics influencing pregnancy desires among female youth is needed. This study compares the childbearing motivations, pregnancy desires, and perceived partner desire for a pregnancy among predominately African-American HIV-infected (n=46) and HIV-uninfected (n=355) female youth (15–24 years). An HIV-infected status was not significantly associated with childbearing motivations or the desire for a future pregnancy, p>0.10. HIV-infection was, however, associated with an increased likelihood to perceive that one's partner would have a positive response to a pregnancy (adjusted odds ratio [aOR] 3.5, 95% confidence interval [CI] 1.2–10.4, p=0.02) compared to uninfected peers. While race was not associated with participants’ own desire for a child, white youth were significantly less likely to perceive a positive partner response to becoming pregnant than their African-American peers (aOR 0.23, 95% CI 0.09–0.56, p=0.001). These data suggest that the desire for childbearing is not diminished by HIV infection among urban female youth, highlighting the need for routine, provider-initiated discussions about childbearing with urban youth to minimized unintended pregnancies and HIV transmission.

This study evaluated the impact of the Teen Prevention Education Program (Teen PEP), a peer-led sexuality education program designed to prevent unintended pregnancy and sexually transmitted infections (STIs) including HIV among high school students. The study design was a quasi-experimental, nonrandomized design conducted from May 2007 to May 2008. The sample consisted of 96 intervention (i.e. Teen PEP peer educators) and 61 comparison students from five high schools in New Jersey. Baseline and 12-month follow-up surveys were conducted. Summary statistics were generated and multiple regression analyses were conducted. In the primary intent-to-treat analyses, and secondary non-intent-to-treat analyses, Teen PEP peer educators (versus comparison students) reported significantly greater opportunities to practice sexual risk reduction skills and higher intentions to talk with friends, parents, and sex partners about sex and birth control, set boundaries with sex partners, and ask a partner to be tested for STIs including HIV. In addition in the secondary analysis, Teen PEP peer educators (as compared with the comparison students) had significantly higher scores on knowledge of sexual health issues and ability to refuse risky sexual situations. School-based sexuality education programs offering comprehensive training to peer educators may improve sexual risk behavior knowledge, attitudes and behaviors among high school students.

Deviation of mean arterial blood pressure (MAP) from the range that optimizes cerebral autoregulatory vasoreactivity (optimal MAP) could increase neurological injury from hypoxic-ischemic encephalopathy (HIE). We tested whether a global magnetic resonance imaging (MRI) brain injury score and regional diffusion tensor imaging (DTI) are associated with optimal MAP in neonates with HIE.Twenty-five neonates cooled for HIE were monitored with the hemoglobin volume index. In this observational study, we identified optimal MAP and measured brain injury by qualitative and quantitative MRIs with the Neonatal Research Network (NRN) score and DTI mean diffusivity scalars. Optimal MAP and blood pressure were compared with brain injury.Neonates with blood pressure measurements within optimal MAP during rewarming had less brain injury by NRN score (P = 0.040). Longer duration of MAP within optimal MAP during hypothermia correlated with higher mean diffusivity in the anterior centrum semiovale (P = 0.008) and pons (P = 0.002). Blood pressure deviation below optimal MAP was associated with lower mean diffusivity in cerebellar white matter (P = 0.033). Higher optimal MAP values related to lower mean diffusivity in the basal ganglia (P = 0.021), the thalamus (P = 0.006), the posterior limb of the internal capsule (P = 0.018), the posterior centrum semiovale (P = 0.035), and the cerebellar white matter (P = 0.008). Optimal MAP values were not associated with the NRN score.The NRN score and the regional mean diffusivity scalars detected injury with mean arterial blood pressure deviations from the optimal MAP. Higher optimal MAP and lower mean diffusivity may be related because of cytotoxic edema and limited vasodilatory reserve at low MAP in injured brain. DTI detected injury with elevated optimal MAP better than the NRN score.

Purpose: Young black gay, bisexual, and other MSM (YBMSM) that carry a disproportionate HIV burden in the US Geosocial networking applications (GSN apps) are environments that may increase HIV risk among users. This study explored the acceptability and feasibility of using these apps for HIV/sexually transmitted infection (STI) public health outreach. Design: Semi-structured in-depth qualitative interviews. Setting: A frequently reported GSN app for meeting sex partners by newly diagnosed HIV-infected MSM in Baltimore. Participants: Seventeen YBMSM aged 18 to 24 (mean = 21.5/SD = 1.8) who were logged-on to the GSN app in venues or census tracts in high HIV transmission areas. Methods: Participants completed 60 to 90 minute semi-structured interviews, which were audio-recorded and transcribed. Interview data were analyzed in NVivo10 using categorical analysis and double-coded until consistency was achieved. Results: Participants described GSN apps as acceptable and feasible resources for public health practitioners seeking to access YBMSM to provide HIV/STI treatment and prevention services and resources. Three themes emerged: (1) the need to authenticate public health messages to distinguish from spam; (2) improved access to YBMSM including opportunities to identify and access virtual congregations of youth in non-gay-related spaces; and (3) the importance of avoiding stigmatizing YBMSM when targeting sexual health messages. Conclusion: GSN apps have great potential as tools for identifying and engaging at-risk YBMSM. Additional work is needed to understand limitations of this medium, to develop strategies to engage YBMSM without further stigmatizing them, and to maximize their outreach potential.

In the context of increasing syphilis rates, particularly among Black men who have sex men (MSM), the objectives were to determine the associations between methamphetamine (meth) use and syphilis and HIV positivity, and to identify sex partner meeting venues as potential intervention access points among Black MSM in a mid-Atlantic US city.This study is an ongoing longitudinal cohort study. Participants were recruited from clinical and nonclinical settings and included sexually active MSM aged 18 to 45 years. The baseline visit included a behavioral survey and testing for syphilis, HIV, gonorrhea, and chlamydia. Logistic regression analyses were used for hypothesis testing.Among 359 MSM completing baseline, 74.4% (268) Black MSM were included; 31% (84) were aged 24 to 29 years, 43.7% (117) reported unprotected anal intercourse at last sex, and 15.3% (41) reported meth use in the past 3 months. Sixteen percent (43) had syphilis, 46.6% (125) were living with HIV, and 19.0% (51) had gonorrhea and/or chlamydia. Meth use was associated with sexual and drug risk behaviors and HIV, but not syphilis. In adjusted analyses, meth use increased the odds of HIV positivity by 6.43 (95% confidence interval, 2.30-17.98) and syphilis positivity by 2.57 (95% confidence interval, 1.23-5.37). Four online sex partner meeting venues were associated with meth use and HIV, whereas syphilis was associated with one.Among Black MSM, meth use and syphilis positivity were associated with more than 6-fold and almost 3-fold increased adjusted odds of HIV positivity, respectively. Four specific sex partner meeting venues may be important access points for HIV/sexually transmitted infection and substance use prevention.

LGBTQ + persons experience significant health inequities and medical distrust resulting from anti-LGBTQ + bias or cultural incompetence from health care workers (HCW). This program evaluation examined whether storytelling events where LGBTQ + persons shared personal and patient experiences changed HCW understanding, beliefs, and practices related to LGBTQ + patients. Five storytelling events, held biannually in Baltimore, Maryland from 2016 to 2018, were evaluated using post-event surveys, written reflections/notes during the event, and a survey of HCW in a citywide care collaborative focused on HIV prevention and treatment for LGBTQ + persons that did and did not attend a storytelling event. We analyzed surveys to measure differences in understanding, beliefs and practices and used thematic qualitative analysis of written reflections/notes from the storytelling events. 416 persons attended storytelling events; 124(30 %) completed post-event surveys and 449 written reflections/notes were collected. 56 HCW completed post-event surveys; 49(87.5 %) strongly agreed/agreed they better understood LGBTQ + patients. Emergent themes from the 43 HCW written reflections/notes included improved understanding and new approaches for engaging LGBTQ + patients. Among HCW survey respondents (n = 111), attending an event was associated with significant differences in beliefs (p = 0.024) and practices (p = 0.000) related to LGBTQ + patients. Storytelling events may serve as effective tools for increasing HCW's understanding, beliefs and practices. This strategy may ultimately help decrease anti-LGBTQ + bias, reduce medical distrust and lower barriers to HIV prevention/treatment for LGBTQ + persons.

Abstract Background The impact of coronavirus disease 2019 (COVID-19) mitigation measures on sexually transmitted infection (STI) transmission and racial disparities remains unknown. Our objectives were to compare sex and drug risk behaviors, access to sexual health services, and STI positivity overall and by race during the COVID-19 pandemic compared with pre-pandemic among urban sexual minority men (MSM). Methods Sexually active MSM aged 18–45 years were administered a behavioral survey and STI testing every 3-months. Participants who completed at least 1 during-pandemic (April 2020–December 2020) and 1 pre-pandemic study visit (before 13 March 2020) that occurred less than 6 months apart were included. Regression models were used to compare during- and pre-pandemic visit outcomes. Results Overall, among 231 MSM, reports of more than 3 sex partners declined(pandemic-1: adjusted prevalence ratio 0.68; 95% confidence interval: .54–.86; pandemic-2: 0.65, .51–.84; pandemic-3: 0.57, .43–.75), substance use decreased (pandemic-1: 0.75, .61–.75; pandemic-2: 0.62, .50–.78; pandemic-3: 0.61, .47–.80), and human immunodeficiency virus/preexposure prophylaxis care engagement (pandemic-1: 1.20, 1.07–1.34; pandemic-2: 1.24, 1.11–1.39; pandemic-3: 1.30, 1.16–1.47) increased. STI testing decreased (pandemic-1: 0.68, .57–.81; pandemic-2: 0.78, .67–.92), then rebounded (pandemic-3: 1.01, .87–1.18). Nei­ther Chlamydia (pandemic-2: 1.62, .75–3.46; pandemic-3: 1.13, .24–1.27) nor gonorrhea (pandemic-2: 0.87, .46 1.62; pandemic-3: 0.56, .24–1.27) positivity significantly changed during vs pre-pandemic. Trends were mostly similar among Black vs. non-Black MSM. Conclusions We observed sustained decreases in STI risk behaviors but minimal change in STI positivity during compared with pre-pandemic. Our findings underscore the need for novel STI prevention strategies that can be delivered without in-person interactions.

Geographic areas characterized by a high prevalence of sexually transmitted infections (STIs) are critical to the maintenance and persistence of STIs within populations. Sex partner concurrency has been shown to be associated with increased risk for individual-level STIs.The objectives of this study were to determine whether gonorrhea rate per census block group and sex partner concurrency independently and interactively are associated with a current bacterial STI among adolescents.Face-to-face interviews and urine testing for Chlamydia trachomatis and Neisseria gonorrhoeae were conducted among female, sexually active, 14- to 19-year-olds presenting for reproductive clinic care between August 2000 and June 2002.Gonorrhea rate per census block group and sex partner concurrency were not independently but were interactively associated with a current bacterial STI. Among participants with a main sex partner who practiced concurrency, living in high-prevalence geographic areas was significantly associated with a current bacterial STI.The results suggest that geographic context may moderate an adolescent sex partner's behaviors. The research adds to the basic understanding of sexually transmitted disease transmission and acquisition in a high-prevalence inner-city setting.

ABSTRACT Objective: This secondary data analysis study examines the relationship between maternal sociodemographic variables, life events, chronic stressors, including asthma control and management and environmental stressors, and maternal depression. Design: Cross‐sectional descriptive design study consisting of baseline data from participants enrolled in a randomized asthma communication educational intervention trial. Sample: 201 mothers of children with asthma (ages 6–12), recruited from community pediatric practices and emergency departments of 2 urban university hospitals. Measurement: Life events were measured using standardized items. Chronic stressors were measured using items from the International Asthma and Allergies in Childhood study and maternal and child exposure to violence. Depressive symptoms were assessed with the Center for Epidemiologic Studies‐Depression scale. Results: Close to 25% of the mothers had high depressive symptoms. In separate multiple logistic regression models, education (adjusted odds ratio [AOR]=2.62; 95% confidence interval [CI]=1.07, 6.39) or unemployment (AOR=2.38; 95% CI=1.16, 4.90) and the use of quick relief medications (AOR=2.74; 95% CI=1.33, 5.66) for asthma were positively associated with depressive symptoms. Conclusions: Implications include the need to assess maternal depressive symptoms of mothers of children with asthma, in order to improve asthma management for low‐income urban children.

Rates of sexually transmitted infections (STIs) are strongly associated with neighborhood poverty; however, the mechanisms responsible for this association remain unclear. Using a population-based study of sexual networks among urban African American adolescents, we tested the hypothesis that poverty, unemployment, and the sex ratio drive STI rates by affecting sexual network structure. Participants were categorized as being in one of three network positions that had previously been found to be strongly linked to infection with chlamydia and gonorrhea: being in a confirmed dyad (i.e., a monogamous pair), being connected to a larger network through one partner, and being in the center of a larger network. We found that only poverty was statistically significantly associated with sexual network position. Residing in the poorest third of neighborhoods was associated with 85% decreased odds of being in confirmed dyads. There was no association of sexual network position with neighborhood employment. Living in a neighborhood with an unequal number of young men and women appeared to be associated with a higher likelihood of being in a confirmed dyad; however, the differences were not statistically significant. These results suggest that poverty may impact STI rates by shaping sexual network structure, but we did not find any evidence that this association operates through unemployment or the sex ratio.

To determine if glial fibrillary acidic protein (GFAP) is associated with brain injury in children with sickle cell disease (SCD), we measured plasma GFAP among cross-sectional groups of unselected children with SCD, subsets of children with SCD and normal brain MRI or MRI evidence of cerebral infarct, healthy pediatric controls, and adults with brain injury. Children with SCD had higher plasma GFAP than healthy pediatric controls (mean concentrations 0.14 ± 0.37 vs. 0.07 ± 0.08 ng/mL; P = 0.003); also, 16.0% (16/100) of children with SCD and cerebral infarct had GFAP elevations above the 95th percentile of healthy pediatric controls (P = 0.04). Although not statistically significant, more children with SCD and cerebral infarct had elevated GFAP levels than with SCD, and no infarct (16/100, 16.0% vs. 14/168, 8.3%; P = 0.07) was observed. Children with SCD and acute brain ischemia had a higher proportion of elevated GFAP than SCD children with normal MRI (3/6, 50% vs. 8.3%; P = 0.01). GFAP was associated with elevated systolic blood pressure in the preceding year and correlated positively with white blood cell count and negatively with age and performance IQ. Plasma GFAP is elevated among children with SCD and may be associated with subclinical brain injury. To determine if glial fibrillary acidic protein (GFAP) is associated with brain injury in children with sickle cell disease (SCD), we measured plasma GFAP among cross-sectional groups of unselected children with SCD, subsets of children with SCD and normal brain MRI or MRI evidence of cerebral infarct, healthy pediatric controls, and adults with brain injury. Children with SCD had higher plasma GFAP than healthy pediatric controls (mean concentrations 0.14 ± 0.37 vs. 0.07 ± 0.08 ng/mL; P = 0.003); also, 16.0% (16/100) of children with SCD and cerebral infarct had GFAP elevations above the 95th percentile of healthy pediatric controls (P = 0.04). Although not statistically significant, children with SCD and cerebral infarct had more elevated GFAP levels than with SCD and no infarct (16/100, 16.0% vs. 14/168, 8.3%; P = 0.07). Children with SCD and acute brain ischemia had a higher proportion of elevated GFAP than SCD children with normal MRI (3/6, 50% vs. 8.3%; P = 0.01). GFAP was associated with elevated systolic blood pressure in the preceding year and correlated positively with white blood cell count and negatively with age and performance IQ. Plasma GFAP is elevated among children with SCD and may be associated with subclinical brain injury. Brain injury in sickle cell disease (SCD) occurs on a spectrum of severity. On one end of the spectrum, children are normal or manifest subtle deficits only on sensitive neurocognitive testing; alternatively, on the severe end of the spectrum, people with SCD can acquire devastating neurologic deficits [1-3]. Cerebral infarct is the most commonly observed form of brain injury, and it may be detected as silent cerebral infarct (SCI) or overt infarct with neurologic deficits. In cases of overt stroke, traumatic brain injury, and other forms of CNS injury, plasma levels of neuronal and glial proteins reflect cellular leak from areas of injury [4-6]. Biomarkers in this group can be very specific for brain injury. This approach of using brain-specific proteins has been taken by investigators to identify biomarkers of overt stroke in adults [7-11]; however, the identification of brain injury from brain-specific proteins leaked into the plasma of SCD patients, or any patient with clinically silent infarct or ischemia, has not been described. GFAP is a highly brain-specific intermediate filament protein, which is a known biomarker of acute stroke and head trauma in adults [6, 12-15]. In ongoing studies of SCD plasma for proteomic discovery of brain injury biomarkers, we noted that GFAP was detectable in the plasma of some patients with SCD; therefore, we tested the hypothesis that elevations in plasma GFAP are associated with brain injury in children with SCD. Baseline characteristics for healthy pediatric controls and children with SCD screened for SCI as part of the SIT Trial with baseline plasma GFAP levels are shown in Supporting Information Table I. Adjudicated MRI readings were available on 268/295 (90.8%) of SIT trial subjects with plasma GFAP measurements. Figure 1A shows GFAP levels for healthy pediatric controls (n = 60), children with SCD (n = 295), and adults with overt brain injury 1–22 days prior (n = 28). To validate that our GFAP assay detected elevated plasma GFAP in the context of brain injury, a positive control population composed of plasma samples from adults after acute stroke (n = 12), brain biopsy (n = 3), or partial brain resection (n = 13) was assayed and found to have mean plasma GFAP levels of 0.906, 1.42, and 5.10 ng/mL, respectively. As the plasma concentration of GFAP in children is unknown, we established the normal range using controls from a general pediatric outpatient clinic. Healthy pediatric controls had a mean plasma GFAP concentration of 0.072 ± 0.083 ng/mL, and children with SCD had a mean of 0.144 ± 0.368 ng/mL (P = 0.003). The 95th percentile for GFAP in healthy pediatric controls was 0.227 ng/mL, with 3/60 healthy pediatric controls (5.0%) above this threshold. Log plot of plasma GFAP concentrations in children with SCD and controls. (A) Displayed are GFAP concentrations in healthy pediatric controls (n = 60), children 5–14 years old with HbSS and HbSβ°–thalassemia (n = 295); and adults with overt brain injury: stroke (n = 12), brain biopsy (n = 3), or partial brain resection (n = 13) 1–22 days prior. There is one GFAP observation per subject. Bars represent mean values. (B) Log plot of plasma GFAP concentrations in subsets of SCD children with no infarct by brain MRI (n = 168), cerebral infarct by brain MRI (n = 100), and MRI (DWI) evidence of acute infarct (n = 6) and plasma drawn within 21 days of the MRI. The dashed line marks the 95th percentile value among 60 healthy pediatric controls, and percentages list the proportions above the 95th percentile of healthy controls. Children with SCD and cerebral infarct on MRI had more elevated GFAP levels than healthy pediatric controls, as defined by the 95th percentile cutoff (16/100, 16.0%; P = 0.04). SCD subjects with normal brain MRI had a similar proportion of elevated GFAP to healthy pediatric controls (14/168, 8.3%; P = 0.6). The proportion of SCD subjects with cerebral infarct and elevated GFAP (16.0%) was higher than SCD subjects with normal MRI and elevated GFAP (8.3%), although the difference was not statistically significant (P = 0.07, Fig. 1B). To determine the temporal relationship between GFAP levels and cerebral infarct, we analyzed GFAP levels in all children with acute brain ischemia by MRI, as defined by restricted diffusion on diffusion-weighted imaging (DWI) and a corresponding decrease in signal intensity on the apparent diffusivity coefficient map. Six children with SCD had plasma samples drawn within 21 days of a brain MRI that showed ischemia and DWI positivity. Among children with SCD and positive DWI, 3/6 had elevated GFAP (50%; Fig. 2), which is greater than the proportion of children with SCD and elevated GFAP and cerebral infarct of undetermined age (13.8%; P = 0.05) and SCD children without infarct (8.3%; P = 0.01). Temporal relationship of plasma GFAP levels to diagnosis of acute cerebral infarct. Diffusion weighted brain MRI imaging (DWI) was positive in six children with SCD. Blood samples were drawn either before or after brain MRI. The dashed line marks the 95th percentile value among 60 healthy pediatric controls. The shaded area indicates the approximate age of infarct, as estimated by DWI. The child with a sample drawn 15 days prior to MRI was ultimately determined to have an overt stroke. All children were clinically asymptomatic at the time of MRI screening and sample acquisition. SCI has previously been correlated with higher WBC count and lower hemoglobin [16]. A positive correlation was seen with WBC count, and a negative correlation, although not statistically significant, was seen with hemoglobin (Supporting Information Table II). When stratified by cerebral infarct status, the association between WBC count and GFAP persisted among children without cerebral infarct (Spearman ρ = 0.18, P = 0.02) and children with cerebral infarct (Spearman ρ = 0.20, P = 0.05). Wechsler Abbreviated Scale of Intelligence [17] performance IQ negatively correlated with GFAP levels (Spearman ρ = −0.29, P = 0.04). The verbal IQ assessment showed a nonstatistically significant negative correlation (Spearman ρ = −0.19, P = 0.19). Systolic blood pressure (SBP) has been associated with SCI and overt stroke in adults [18, 19], and we postulated that a relationship may exist between elevated SBP and elevated GFAP in SCD. There was little correlation between GFAP and peak SBP in the year prior to study screening (Supporting Information Table II). To address the possibility that GFAP elevations occur above a threshold SBP, we compared peak SBP over the year before study screening to the presence of elevated GFAP levels. Among children with SCD and peak SBP >2 standard deviations above the sex, height, and age-adjusted mean, GFAP was elevated (>95th percentile of controls) more frequently than among children with SCD and normal peak SBP (17.7% vs. 8.6%, P = 0.04). When stratified by cerebral infarct status, a weak association between peak SBP and GFAP remained among children without cerebral infarct (Spearman ρ = 0.11, P = 0.15) but not children with cerebral infarct (Spearman ρ = 0.01, P = 0.9). There was a negative correlation between age and plasma GFAP concentrations (Supporting Information Table II), which was statistically significant among children with SCD. A negative correlation was also observed among the age-matched healthy pediatric controls (Spearman ρ = −0.19, P = 0.15). Age or developmental-dependent levels of circulating GFAP have not been described previously. We report the distribution of plasma GFAP concentrations and their associations with the spectrum of brain injury in SCD, as assessed by MRI and other measures associated with cerebral infarct. As a group, patients with SCD showed elevated levels of GFAP when compared to healthy pediatric controls, and there was a nonstatistically significant difference between children with and without cerebral infarct. In a subset of six children enriched for acute cerebral ischemia, GFAP was most strongly correlated. The observation that these children had the highest proportion of elevated GFAP (50%), followed by children with SCD and cerebral infarct of undetermined age (13.8%), and, finally, children with SCD and no cerebral infarct (8.3%) suggests that elevated plasma GFAP concentrations may identify some children with cerebral infarct, particularly acute infarct; however, this study design precludes any meaningful conclusions about overall sensitivity and specificity. Plasma GFAP is not elevated in most patients with SCD, even those with a prior cerebral infarct. Thus, GFAP is only weakly associated with cerebral infarct of undetermined age and would not be useful clinically on a cross-sectional basis. The apparent temporal relationship between cerebral infarct and elevated GFAP posed a particular challenge for this study. Because this study was cross sectional, the ages of cerebral infarcts on MRI were unknown, with the exception of six subjects who were serendipitously determined to have acute ischemia. After acute stroke in adults, blood GFAP levels are elevated but return towards baseline within approximately 7 days [6, 14]. The reduction in plasma concentrations of GFAP after brain injury likely represents a combination of the extent and time-course of injury, as well as clearance of plasma proteins by renal and proteolytic pathways; furthermore, clearance may be uniquely affected by SCD pathophysiology, for example, renal hyperfiltration or hemolysis, but the mechanisms of GFAP clearance from blood have yet to be characterized. With our cross-sectional study design, linking an episodic, subclinical event to a transiently elevated plasma biomarker would be a chance event. Longitudinal studies including MRI are necessary to define how long GFAP is elevated in children with SCD and to define further the relationship of GFAP levels to the spectrum of brain MRI findings in SCD. The most striking finding of this study may be that 11.2% of children with SCD and, no overt evidence of neurologic symptoms had elevated GFAP. Children with SCD and elevated GFAP may have ongoing brain injury, regardless of MRI status, as many of these children have extremely high levels that may be consistent with brain injury, and we observed a negative correlation between IQ and GFAP levels. At completion of the SIT Trial, longitudinal studies of serial GFAP measurements and 3-year follow up MRI and neurocognitive studies will be evaluated to determine if elevated plasma GFAP levels precede evidence of brain injury. This longitudinal analysis will be especially important for the children with normal brain MRIs and elevated GFAP, because elevated GFAP may be a harbinger of cerebral infarct or future neurocognitive decline. In summary, we demonstrate for the first time that elevations of plasma GFAP, a known marker of CNS injury, can be detected in the plasma of children with SCD who did not show clinical signs of brain injury, and elevations of GFAP correlate with acute cerebral infarct in SCD, albeit weakly in those of undetermined age. Exploratory associations find that GFAP levels may correlate positively with WBC count and SBP and negatively with age and performance IQ. Further studies of brain-specific blood biomarkers in SCD should increase our understanding of the epidemiology of brain injury and enhance detection, prevention, and treatment of CNS injury in SCD. Four groups of patients were studied: children with SCD, subsets of children with SCD and normal brain MRI or MRI evidence of cerebral infarct, healthy pediatric controls, and adults with overt brain injury and no SCD. The study population of children with SCD was selected from those screened for the SIT Trial (ClinicalTrials.gov NCT00072761) [20]. The SIT Trial is a randomized controlled trial in which children 5 to 14 years old with either HbSS or HbSβ0-thalassemia (n = 1,211) were screened for SCI, and eligible children were randomly assigned to receive blood transfusion therapy or conventional therapy for 36 months. Plasma sample acquisition from the SIT trial was optimized for proteomic studies starting February 2007. For this nested analysis, children with SCD, who were screened in the SIT trial from February 2007 to May 2009, were included. An additional three samples were selected from outside this time-period to include all SIT subjects with known acute brain ischemia on MRI. MRI imaging sequences for acute ischemia (DWI) was not required by the SIT trial, but a subset of study sites elected to perform these sequences. The final sample size included 295 SCD children. Cerebral infarct is defined as MRI signal abnormality visible on two views on T2-weighted images. The signal abnormality must measure at least 3 mm in one dimension, and a determination of cerebral infarct status is adjudicated by a panel of neuroradiologists [20, 21]. The SIT trial is supervised by the Institutional Review Boards at each participating institution. All SIT trial participants signed informed consent. Healthy pediatric controls (5–16 years, n = 60) and adults with overt brain injury (≥18 years, n = 28 with acute stroke, brain biopsy, or partial brain resection) were selected from Johns Hopkins Hospital clinics and inpatient units. For healthy pediatric controls, clinic notes were reviewed to exclude patients with any acute illness, neurologic disorder, or chronic illness other than asthma, obesity, and behavior/mood disorders. Blood from healthy pediatric controls was drawn for routine testing. Deidentified blood samples and clinical data on healthy pediatric controls and adults with overt brain injury were obtained through a separate IRB approved study at Johns Hopkins Hospital. Data were extracted from a central data-coordinating center. SBP was analyzed using gender, height, and age-specific z-scores as values for these measurements. IQ testing was performed only on those children who were eligible by screening criteria and consented to be allocated randomly to treatment assignment in the SIT trial. Blood was collected into ACD or EDTA tubes, spun at 1,500g for 8 min at room temperature per the SIT trial protocol, and stored at −80°C in the biologic repository for the SIT trial at Johns Hopkins University School of Medicine until analysis. Two plasma samples were inadvertently diluted 3.3-fold through a systematic error, and GFAP levels for these samples were adjusted accordingly. The error was reproduced in an experiment to confirm the dilution factor of 3.3. The GFAP assay and performance has been described previously [4]. The primary analysis was to assess whether elevations in plasma GFAP concentrations were different among the following three groups: children with SCD and cerebral infarct, children with SCD and no cerebral infarct, and healthy pediatric controls. GFAP values from adults with overt brain injury are presented to calibrate our GFAP assay with the spectrum of brain injury, and no statistical comparisons are made between these adults and the various pediatric groups. Among children with SCD, we also compared GFAP levels among those with cerebral infarct of undetermined age and a subset of children with positive (DWI) scans by brain MRI, indicating acute or subacute cerebral infarction (within 10–14 days [22, 23]). Twenty-seven children did not have cerebral infarct determination because of withdrawal from the study from screening before MRI (n = 21) or inadequate MRI studies (n = 6). Children were included in analyses if the relevant clinical and laboratory data were available. Means between groups were compared using two-tailed t tests with unequal variance. We compared proportions of elevated concentrations in each SCD group to pediatric healthy controls (abnormal defined by >95% percentile of controls). Tests of proportion were performed using a two-tailed Fisher's exact test. Correlations between GFAP concentrations and other continuous variables were assessed using the Spearman correlation coefficient. Statistical significance was defined as P < 0.05. Values of GFAP below the lower limit of quantification of the assay (0.040 ng/mL) were recorded as zero. Analyses were conducted using Stata v11.1 (Stata Corporation, College Station, TX). W.S. designed and performed research, analyzed data, and wrote the article. E.B.C. designed and performed research. Z.F. designed and performed research. P.D. performed research. L.W. performed research. B.C. designed research. D.W. performed and designed research and analyzed data. J.J. analyzed data and wrote the article. J.V.E. designed research and contributed vital research tools. M.D. designed research, analyzed data, and wrote the article. A.D.E. designed research, analyzed data, and wrote the article. J.C. designed research, performed research, analyzed data, and wrote the article. Additional Supporting Information may be found in the online version of this article. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Our objective was to identify perinatal risk factors that are available within 1 hour of birth that are associated with severe brain injury after hypothermia treatment for suspected hypoxic-ischemic encephalopathy.One hundred nine neonates at ≥35 weeks' gestation who were admitted from January 2007 to September 2012 with suspected hypoxic-ischemic encephalopathy were treated with whole-body hypothermia; 98 of them (90%) underwent brain magnetic resonance imaging (MRI) at 7-10 days of life. Eight neonates died before brain imaging. Neonates who had severe brain injury, which was defined as death or abnormal MRI results (cases), were compared with surviving neonates with normal MRI (control subjects). Logistic regression models were used to identify risk factors that were predictive of severe injury.Cases and control subjects did not differ with regard to gestational age, birthweight, mode of delivery, or diagnosis of nonreassuring fetal heart rate before delivery. Cases were significantly (P < .05) more likely to have had an abruption, a cord and neonatal arterial gas level that showed metabolic acidosis, lower platelet counts, lower glucose level, longer time to spontaneous respirations, intubation, chest compressions in the delivery room, and seizures. In multivariable logistic regression, lower initial neonatal arterial pH (P = .004), spontaneous respiration at >30 minutes of life (P = .002), and absence of exposure to oxytocin (P = .033) were associated independently with severe injury with 74.3% sensitivity and 74.4% specificity.Worsening metabolic acidosis at birth, longer time to spontaneous respirations, and lack of exposure to oxytocin correlated with severe brain injury in neonates who were treated with whole-body hypothermia. These risk factors may help quickly identify neonatal candidates for time-sensitive investigational therapies for brain neuroprotection.

PurposeThis study aimed to describe young men's sexual and reproductive health care (SRHC) receipt by sexual behavior and factors associated with greater SRHC receipt.MethodsThere were 427 male patients aged 15–24 who were recruited from 3 primary care and 2 sexually transmitted disease (STD) clinics in 1 urban city. Immediately after the visit, the survey assessed receipt of 18 recommended SRHC services across four domains: screening history (sexual health, STD/HIV test, family planning); laboratories (STDs/HIV); condom products (condoms/lubrication); and counseling (STD/HIV risk reduction, family planning, condoms); in addition, demographic, sexual behavior, and visit characteristics were examined. Multivariable Poisson regressions examined factors associated with each SRHC subdomain adjusting for participant clustering within clinics.ResultsOf the participants, 90% were non-Hispanic black, 61% were aged 20–24, 90% were sexually active, 71% had female partners (FPs), and 20% had male or male and female partners (M/MFPs). Among sexually active males, 1 in 10 received all services. Half or more were asked about sexual health and STD/HIV tests, tested for STDs/HIV, and were counseled on STD/HIV risk reduction and correct condom use. Fewer were asked about family planning (23%), were provided condom products (32%), and were counseled about family planning (35%). Overall and for each subdomain, never sexually active males reported fewer services than sexually active males. Factors consistently associated with greater SRHC receipt across subdomains included having M/MFPs versus FPs, routine versus non–STD-acute visit, time alone with provider without parent, and seen at STD versus primary care clinic. Males having FPs versus M/MFPs reported greater family planning counseling.ConclusionsFindings have implications for improving young men's SRHC delivery beyond the narrow scope of STD/HIV care.

Experiencing violence has been associated with negative health outcomes. The objectives of this study were to determine whether experiencing violence is associated increased support service needs and suboptimal general health indicators. In addition, we explore the relationship between these and perceived social support among a select sample of urban predominantly male adults in Baltimore City. A cross-sectional survey was conducted among 187 adults being seen in one of seven urban partner agencies participating in a parent HIV prevention and treatment demonstration project. Associations were examined using a multivariable logistic regression model, adjusting for the clinic site at which the client was being seen as well as age and gender identity. There was a significant amount of violence experienced by this population; 131 (72%) reported having seen someone be physically assaulted, and 89 (49%) had been physically assaulted without a weapon. Direct victimization from violence was associated with a threefold increased odds of needing housing and mental health/substance use services. Exposure to violence was associated with a threefold increase in needing housing and mental health/substance use services, and with sub-optimal health status. Perceived social support was associated with 30% decreased reports of experiencing violence. In conclusion, our select sample of urban adults report having experienced high rates of violence, and this is associated with increased support service needs as well as suboptimal perceived health status. Incorporating care for the effects of experiencing violence as well as social service needs are important in optimizing the health of urban populations.

Reducing HIV incidence requires addressing persistent racial/ethnic disparities in HIV burden. Our goal was to evaluate preexposure prophylaxis (PrEP) delivery, overall and relative to community need, among 7 clinical sites participating in a health department-led demonstration project to increase PrEP in Baltimore city, MD.PrEP care continuum stages (screened, indicated, referred, linked, evaluated, prescribed) were examined among HIV-negative individuals receiving services at participating sites between September 30, 2015 and September 29, 2019. Community need was defined using information on new HIV diagnoses (2016-2018). Differences in care continuum progression by demographics/priority population and comparison of demographic compositions between care continuum stages and new HIV diagnoses were examined using modified Poisson regression and χ2 tests, respectively.Among 25,886 PrEP-screened individuals, the majority were non-Hispanic (NH) black (81.1%, n = 20,998), cisgender male (61.1%, n = 15,825), and heterosexual (86.7%, n = 22,452). Overall, 31.1% (n = 8063) were PrEP-indicated; among whom, 56.8% (n = 4578), 15.6% (n = 1250), 10.8% (n = 868), and 9.0% (n = 722) were PrEP-referred, linked, evaluated, and prescribed, respectively. Among 2870 men who have sex with men (MSM), 18.7% (n = 538) were PrEP-prescribed. Across all groups, the highest attrition was between PrEP-referred and PrEP-linked. NH-black race (vs. NH-white) was independently associated with lower likelihood of PrEP prescription (aPR, 0.89; 95% confidence interval, 0.81 to 0.98 controlling for age/gender). Relative to the demographic composition of new HIV diagnoses, fewer NH-blacks (80.2% vs. 54.3%) and more NH-whites (10.7% vs. 30.3%) and MSM were PrEP prescribed (55.2% vs. 74.5%).This project showed promise delivering PrEP referrals and prescriptions overall and to MSM. Substantial improvement is needed to improve linkage overall and to decrease disparities in PrEP prescriptions among NH-blacks. Future work should focus on addressing service gaps that hinder PrEP utilization.

Pre-exposure prophylaxis (PrEP) prevents HIV yet uptake remains suboptimal across the United States. This paper evaluates the impact of outreach activities led by nurse supervised community healthcare workers (CHWs) on the PrEP care cascade.This is an observational programmatic evaluation of LGBTQ + community outreach between March 1, 2016, to March 31, 2020, as part of a public health initiative. Descriptive statistics are used to characterize the data by outreach type.2,465 participants were reached. Overall, a PrEP appointment was scheduled for 94 (3.8%) with 70 (2.8%) confirmed to have completed a PrEP visit. Success for each type of community outreach activity was evaluated with virtual models outperforming face-to-face. Face-to-face outreach identified nine persons among 2,188 contacts (0.41%) completing an initial PrEP visit. The website prepmaryland.org identified 4 among 24 contacts (16.7%) and the PrEP telephone/text warm-line identified 18 among 60 contacts (30%). The PrEPme smartphone application identified 39 among 168 contacts (23.2%).Face-to-face community outreach efforts reached a large number of participants, yet had a lower yield in follow-up and confirmed PrEP visits. All virtual platforms reached lower total numbers, but had greater success in attendance at PrEP visits, suggesting enhanced linkage to care.

Although physical attributes have been shown to be associated with sexually transmitted disease (SD) rates, there is little information about the association between social attributes and STD rates.The objective of this study was to determine the association between gonorrhea prevalence and perceptions of social cohesion in impoverished, urban neighborhoods.We conducted a street-based survey of 18- to 24-year-olds residing in selected census block groups in Baltimore City, Maryland. Census block groups eligible for selection were defined as impoverished (greater than 20% in poverty) and unstable (lowest 25th percentile for stability). From the eligible census block groups, 5 from high gonorrhea rate (greater than the 75th percentile) census block groups and 5 from the lower gonorrhea rate (lowest 25th percentile to equal or greater than the 75th percentile) census block groups were randomly selected. Participants within the 10 selected census block groups were recruited using a street-intercept method. Participants were asked about perceived social cohesion and control.Results showed that for young adults 18 to 24 years of age residing in high gonorrhea census block groups, the mean social cohesion index scores were 1.7 points lower than mean social cohesion index scores of the participants residing in the low gonorrhea census block groups (P <0.01).Future research needs to be conducted to determine the temporal association between gonorrhea prevalence and local social cohesion dynamics.

Moyamoya syndrome carries a high risk of cerebral ischemia, and impaired cerebrovascular autoregulation may play a critical role. Autoregulation indices derived from near-infrared spectroscopy (NIRS) may clarify hemodynamic goals that conform to the limits of autoregulation.The aims of this pilot study were to determine whether the NIRS-derived indices could identify blood pressure ranges that optimize autoregulation and whether autoregulatory function differs between anatomic sides in patients with unilateral vasculopathy.Pediatric patients undergoing indirect surgical revascularization for moyamoya were enrolled sequentially. NIRS-derived autoregulation indices, the cerebral oximetry index (COx) and the hemoglobin volume index (HVx), were calculated intraoperatively and postoperatively to measure autoregulatory function. The 5-mmHg ranges of optimal mean arterial blood pressure (MAPOPT ) with best autoregulation and the lower limit of autoregulation (LLA) were identified.Of seven enrolled patients (aged 2-16 years), six had intraoperative and postoperative autoregulation monitoring and one had only intraoperative monitoring. Intraoperative MAPOPT was identified in six (86%) of seven patients with median values of 60-80 mmHg. Intraoperative LLA was identified in three (43%) patients with median values of 55-65 mmHg. Postoperative MAPOPT was identified in six (100%) of six patients with median values of 70-90 mmHg. Patients with unilateral disease had higher intraoperative HVx (P = 0.012) on side vasculopathy.NIRS-derived indices may identify hemodynamic goals that optimize autoregulation in pediatric moyamoya.

To determine whether blood levels of the brain-specific biomarker glial fibrillary acidic protein rise during cardiopulmonary bypass for repair of congenital heart disease.This is a prospective observational pilot study to characterise the blood levels of glial fibrillary acidic protein during bypass. Children <21 years of age undergoing bypass for congenital heart disease at Johns Hopkins Hospital and Texas Children's Hospital were enrolled. Blood samples were collected during four phases: pre-bypass, cooling, re-warming, and post-bypass.A total of 85 patients were enrolled between October, 2010 and May, 2011. The median age was 0.73 years (range 0.01-17). The median weight was 7.14 kilograms (range 2.2-86.5). Single ventricle anatomy was present in 18 patients (22%). Median glial fibrillary acidic protein values by phase were: pre-bypass: 0 ng/ml (range 0-0.35); cooling: 0.039 (0-0.68); re-warming: 0.165 (0-2.29); and post-bypass: 0.112 (0-0.97). There were significant elevations from pre-bypass to all subsequent stages, with the greatest increase during re-warming (p = 0.0001). Maximal levels were significantly related to younger age (p = 0.03), bypass time (p = 0.03), cross-clamp time (p = 0.047), and temperature nadir (0.04). Peak levels did not vary significantly in those with single ventricle anatomy versus two ventricle repairs.There are significant increases in glial fibrillary acidic protein levels in children undergoing cardiopulmonary bypass for repair of congenital heart disease. The highest values were seen during the re-warming phase. Elevations are significantly associated with younger age, bypass and cross-clamp times, and temperature nadir. Owing to the fact that glial fibrillary acidic protein is the most brain-specific biomarker identified to date, it may act as a rapid diagnostic marker of brain injury during cardiac surgery.

This study examined temporal and spatial relationships between neighborhood drug markets and gonorrhea among census block groups from 2002 to 2005. This was a spatial, longitudinal ecologic study. Poisson regression was used with adjustment in final models for socioeconomic status, residential stability and vacant housing. Increased drug market arrests were significantly associated with a 11% increase gonorrhea (adjusted relative risk (ARR) 1.11; 95% CI 1.05, 1.16). Increased drug market arrests in adjacent neighborhoods were significantly associated with a 27% increase in gonorrhea (ARR 1.27; 95% CI 1.16, 1.36), independent of focal neighborhood drug markets. Increased drug market arrests in the previous year in focal neighborhoods were not associated with gonorrhea (ARR 1.04; 95% CI 0.98, 1.10), adjusting for focal and adjacent drug markets. While the temporal was not supported, our findings support an associative link between drug markets and gonorrhea. The findings suggest that drug markets and their associated sexual networks may extend beyond local neighborhood boundaries indicating the importance of including spatial lags in regression models investigating these associations.

Abstract Background Cerebrovascular reactivity monitoring has been used to identify the lower limit of pressure autoregulation in adult patients with brain injury. We hypothesise that impaired cerebrovascular reactivity and time spent below the lower limit of autoregulation during cardiopulmonary bypass will result in hypoperfusion injuries to the brain detectable by elevation in serum glial fibrillary acidic protein level. Methods We designed a multicentre observational pilot study combining concurrent cerebrovascular reactivity and biomarker monitoring during cardiopulmonary bypass. All children undergoing bypass for CHD were eligible. Autoregulation was monitored with the haemoglobin volume index, a moving correlation coefficient between the mean arterial blood pressure and the near-infrared spectroscopy-based trend of cerebral blood volume. Both haemoglobin volume index and glial fibrillary acidic protein data were analysed by phases of bypass. Each patient’s autoregulation curve was analysed to identify the lower limit of autoregulation and optimal arterial blood pressure. Results A total of 57 children had autoregulation and biomarker data for all phases of bypass. The mean baseline haemoglobin volume index was 0.084. Haemoglobin volume index increased with lowering of pressure with 82% demonstrating a lower limit of autoregulation (41±9 mmHg), whereas 100% demonstrated optimal blood pressure (48±11 mmHg). There was a significant association between an individual’s peak autoregulation and biomarker values (p=0.01). Conclusions Individual, dynamic non-invasive cerebrovascular reactivity monitoring demonstrated transient periods of impairment related to possible silent brain injury. The association between an impaired autoregulation burden and elevation in the serum brain biomarker may identify brain perfusion risk that could result in injury.

AbstractWhile HIV is prevalent among adolescents and young adults, testing levels remain low and little is known about gender differences in HIV testing. The objectives of this study were to describe the prevalence of past-year HIV testing and evaluate associations between HIV testing and individual- and partner-level factors by gender among heterosexually experienced youth (15–24 years) in Baltimore, Maryland (N = 352). Past-year HIV testing was prevalent (60.1%) and differed by gender (69.4% among women vs. 49.6% among men, p = 0.005). For women, African-American race (AOR 3.09) and recent older partner by ≤2 years (AOR 4.04) were significantly associated with testing. Among men, only African-American race was associated with testing (OR 4.23), with no patterns identified based on risk behavior or perceived partner risk. HIV testing among adolescent and young adults was prevalent in this highly affected urban area. Findings emphasize the value of a gender lens, and provide direction for optimizing engagement in HIV testing.Keywords: adolescentHIV testinggender differences Additional informationFundingThis study was supported by the National Institute of Child Health and Human Development [NICHD R01HD057789; PI Sherman] and the Johns Hopkins Center for AIDS Research [JHU CFAR; NIAID 1P30AI094189; PI Chaisson].

Background The release of the first drug for human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) in 2012 marked the beginning of a new era of HIV prevention. Although PrEP is highly efficacious, identifying and ultimately increasing uptake among the highest risk male subgroups remains a challenge. Methods Public health surveillance data from 2009 to 2016 was used to evaluate the risk of an HIV diagnosis after a syphilis (ie, primary, secondary, or early latent), gonorrhea, and repeat diagnoses among urban males, including men who have sex with men (MSM) and non-MSM in Baltimore City. Results Of the 1531 males with 898 syphilis diagnoses and 1243 gonorrhea diagnoses, 6.8% (n = 104) were subsequently diagnosed with HIV. Within 2 years, 1 in 10 syphilis or gonorrhea diagnoses were followed by an HIV diagnosis among MSM, and 1 in 50 syphilis or gonorrhea diagnoses were followed by an HIV diagnosis among non-MSM. Among non-MSM with gonorrhea, the rate of HIV incidence was 5.36 (95% confidence interval, 2.37–12.14) times higher in those with (vs. without) a subsequent syphilis diagnosis or gonorrhea diagnosis. Conclusions Local health care providers should offer PrEP to MSM diagnosed with syphilis or gonorrhea and to non-MSM with a previous gonorrhea diagnosis at time of a syphilis or gonorrhea diagnosis. The high proportion and short time to an HIV diagnosis among MSM after a syphilis or gonorrhea diagnosis suggest immediate PrEP initiation.

Objective: There are few cost-effectiveness analyses that model alcohol outlet zoning policies. This study determines the potential decreases in homicides, disability-adjusted life years (DALYs), and victim and criminal justice costs associated with four policy options that would reduce the alcohol outlet access in Baltimore. Method: This cost-effectiveness analysis used associations between on-premise (incidence rate ratio [IRR] = 1.41), off-premise (IRR = 1.76), and combined on- and off-premise outlet density (IRR = 1.07) and homicide in Baltimore. We determined the potential change in the level of homicide that could occur with changes in the density of alcohol outlets, assuming that 50% of the association was causal. Results: Reducing alcohol outlet density in Baltimore City by one quintile was associated with decreases of 51 homicides per year, $63.7 million, and 764 DALYs. Removing liquor stores in residential zones was associated with 22 fewer homicides, which would cost $27.5 million and lead to 391 DALYs. Removing bars/taverns operating as liquor stores was associated with a decrease of one homicide, $1.2 million, and 17 DALYs. Removing both the liquor stores in residential zones and the bars/taverns operating as liquor stores was associated with 23 fewer homicides, which translated to $28.7 million and 409 DALYs. Conclusions: For preventing homicides, the strategy of removing liquor stores in residential zones was preferred because it was associated with substantial reductions in homicides without closing unacceptably high numbers of outlets. It is possible that policies that close the bars/taverns operating as liquor stores would be associated with decreases in other types of violent crime.

Etiologies of HIV disparities are multifaceted; anti-LGBTQ stigma and social marginalization are contributory factors. A city health department developed a program, #ProjectPresence, exhibiting professional photos of Black LGBTQ persons in public spaces. An academic partner explored the relationship of the program to visibility, anti-LGBTQ stigma and social marginalization of Black LGBTQ persons, i.e. models, directly involved in the program and their perceptions of these relationships more broadly for community members. Brief self-administered surveys and semi-structured, in-depth interviews with #ProjectPresence models (n = 15) were conducted after the program to gather their experiences before, during and after the program. Descriptive analyses of survey responses were conducted using Stata 15.1. Interviews were audio-recorded, transcribed and analyzed in NVivo10 using categorical analysis. Surveys indicated prevalent experiences of enacted stigma (73 %) and perceptions of poor local acceptance of LGBTQ people (53 %). Interviews suggested that the program may have influenced positive individual- and community-level changes by increasing visibility of LGBTQ communities and improving acceptance among non-LGBTQ persons, inspiring personal growth and self-acceptance among models, and providing opportunities to foster new connections among LGBTQ subpopulations. Our findings suggest similar programs may present promising approaches for the reduction of stigma and social marginalization affecting LGBTQ persons and communities.

Syphilis incidence is increasing among reproductive-aged women, and previous sexually transmitted infections (STIs) are a risk factor for subsequent STIs. This study aimed to determine syphilis incidence after a chlamydia, gonorrhea, or HIV diagnosis, and identify characteristics associated with higher syphilis incidence rates among reproductive-aged women in 1 mid-Atlantic city.A retrospective cohort of 85,113 chlamydia, gonorrhea, and HIV diagnoses occurring between 2009 and 2021 and among women aged 13 to 50 years was constructed using public health surveillance data. Cumulative incidence curves were estimated to examine time to early syphilis (i.e., primary, secondary, or early latent) diagnosis, and multivariable analyses determined incidence rate ratios by age (<25 vs. ≥25 years) and number of prior STI diagnoses (0 vs. ≥1) during the study period, stratified by STI.There were 85,113 reportable STI diagnoses and 646 syphilis diagnoses in the cohort. Approximately 1 of 150 chlamydia, 1 of 100 gonorrhea, and 1 of 50 HIV diagnoses were followed by a syphilis diagnosis within 5 years. Cumulative incidence of syphilis differed significantly by STI diagnosis ( P < 0.001). In multivariable analysis, syphilis incidence rates were higher among women diagnosed with ≥1 (vs. 0) prior STI regardless of STI type ( P < 0.05) and among women ≥25 (vs. <25) years old diagnosed with gonorrhea ( P < 0.05).There were significant differences in syphilis incidence by prior STI type, number of STIs, and age. Our data support targeted screening for syphilis among women with a history of STIs, parwomen with ≥1 prior STI diagnosis, and older women diagnosed with gonorrhea.

&lt;div class="section abstract"&gt;&lt;div class="htmlview paragraph"&gt;With the shift towards electrification, automakers are constantly looking for ways to increase efficiency of the electric vehicles (EVs). Whether through advanced materials, battery technology, powertrain optimization, software optimization, or reliability improvements, these strategies can help improve EV range, performance, and energy efficiency, making EVs a more attractive option for consumers. This paper focuses on powertrain optimization by utilizing a two-speed transmission instead of a conventional single-speed solution. Multi-speed transmissions offer faster acceleration, increased speed, better gradeability, and reduced energy consumption, which translates to increased vehicle range. Cost and space are critical factors in development and are considered when selecting architecture. The gear ratios are selected by solving an optimization problem to minimize the energy loss and maximize the dynamic performance. The vehicle system-level simulation is set up in the MATLAB/Simulink environment and comprises the electric plant, drivetrain subsystems, and associated control algorithms. Particle Swarm Optimization (PSO) iteratively searches for the optimal solution, ensuring the motor and the inverter operate in the most efficient region during the selected drive cycle. The present architecture considers a three-plane or 3-stage with a 2-speed design. Stages 1 &amp;amp; 3 incorporate compound offset gearing with the 3rd stage connecting to the differential. The shiftable 2nd stage is proposed as a planetary gearset with a sun connection to the 1st stage and carrier connection to the 3rd stage. The planetary ring member can be fixed or released in case of 1st speed or 2nd speed respectively. The ring member release can also support free-wheel conditions in the case of all-wheel drive (AWD) vehicles in one-axle drive mode. Bi-stable electromagnetic clutches are used instead of conventional frictional clutches, making it a compact and efficient solution. Software control is used to optimize the handshake between clutches to facilitate the feel of a power shift. The initial findings suggest that by incorporating a multispeed transmission, the main motor in an electric vehicle can be downsized to half its power while maintaining two-thirds of its torque. Simulation suggests an increase of 52% in overall efficiency for such a configuration.&lt;/div&gt;&lt;/div&gt;

Objectives: To determine if hours of daily television viewed by varying age groups of young children with Hispanic mothers differs by maternal language preference and to compare these differences with young children with white mothers.Design: Cross-sectional analysis of data collected in 2000 from the National Survey of Early Childhood Health.Setting: Nationally representative sample.Participants: One thousand three hundred forty-seven mothers of children aged 4 to 35 months.Main Exposure: Subgroups of self-reported maternal race/ethnicity (white or Hispanic) and within Hispanic race/ethnicity, stratification by maternal language preference (English or Spanish).Outcome Measure: Hours of daily television the child viewed.Results: Bivariate analyses showed that children of English-vs Spanish-speaking Hispanic mothers watched more television daily (1.88 vs 1.31 hours, P Ͻ.01).Multivariable regression analyses stratified by age revealed differences by age group.Among 4-to 11-month-old in-

To inform policy debates surrounding marijuana decriminalization and add to our understanding of social and structural influences on youth drug use, we sought to determine whether there was an independent association between neighborhood drug prevalence and individual-level marijuana use after controlling for peer drug and alcohol norms. We analyzed cross-sectional data from a household survey of 563 youth aged 15–24 in Baltimore, Maryland. The study population was 88 % African-American. Using gender-stratified, weighted, multilevel logistic regression, we tested whether neighborhood drug prevalence was associated with individual-level marijuana use after controlling for peer drug and alcohol norms. Bivariate analyses identified a significant association between high neighborhood drug prevalence and marijuana use among female youth (AOR = 1.76, 95 % CI = 1.26, 2.47); the association was in a similar direction but not significant among male youth (AOR = 1.26, 95 % CI = 0.85, 1.87). In multivariable regression controlling for peer drug and alcohol norms, high neighborhood drug prevalence remained significantly associated among female youth (AOR = 1.59, 95 % CI = 1.12, 2.27). Among male youth, the association was attenuated toward the null (AOR = 0.95, 95 % CI = 0.63, 1.45). In the multivariable model, peer drug and alcohol norms were significantly associated with individual-level marijuana use among female youth (AOR = 1.54, 95 % CI = 1.17, 2.04) and male youth (AOR = 2.59, 95 % CI = 1.65, 4.07). This work suggests that individual-level marijuana use among female youth is associated with neighborhood drug prevalence independent of peer norms. This finding may have important implications as the policy landscape around marijuana use changes.

Gay, bisexual, and other sexual minority men have expressed the acceptability of patient portals as tools for supporting HIV prevention behaviors, including facilitating disclosure of HIV and other sexually transmitted infection (STI/HIV) laboratory test results to sex partners. However, these studies, in which Black or African American sexual minority men were undersampled, failed to determine the relationship of reported history of discussing HIV results with sex partners and anticipated willingness to disclose web-based STI/HIV test results using a patient portal.Among a sample of predominantly Black sexual minority men, this study aimed to (1) determine preferences for patient portal use for HIV prevention and (2) test the associations between reported history of discussing HIV results and anticipated willingness to disclose web-based STI/HIV test results with most recent main and nonmain partners using patient portals.Data come from audio-computer self-assisted interview survey data collected during the 3-month visit of a longitudinal cohort study. Univariate analysis assessed patient portal preferences by measuring the valuation rankings of several portal features. Multiple Poisson regression models with robust error variance determined the associations between history of discussing HIV results and willingness to disclose those results using web-based portals by partner type, and to examine criterion validity of the enhancing dyadic communication (EDC) scale to anticipated willingness.Of the 245 participants, 71% (n=174) were Black and 22% (n=53) were White. Most participants indicated a willingness to share web-based STI/HIV test results with their most recent main partner. Slightly fewer, nonetheless a majority, indicated a willingness to share web-based test results with their most recent nonmain partner. All but 2 patient portal features were valued as high or moderately high priority by >80% of participants. Specifically, tools to help manage HIV (n=183, 75%) and information about pre- and postexposure prophylaxis (both 71%, n=173 and n=175, respectively) were the top-valuated features to include in patient portals for HIV prevention. Discussing HIV test results was significantly associated with increased prevalence of willingness to disclose web-based test results with main (adjusted prevalence ratio [aPR] 1.46, 95% CI 1.21-1.75) and nonmain partners (aPR 1.54, 95% CI 1.23-1.93).Our findings indicate what features Black sexual minority men envision may be included in the patient portal's design to optimize HIV prevention, further supporting the criterion validity of the EDC scale. Efforts should be made to support Black sexual minority men's willingness to disclose STI/HIV testing history and status with partners overall as it is associated significantly with a willingness to disclose testing results digitally via patient portals. Future studies should consider discussion behaviors regarding past HIV test results with partners when tailoring interventions that leverage patient portals in disclosure events.

Smoking is a major contributor to morbidity and mortality among individuals with serious mental illness (SMI) and social networks may play an important role in smoking behaviors.Our objectives were to (1) describe the network characteristics of adults with SMI who smoke tobacco (2) explore whether network attributes were associated with nicotine dependence.We performed a secondary analysis of baseline data from a tobacco smoking cessation intervention trial among 192 participants with SMI. A subgroup (n = 75) completed questions on the characteristics of their social network members. The network characteristics included network composition (e.g. proportion who smoke) and network structure (e.g. density of connections between members). We used multilevel models to examine associations with nicotine dependence.Participant characteristics included: a mean age 50 years, 49% women, 48% Black, and 41% primary diagnosis of schizophrenia/schizoaffective disorder. The median personal network proportion of active smokers was 22%, active quitters 0%, and non-smokers 53%. The density of ties between actively smoking network members was greater than between non-smoking members (55% vs 43%, p = .02). Proportion of network smokers was not associated with nicotine dependence.We identified potential social network challenges and assets to smoking cessation and implications for network interventions among individuals with SMI.

The social determinants of health (SDH) include factors apart from genes and biology that affect population health. Zoning is an urban planning tool that influences neighborhood built environments. We describe the methods and results of a health impact assessment (HIA) of a rezoning effort in Baltimore, Maryland, called TransForm Baltimore. We highlight findings specific to physical activity, violent crime, and obesity.We conducted a multistage HIA of TransForm Baltimore using HIA practice guidelines. Key informant interviews identified focus areas for the quantitative assessment. A literature review and a zoning code analysis evaluated potential impacts on neighborhood factors including physical activity, violent crime, and obesity. We estimated potential impacts in high- and low-poverty neighborhoods. The findings resulted in recommendations to improve the health-promoting potential of TransForm Baltimore.Mixed-use and transit-oriented development were key goals of TransForm Baltimore. Health impacts identified by stakeholders included walkability and healthy communities. For Baltimore residents, we estimated that (1) the percentage of people living in districts allowing mixed-use and off-premise alcohol outlets would nearly triple, (2) 18% would live in transit-oriented development zones, and (3) all residents would live in districts with new lighting and landscaping guidelines. Limiting the concentration of off-premise alcohol outlets represented an opportunity to address health promotion.Changes to Baltimore's zoning code could improve population health including decreasing violent crime. HIAs are an important platform for applying SDH to public health practice. This HIA specifically linked municipal zoning policy with promoting healthier neighborhoods.

Baltimore, Maryland ranks among U.S. cities with the highest incidence of HIV infection among men who have sex with men (MSM). HIV screening at sex partner meeting places or venues frequented by MSM with new diagnoses and/or high HIV viral load may reduce transmission by identifying and linking infected individuals to care. We investigated venue-based clustering of newly diagnosed MSM to identify high HIV transmission venues. HIV surveillance data from MSM diagnosed between October 2012-June 2014 and reporting ≥1 sex partner meeting place were examined. Venue viral load was defined according to the geometric mean viral load of the cluster of cases that reported the venue and classified as high (>50,000 copies/mL), moderate (1500-50,000 copies/mL), and low (<1500 copies/mL). 143 MSM provided information on ≥1 sex partner meeting place, accounting for 132 unique venues. Twenty-six venues were reported by > 1 MSM; of these, a tightly connected cluster of six moderate viral load sex partner meeting places emerged, representing 66% of reports. Small, dense networks of moderate to high viral load venues may be important for targeted HIV control among MSM.

Following the 2014 expansions of Medicaid and private health insurance through the Affordable Care Act, municipal sexually transmitted disease (STD) clinics-which have historically served predominantly uninsured patients-have been threatened with budget cuts nationwide. This study was conducted to evaluate the impact of the insurance expansions on the demand for STD clinic services.The proportion of total incident sexually transmitted infections in Baltimore City that were diagnosed at STD clinics was compared between 2013 and 2014, and a multivariate analysis was conducted to determine factors associated with diagnosis at an STD clinic. Analyses were conducted in July 2015.There was no change in the overall proportion of sexually transmitted infection diagnoses made at STD clinics from 2013 to 2014 (relative rate, 1.03; 95% CI=0.95, 1.11). Hispanic ethnicity, black race, male sex, and age >24 years were associated with an increased likelihood of STD clinic utilization (p<0.0001).Despite the Affordable Care Act's insurance expansion measures, the demand for STD clinics remained stable. These safety net clinics serve patients likely to face barriers to accessing traditional health care and their preservation should remain a priority.

Background: HIV pre-exposure prophylaxis (PrEP) retention, defined as quarterly clinical evaluation, is critical to reducing HIV incidence. Our objectives were to determine: (1) visit- and individual-level PrEP retention patterns; (2) and individual-level characteristics associated with low-level PrEP retention 12 months after initiation among PrEP users in Baltimore City, Maryland. Methods: Information was abstracted from medical records among individuals initiating PrEP between October 1, 2015 and February 28, 2018. Visit-level PrEP retention was defined as evidence of PrEP use, documented PrEP prescription, or current PrEP use at each quarterly follow-up visit. Low-level PrEP retention was defined as &lt;3/4 quarters with documented PrEP use. Multilevel mixed effects Poisson regression was used to determine characteristics associated with low-level PrEP retention. Results: Among 412 individuals initiating PrEP and followed for 12 months, the majority was: cis-gender male (83.7%, n = 345), non-Hispanic Black (56.3%, n = 232) and gay, bisexual, or other man who has sex with men (74.0%, n = 305). By quarterly visits, PrEP retention was: 3-month: 69.4% (n = 286); 6-month: 51.9% (n = 214); 9-month: 44.5% (n = 183); and 12-month: 41.1% (n = 169). Three-fifths (58.5%, n = 241) had low-level PrEP retention. Cis-gender females (vs. cis-gender males) (adjusted relative risk: 1.36, 95% confidence interval: 1.04 to 1.77) were more likely to have low-level PrEP retention. Conclusions: Our observed PrEP retention rates are lower than what may be needed to reduce HIV incidence. Future research should examine individual- and clinic-level barriers and facilitators to PrEP retention programs by key population to inform interventions for PrEP retention.

Background: Black men who have sex with men (MSM) carry the greatest burden of new HIV diagnoses in the United States. Ending the HIV epidemic requires strategic, culturally specific approaches to target factors contributing to persistent HIV disparities. Setting: Safe Spaces 4 Sexual Health (SS4SH), a community-informed HIV/sexually transmitted infection (STI) testing strategy combining mobile van testing with online outreach, was implemented over a 14-month period from 2018 to 2019 in Baltimore, MD. Methods: We evaluated the reach of MSM at high risk with high acquisition or transmission risk by SS4SH mobile van combined with online outreach as compared with the Baltimore City Health Department's venue-based mobile van (with no online outreach) operating during the same period based on the following HIV/STI testing outcome measures: (1) number of MSM HIV or STI tested, (2) new HIV diagnosis rate, (3) percent with new syphilis diagnosis, (4) percent at high risk for HIV acquisition, and (5) percent people living with HIV at high risk for transmission. Results: Over a 14-month period, SS4SH HIV/STI tested 151 MSM. Of these, 74% were Black and the mean age was 34 (SD = 10, range = 19–68). Seven percent (10/148) were new HIV diagnoses, and 10% (13/130) were diagnosed with syphilis. The Baltimore City Health Department's venue-based mobile van strategy yielded 53% (231) more MSM (71% Black, mean age 38, SD = 14, range = 15–74), but the HIV/syphilis positivity rate was significantly lower: 0.5% new HIV diagnosis rate ( P &lt; 0.001) and 0.5% with syphilis diagnosis ( P &lt; 0.001). Conclusions: Our findings suggest SS4SH combing online outreach with mobile van testing may be more effective at reaching high-risk Black MSM than venue-based mobile testing.

In sexual networks, bridge members engaging in discordant partnering play key roles in maintaining and transmitting sexually transmitted infections (STIs) within a population.The goal was to characterize adolescents likely to engage in discordant sexual relationships with main and casual sex partners.Egocentric data about adolescents and their most recent sex partner(s) collected over 6 months were analyzed with use of logistic regression.History of STI, drug use, and meeting venue were significantly associated with discordant sexual partnering among high-risk adolescents. Participants with histories of high-risk behavior, e.g., hard drug use or STI, were more likely to have had a recent, dissimilar partner than those with lower-risk profiles. Particular meeting venues, such as clubs and street locations, were more likely to be associated with age-discordant, race-discordant, and drug use-discordant partnerships for females.Bridge members of adolescent sexual networks were more likely to have a history of STI, hard drug use, or meeting their sex partner through particular venues.

Silent cerebral infarction (SCI) is a prevalent problem in sickle cell anaemia (SCA, defined herein as HbSS or HbSB0 thalassaemia); by age 6 years, 27% of children with SCA have had a SCI (Kwiatkowski et al, 2009) and by age 14 years, 37% (Bernaudin et al, 2011). Children with SCI are at greater risk for overt stroke, recurrent or progressive SCI, and impaired cognitive function than the general SCA population. SCI is presumed, but not proven to represent infarctive injury. The mechanism underlying SCI in SCA is not fully understood, but is probably multifactorial. Anaemia and relative high blood pressure, endothelial cell activation, hypercoagulopathy, alterations in vasomotor tone secondary to decreased nitric oxide bioavailabilty, reperfusion injury, intravascular haemolysis and the impaired haemodynamics and resultant increased blood flow to the brain that result from anaemia have been postulated to contribute to the pathogenesis of infarction in SCA patients (Kato et al, 2007; DeBaun et al, 2012). Thrombospondin 1 (THBS1 or TSP1) and L-selectin have been implicated in sickle cell-related complications, including vaso-occlusive crisis and stroke, but their role in SCI has not been evaluated. We tested the hypothesis that children with SCA and SCI would have altered plasma THSB1 and L-selectin levels when compared to children with SCA and no SCI. We used commercially available immunoassays to measure plasma THSB1 and L-selectin levels in 116 children with SCA (n = 65 with SCI, n = 51 without SCI, one sample per patient). These steady state plasma samples were obtained from the Silent Infarct Transfusion (SIT) Trial Biologic Repository at the Johns Hopkins University. This was a convenience sample, selected from 524 available undiluted plasma samples from patients who were enrolled in the trial between February 2007 and May 2009 and had plasma samples that were processed per protocol (Casella et al, 2010). Baseline characteristics were similar between the SCI and non-SCI groups; no differences in mean Hb, white blood cell or platelet counts were observed. Children with SCI had higher median THSB1 values than the non-SCI controls (8·4 vs. 6·2 μg/ml for SCI and non-SCI, respectively, P = 0·03; Fig 1A). Compared to without SCI, 14% (n = 9/65) of children with SCI had THSB1 values above the 95th percentile for non-SCI THSB1 values (Fig 1B). L-selectin was significantly higher in children with SCI when compared to non-SCI controls (median values of 1·46 vs. 1 35 μg/ml for SCI and non-SCI controls, respectively, P = 0·03; Fig 2A). Fifteen percent (10/65) of children with SCI had L-selectin values above the 95th percentile for non-SCI values (Fig 2B). Baseline oxygen saturation, a reported risk factor for a number of sickle-related complications, correlated inversely with THSB1 in children with SCA (r = −0·4, P < 0·001). Systolic blood pressure, a known risk factor for SCI, correlated directly with L-selectin in children with SCI (r = 0·28, P = 0·02). THSB1 and L-selectin were chosen for this study based on biological plausibility. Our results indicating differentially elevated plasma THSB1 in SCA children with SCI suggest that these patients are also at risk for an increased inflammatory response that is observed after recurrent ischaemia/hypoxia and reoxygenation. Furthermore, we observed a correlation between plasma THSB1 and baseline oxygen saturations, which support other studies that have reported increased risk for complications, such as overt stroke, in SCA patients with steady state oxygen desaturation (Quinn & Sargent, 2008). These findings may have practical implications for therapeutic intervention with hydroxycarbamide, which decreases the in vitro adhesion of sickle erythrocytes to THSB1 (Hillery et al, 2000), and aspirin, which has been shown to inhibit the release of THSB1 (Coppinger et al, 2007). The increased L-selectin levels observed in SCA suggest increased systemic inflammatory stress and provide evidence for concomitant immune activation. Whereas previous studies report associations of L-selectin with various clinical parameters, including decreased oxygen saturations, we report a direct relationship with SBP. We and others have reported an increased risk of SCI with increased SBP (DeBaun et al, 2012), strengthening the plausibility of elevated L-selectin as a potential risk factor for SCI. If this observation were validated, additional studies to evaluate for a potential neuroprotective role for selective- and pan-selectin inhibitors would be informative. Although we have identified the first two plasma proteins that are statistically significantly associated with SCI in children with SCA, our study was not designed to measure time-dependent correlations with brain injury. There is evidence to suggest that children with SCA are at risk for both chronic and intermittent acute cerebral ischaemia events (Savage et al, 2011; Quinn et al, 2013); however, it is not possible to assess whether increased plasma THSB1 and L-selectin levels reflect ongoing, past, or sporadic subclinical brain injury. We have previously reported that plasma levels of GFAP, an intracellular glial cell intermediate filament protein, are elevated in a significant fraction of children with SCA and are associated with acute cerebral infarction in SCA, with a weak association with SCI; inverse correlations with performance IQ were observed (Savage et al, 2011), as well as with elevated systolic blood pressure, a known correlate of SCI and stroke in SCD (DeBaun et al, 2012). The GFAP study was limited by the same time-dependency issues as the present study; however, the finding of correlations in both studies, despite the fact that samples were most probably obtained remotely from the event, suggests that detection of central nervous system events and ongoing injury in SCA may be feasible using biomarkers. In addition, patients with higher risk of stroke, including those with previous stroke and abnormal TCDs, were excluded from the SIT trial, which introduces concerns for generalizability. Similarly, the use of nonrandom sampling introduces the potential for sampling bias, and may limit our ability to make specific inferences; however, the lack of difference in clinical parameters between the two groups is reassuring in this regard. Future studies to examine how longitudinal changes in THSB1 and L-selectin and other potential markers of brain injury, such as GFAP, correlate with clinical outcomes and quantitative magnetic resonance imaging measures of lesion burden are needed in order to determine causality and to assess risk for SCI. In summary, our results indicate that THSB1 and L-selectin are associated with SCI in children with SCA. These findings, which may provide additional insight into the pathophysiology of disease for children with SCA, need to be substantiated in additional studies and clinical trials. The authors would like to thank Barbara Crain for her thoughtful comments during the inception and preparation of this report. This study was supported by award numbers K12-HL087169 (JFC), U54HL090515 and 5R01HL091759 (AE and JFC) from the National Heart, Lung and Blood Institute (NHLBI) and the Johns Hopkins ITCR/CTSA Biomarker Development Center funded in part by National Institutes of Health (NIH) grant U54RR023561 (JVE). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NHLBI or the NIH. L.M. Faulcon designed research, performed research, analysed and interpreted data, performed statistical analysis, and wrote the manuscript. J.F. Casella and A. Allen designed research, analysed and/or interpreted data, and critically revised the manuscript. J.E. Van Eyk and Michael DeBaun designed research and critically revised the manuscript. Z. Fu and P. Dulloor performed research. E. Barron-Casella performed research and critically revised the manuscript. W. Savage and J.M. Jennings analysed and interpreted data, and critically revised the manuscript. Dr. Casella has received an honorarium and travel expenses in the past and presently receives salary support through Johns Hopkins for providing consultative advice to Adventrx Pharmaceuticals regarding a proposed clinical trial of an agent for treating vaso-occlusive crisis in sickle cell disease.

Cardiopulmonary injury is common in neonatal encephalopathy, but the link with cerebrovascular dysfunction is unknown. We hypothesized that alterations of cerebral autoregulation are associated with cardiopulmonary injury in neonates treated with therapeutic hypothermia (TH) for neonatal encephalopathy. The cerebral hemoglobin volume index (HVx) from near-infrared spectroscopy was used to identify the mean arterial blood pressure (MAP) with optimal autoregulatory vasoreactivity (MAPOPT). We measured associations between MAP relative to MAPOPT and indicators of cardiopulmonary injury (duration of mechanical respiratory support and administration of inhaled nitric oxide (iNO), milrinone, or steroids). We identified associations between cerebrovascular autoregulation and cardiopulmonary injury that were often sex-specific. Greater MAP deviation above MAPOPT was associated with shorter duration of intubation in boys but longer ventilatory support in girls. Greater MAP deviation below MAPOPT related to longer intensive care stay in boys. Milrinone was associated with greater MAP deviation below MAPOPT in girls. MAP deviation from MAPOPT may relate to cardiopulmonary injury after neonatal encephalopathy, and sex may modulate this relationship. Whereas MAP above MAPOPT may protect the brain and lungs in boys, it may be related to cardiopulmonary injury in girls. Future studies are needed to characterize the role of sex in these associations.

In Brief OBJECTIVE: To estimate whether cell-free DNA is present in nonviable pregnancies and thus can be used in diagnostic evaluation in this setting. METHODS: We conducted a prospective cohort study of 50 participants at MedStar Washington Hospital Center, Washington, DC, between June 2013 and January 2014. Included were women with pregnancies complicated by missed abortion or fetal demise. All gestational ages were considered for study participation. Participants with fetal demise were offered the standard workup for fetal death per the American College of Obstetricians and Gynecologists. Maternal blood samples were processed to determine the presence of cell-free DNA, the corresponding fetal fractions, and genetic abnormalities. RESULTS: Fifty samples from nonviable pregnancies were analyzed. The average clinical gestational age was 16.9 weeks (standard deviation 9.2). The mean maternal body mass index was 30.3 (standard deviation 9.1). Seventy-six percent (38/50) of samples yielded cell-free DNA results, that is, had fetal fractions within the detectable range of 3.7–65%. Among the 38, 76% (29) were classified as euploid, 21% (8) as trisomies, and 3% (1) as microdeletion. A cell-free DNA result was obtained more frequently at ultrasonographic gestational ages of 8 weeks or greater compared with less than 8 weeks (87.9% [n=29/33, 95% confidence interval (CI) 72.7–95.2; and 52.9%, n=9/17, 95% CI 31.0–73.8] of the time, respectively, P=.012). Time from demise was not associated with obtaining a result. CONCLUSION: Among nonviable pregnancies, cell-free DNA is present in the maternal plasma with fetal fractions greater than 3.7% in more than three fourths of cases after an ultrasonographic gestational age of 8 weeks. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01916928. LEVEL OF EVIDENCE: III Cell-free DNA can be isolated from maternal plasma in the presence of nonviable pregnancies.

We studied whether cerebral blood pressure autoregulation and kidney and liver injuries are associated in neonatal encephalopathy (NE). We monitored autoregulation of 75 newborns who received hypothermia for NE in the neonatal intensive care unit to identify the mean arterial blood pressure with optimized autoregulation (MAPOPT). Autoregulation parameters and creatinine, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were analyzed using adjusted regression models. Greater time with blood pressure within MAPOPT during hypothermia was associated with lower creatinine in girls. Blood pressure below MAPOPT related to higher ALT and AST during normothermia in all neonates and boys. The opposite occurred in rewarming when more time with blood pressure above MAPOPT related to higher AST. Blood pressures that optimize cerebral autoregulation may support the kidneys. Blood pressures below MAPOPT and liver injury during normothermia are associated. The relationship between MAPOPT and AST during rewarming requires further study.

The United States (US) is in the midst of a housing affordability crisis and an eviction epidemic, which is particularly impacting vulnerable populations: low-income households, people of color, single mothers, and children.1–5 Two thirds of low-income US families live in rental housing,6 a proportion that has grown in the wake of the 2008 Great Recession.7 Since the Recession, low-income households have experienced rising housing costs while their incomes have remained stagnant.7,8 As a result, most poor renting households spend over half of their incomes on housing, whereas nearly 1 in 4 spends over 70%.8 As more and more families struggle to pay rent, the rate of evictions has increased. Recent estimates suggest that 2% to 3% of renters nationwide experience eviction, with rates of eviction as high as 16% (ie, 16 eviction judgments per 100 renter-occupied homes) in some parts of the country.9 Although the links between housing instability and population health more broadly are well established,10 there is a dearth of research specifically examining the connections between eviction and health, including sexual health outcomes.11 This is an important gap for 2 key reasons. First, evictions are considered by experts to be among the most deleterious sources of housing instability12 in that they often come about suddenly, create extreme financial strain and stress, and carry lasting legal consequences that can preclude families from accessing quality, affordable housing in the future. This suggests that eviction may have profound health effects and may operate both as a fundamental cause of disease,13 operating through poverty, and a pathway through which poverty becomes embodied in health outcomes.14 Second, eviction as a source of housing instability is both specific and policy-sensitive. Levers at the city and state for eviction may include reforming eviction law, changing rent court processes, or expanding existing housing voucher programs. In this issue of Sexually Transmitted Diseases, Linda Niccolai and colleagues investigate the ecological (county-level) relationship between eviction and 2 sexually transmitted infections (STIs) (ie, chlamydia and gonorrhea),15 an interesting foray joining a long line of research demonstrating that STI incidence is highly sensitive to social processes.16–18 The authors leverage a novel data source, the Eviction Lab National Database, to answer this research question. The Eviction Lab data represents the first attempt to compile court records of eviction filings and judgments on a national scale.9 After controlling for a number of county-level demographic, social, and geographic covariates, the authors found that, on average, counties with high eviction rates (>1.9 eviction judgments per 100 renter-occupied households) had 63.8 (95% confidence interval, 45.1–82.5) more chlamydia cases and 20.4 (95% confidence interval, 13.5–27.4) more gonorrhea cases per 100,000 population 1 year later, when compared with counties with low eviction rates (<0.59 judgments per 100 renter-occupied households). These findings were statistically significant and proved robust to a number of thoughtful sensitivity analyses. The authors present several plausible explanations for the identified associations between eviction rates and STIs 1 year later at the county-level. In general, the authors make the case that eviction may increase sexual and/or social vulnerabilities in ways that increase community levels of STIs. For example, individuals may change their behavior including engaging in sex work or increasing risky sexual behaviors in exchange for housing or other material needs (eg, food, transportation). They may also change their behavior in ways that increase risks for STIs (eg, alcohol or drug use) in an effort to cope with the stress that housing instability and the associated material hardship presents. Evictions may also cause changes to relationships (ie, disruptions in monogamous relationships, initiation of new relationships), resulting in changes to sexual network structures and increasing STI transmission potential within communities. Eviction and the resultant displacement may also disrupt health care access and decrease opportunities for STI testing and treatment, resulting in longer durations of infection. These mechanisms may impact vulnerable populations in particular who have little or no buffer to safeguard against the more deleterious outcomes related to eviction. Although we find this a well-conceptualized study, we offer 1 comment and 2 potential limitations. The authors suggest that the study's ecological design is a limitation. Although we agree that the results cannot be interpreted as the effect of individual-level eviction on individual STI risk, it is also true that solutions to the eviction epidemic will likely be implemented and evaluated at a community level (eg, county or state). Thus, we encourage researchers to continue to focus on policy-relevant geographies to aid in the identification of policy-based solutions to eviction and its downstream health effects. One limitation that bears mentioning is the potential for selection bias. Approximately 17% of US counties had missing eviction rates and were excluded from the analyses. Although it could be the case that the excluded counties do not differ systematically from the analytic set, this is difficult to assess based on the data presented and suggests that the generalizability of the findings might be limited to those counties with eviction data. It should also be noted that even among counties with available data, Eviction Lab data quality may vary by state.19 An additional limitation in this study is that it is unclear whether highly advantaged US counties (ie, largely white, with high income, high education, and low unemployment) ever experience high rates of eviction. If not, effect estimates for this subgroup of counties might be “off-support,” relying heavily on extrapolation.20,21 Moreover, these estimates may have limited utility,20,22 begging the question: How do we interpret the effect of exposure to high eviction rates in counties that are very unlikely to experience high eviction? To judge how much this issue, referred to in the epidemiology literature as “nonpositivity,” might threaten causal inference in this study, it would be useful for the authors to present data illustrating the degree to which combinations of the various covariates included in the multivariable regression models are predictive of exposure to eviction, as is common practice in studies that use propensity score-based approaches to address confounding.21,23 Limitations aside, this publication contributes to a small but growing body of literature linking eviction to negative health outcomes.24–30 We look forward to more research focused on eviction and sexual health outcomes to confirm and strengthen these findings. Perhaps, more importantly, we look forward to research pointing to specific interventions to prevent eviction and its downstream effects on sexual health. Some interesting work evaluating the impact of housing programs on health is already charting a course. For instance, a randomized trial evaluating the Housing Opportunities for People with acquired immune deficiency syndrome program in 3 US sites (Baltimore, MD; Chicago, IL; and Los Angeles, CA) demonstrated that provision of rental assistance could effectively address the mental and physical health needs in unstably housed and homeless people living with human immunodeficiency virus/acquired immune deficiency syndrome.31 In an observational study among public housing residents in Atlanta, GA, relocation from public housing to other neighborhoods resulted in a reduced odds of testing positive for an STI (chlamydia, gonorrhea, and trichomonas).32 Given the health promoting potential of high-quality, stable housing, researchers and public health advocates should lend their expertise to the planning, implementation, and evaluation of interventions to address the root problem of affordable housing in the United States. Adopting a “Health in All Policies” approach, we can address this important social determinant of health, advance health equity, and promote population health.33,34

Abstract Syphilis and HIV among gay, bisexual and other men who have sex with men (MSM) are syndemic suggesting current prevention strategies are not effective. Sex partner meeting places and their networks may yield effective and optimal interventions. From 2009 to 2017, 57 unique venues were reported by &gt; 1 MSM and 7.0% (n = 4), 21.1% (n = 12) and 71.9% (n = 41) were classified as syphilis, HIV or co-diagnosed venues, respectively. Forty-nine venues were connected in one main network component with four online, co-diagnosis venues representing 51.6% of reports and the highest degree and eigenvector centralities. In a sub-analysis during a local syphilis epidemic, the proportion of venues connected in the main component increased 38.7% (61.5% to 86.4%); suggesting increasing overlap in syphilis and HIV transmission and density of the venue network structure over time. This network analysis may identify the optimal set of venues for tailored interventions. It also suggests increasing difficulty of interrupting network transmission through fragmentation.

This study utilized multilevel cross-classified models to longitudinally assess the association between neighborhood residential rehabilitation and injection drug use. We also assessed whether relocating between neighborhoods of varying levels of residential rehabilitation was associated with injection drug use. Residential rehabilitation was categorized into three groups (e.g. low, moderate, high), and lagged one visit to ensure temporality. After adjusting for neighborhood and individual-level factors, residence in a neighborhood with moderate residential rehabilitation was associated with a 23% reduction in injection drug use [AOR=0.77; 95% CI (0.67,0.87)]; residence in a neighborhood with high residential rehabilitation was associated with a 26% reduction in injection drug use [AOR=0.74; 95% CI (0.61,0.91)]. Continuous residence within neighborhoods with moderate/high rehabilitation, and relocating to neighborhoods with moderate/high rehabilitation, were associated with a lower likelihood of injection drug use. Additional studies are needed to understand the mechanisms behind these relationships.

Sex partner meeting places may be important locales to access men who have sex with men (MSM) and implement targeted HIV control strategies. These locales may change over time, but temporal evaluations have not been performed.The objectives of this study were to describe the frequency of report of MSM sex partner meeting places over time and to compare frequently reported meeting places in the past 5 years and past year among newly HIV-diagnosed MSM in Baltimore City, Maryland. Public health HIV surveillance data including partner services information were obtained for this study from the Baltimore City Health Department from May 2009 to June 2014.A total of 869 sex partner meeting places were reported, including 306 unique places. Bars/clubs (31%) and Internet-based sites (38%) were the most frequently reported meeting place types. Over the 5-year period, the percentage of bars/clubs decreased over time and the percentage of Internet-based sites increased over time. Among bars/clubs, 4 of 5 of those most frequently reported in the past 5 years were also most frequently reported in the most recent year. Among Internet-based sites, 3 of 5 of those most frequently reported in the past 5 years were also in the top 5 most frequently reported in the past year.This study provides a richer understanding of sex partner meeting places reported by MSM over time and information to health departments on types of places to access a population at high risk for HIV transmission.

When families transition from the neonatal intensive care unit (NICU) to the home, they become responsible for their infant's daily medical needs. Though neonatology physicians prepare families for hospital discharge, it is unclear how much clinicians understand about how their teaching and instructions translate into home care. The goal of this study was to evaluate the influence of a home visiting program on neonatology fellows' understanding of family needs soon after hospital discharge.Neonatology fellows conducted a home visit for an infant recently discharged. Before the visit, fellows reviewed their original discharge instructions, along with information about the family's neighborhood. During the home visit, fellows reviewed their discharge planning with families and discussed any challenges experienced. Afterwards, fellows completed a semi-structured interview; these transcriptions were manually coded for themes.Fellows identified several common women/family discharge challenges. These challenges fall into four domains: (1) inadequate discharge preparation, (2) medicalization of the home, (3) family adjustment to new "normal," and (4) the relevance of social context to discharge planning. Most (90%) fellows reported the home visit experience would affect their future NICU discharge practices and all agreed that home visits should be a part of neonatology training.Home visits allowed neonatology fellows to examine how their discharge preparation did, or did not, meet the family's needs. Incorporating home visits into neonatology training could help fellows learn about the relevance of social and community factors that are difficult to assess in the inpatient setting.

Sexual concurrency may increase risk for HIV/STIs among youth. Attitudes about gender roles, including power balances within sexual partnerships, could be a driver. We examined this association among Baltimore youth (N = 352), aged 15-24. Data were collected from February, 2011 to May, 2013. We examined whether index concurrency in male-reported partnerships (N = 221) and sex partner's concurrency in female-reported partnerships (N = 241) were associated with youth's attitudes towards relationship power. Males with more equitable beliefs about power were less likely to report index concurrency. Females with more equitable beliefs were more likely to report sex partner's concurrency. The relationship was significant in main and casual partnerships among females and main partnerships among males. The strongest associations were detected among middle-socioeconomic status (SES) males and low-SES and African American females. Implementing interventions that recognize the complex relationship between socioeconomic context, partner dynamics, gender, and sexual behavior is an important step towards reducing HIV/STI risk among youth.

As demonstrated by the consistently documented disproportionately high rates of HIV and STIs (sexually transmitted infections) among Black sexual minority men (BSMM), current efforts to develop responsive interventions to reduce HIV and other STIs within this population have not been sufficient. It is therefore critical that public health researchers reflect meaningfully on the ways in which they investigate HIV and STIs. Engagement with BSMM is crucial in addressing the disproportionately high rates of HIV and STIs experienced, and thus the goal of the current research was to identify community-developed strategies that may enhance community engagement in research with BSMM. Seven focus groups ( N = 38) were held with cisgender BSMM ages 18 to 45 years in Baltimore, Maryland to explore how to better engage this population and improve HIV and STI research. Data analysis of the text was conducted using an iterative, thematic constant comparison process informed by grounded theory. Four distinct themes related to trust-building within the broader community emerged: (1) authentic engagement with the community, (2) increased transparency of the research process, (3) capacity building of research staff from the community, and (4) a balance of research and action. Strategies for researchers to build community trust were identified that are related to, but slightly distinct from, common discussions in the community engaged research literature that are centered more specifically on trust-building within community–academic partnerships. Engagement with BSMM is crucial in addressing HIV and STI health disparities. It is critical that community engagement also be a priority to policy makers, research institutions, and funding institutions.

We determined whether racial disparities in HIV infection among gay and bisexual men (MSM) may be partially explained by racial differences in the HIV transmission potential (i.e. mixing of people living with HIV and people not living with HIV or of unknown HIV serostatus) and density (i.e. sex partner concurrency) of sexual networks. Data included a behavioral survey, testing for HIV, and an egocentric sexual network survey. Mixed effects logistic regressions were used for hypothesis testing. Black (vs. non-Black) MSM were more likely to not know their partner's HIV serostatus (21.8% vs. 9.6%). Similar proportions reported sex partner concurrency (67.1% vs. 68.0%). In adjusted analyses, among Black MSM, sex partner concurrency significantly increased the odds of an HIV transmission potential partnership (TPP), and this association was not significant among non-Black indexes. The association between an HIV TPP and sex partner concurrency may help explain persistent racial disparities in HIV prevalence.Determinamos si las disparidades raciales en infecciones del VIH entre hombres homosexuales y bisexuales (hombres que tienen sexo con hombres) puede ser parcialmente explicado por diferencias raciales en el potencial de transmisión del VIH (es decir, mezcla de personas viviendo con VIH y personas que no viven con VIH o cuyo estado serológico del VIH es desconocido) y densidad (es decir, concurrencia de pareja sexual) de redes sexuales. Los datos incluyeron una encuesta de comportamiento, pruebas para el VIH y una encuesta de redes sexuales egocéntrica. Regresiones logísticas de efectos mixtos fueron usados para la prueba de hipótesis. HSH negros (vs. HSH no-negros) eran más propensos a no saber el estado serológico del VIH de su pareja (21.8% vs. 9.6%). Proporciones similares reportaron concurrencia de pareja sexual (67.1% vs. 68.0%). En análisis ajustados, entre HSH negros, la concurrencia de pareja sexual aumentó significativamente las probabilidades de una asociación potencial de transmisión del VIH (TPP por sus siglas en inglés), y esta asociación no fue significativa entre índices de no-negros. La asociación entre una TPP VIH y concurrencia de pareja sexual puede ayudar a explicar disparidades raciales persistentes en la prevalencia del VIH.

In a survey of 133 caregivers in a pediatric clinic, 30 women (23%) disclosed domestic violence, with 2 reporting coercive control but not physical violence. Seventeen women stated that a child had been exposed as well. Domestic violence is not a "private" adult problem; further study of an appropriate pediatric-based screener is needed.

Herpes simplex virus type 2 (HSV-2) is one of the most prevalent sexually transmitted infections, and it increases the risk of transmission of human immunodeficiency virus type 1 at least twofold. Individual-level factors are insufficient to explain geographic and population variation in HSV-2, suggesting the need to identify ecologic factors. The authors sought to determine the geographic prevalence and community-level factors associated with HSV-2 after controlling for individual-level factors among slums in Chennai, India. From March to June 2001, participants aged 18-40 years voluntarily completed a survey and were tested for HSV-2. Community characteristics were assessed through interviews with key informants and other secondary data sources. Multilevel nonlinear analysis was conducted. Eighty-five percent of eligible persons completed the survey; of these, 98% underwent HSV-2 testing, producing a final sample of 1,275. Participants were of Tamil ethnicity, were predominantly female and married, and were on average 30 years old. Fifteen percent were infected with HSV-2, and there was significant variation in HSV-2 prevalence among communities. After controlling for individual-level factors, the authors identified community-level factors, including socioeconomic status and the presence of injection drug users, that were independently associated with HSV-2 and explained 11% of the variance in prevalence. Future studies are needed to test mechanisms through which these community-level factors may be operating.

In Brief Background: Secondary transmission remains a significant concern among HIV-infected youth. Little is known, however, about how partner-specific sexual risk behaviors for the secondary transmission of HIV may differ between the 2 largest subgroups of HIV-positive youth, women-who-have-sex-with-men (WSM) and men-who-have-sex-with-men (MSM), Methods: During 2003-2004, a convenience sample of HIV-infected youth, 13 to 24 years of age, were recruited from 15 Adolescent Medicine Trials Network clinical sites. Approximately 10 to 15 youth were recruited at each site. Participants completed an ACASI survey including questions about sex partners in the past year. Cross-sectional data analyses, including bivariate and multivariable regressions, using generalized estimating equations, were conducted during 2008 to compare recent partner-specific sexual risk behaviors between WSM and MSM. Results: Of 409 participants, 91% (371) were included in this analysis, including 176 WSM and 195 MSM. Ninety-two percent (163 WSM, 177 MSM) provided information on characteristics of their sexual partners. There were significant differences between the 2 groups in recent partner-specific sexual risk behaviors including: lower rates of condom use at last sex among WSM (61% WSM vs. 78% MSM; P = 0.0011); a larger proportion of the sex partners of MSM reported as concurrent (56% MSM vs. 36% WSM; P = 0.0001); and greater use of hard drugs at last sex by MSM and/or their partner (18% MSM vs. 4% WSM; P = 0.0008). When measuring risk as a composite measure of sexual risk behaviors known to be associated with HIV transmission, both groups had high rates of risky behaviors, 74.7% among young MSM compared to 68.1% of WSM. Conclusions: These data suggest that recent partner-specific sexual risk behaviors for HIV transmission are high among young infected MSM and WSM. These findings suggest the need to offer interventions to reduce the secondary transmission of HIV to all HIV-positive youth in care. However, differences in risk behaviors between young MSM and WSM supports population-specific interventions. A comparison of risks for the secondary transmission of HIV between young HIV-infected women-who-have-sex-with-men and men-who-have-sex-with-men found that recent partner-specific sexual risk behaviors are high among both populations. However, differences in the specific behaviors between women-who-have-sex-with-men and men-who-have-sex-with-men support population-specific interventions to reduce the secondary transmission of HIV.

A clear understanding of local transmission dynamics is a prerequisite for the design and implementation of successful HIV prevention programs. There is a tremendous need for such programs geared towards young African-American women living in American cities with syndemic HIV and injection drug use. In some of these American cities, including Baltimore, the HIV prevalence rate among young African-American women is comparable to that in some African nations. High-risk heterosexual sex, i.e., sex with an injection drug user or sex with someone known to have HIV, is the leading risk factor for these young women. Characterizing transmission dynamics among heterosexuals has been hampered by difficulty in identifying HIV cases in these settings. The case identification method described in this paper was designed to address challenges encountered by previous researchers, was based on the Priorities for Local AIDS Cases methodology, and was intended to identify a high number of HIV cases rather than achieve a representative sample (Weir et al., Sex Transm Infect 80(Suppl 2):ii63-8, 2004. Through a three-phase process, 87 venues characterized as heterosexual sex partner meeting sites were selected for participant recruitment in Baltimore, MD. One thousand six hundred forty-one participants were then recruited at these 87 venues, administered a behavioral risk questionnaire, and tested for HIV. The HIV prevalence was 3 % overall, 3 % among males, and 4 % among females and ranged from 1.7 to 22.6 % among high-HIV-risk subgroups. These findings indicate that attributing HIV transmission to high-risk heterosexual sex vs. other high-HIV-risk behaviors would be difficult. Moving beyond individual risk profiles to characterize the risk profile of venues visited by heterosexuals at high risk of HIV acquisition may reveal targets for HIV transmission prevention and should be the focus of future investigations.

This study explored the relationship between the social organization of neighborhoods including informal social control and social cohesion and a current bacterial sexually transmitted infection (STI) among adolescents and young adults in one U.S. urban setting. Data for the current study were collected from April 2004 to April 2007 in a cross-sectional household study. The target population included English-speaking, sexually-active persons between the ages of 15 and 24 years who resided in 486 neighborhoods. The study sample included 599 participants from 63 neighborhoods. A current bacterial STI was defined as diagnosis of a chlamydia and/or gonorrhea infection at the time of study participation. Participants reported on informal social control (i.e. scale comprised of 9 items) and social cohesion (i.e. scale comprised of 5 items) in their neighborhood. In a series of weighted multilevel logistic regression models stratified by gender, greater informal social control was significantly associated with a decreased odds of a current bacterial STI among females (AOR 0.53, 95% CI 0.34, 0.84) after controlling for individual social support and other factors. The association, while in a similar direction, was not significant for males (AOR 0.73, 95% CI 0.48, 1.12). Social cohesion was not significantly associated with a current bacterial STI among females (OR 0.85, 95% CI 0.61, 1.19) and separately, males (OR 0.98, 95% CI 0.67, 1.44). Greater individual social support was associated with an almost seven-fold increase in the odds of a bacterial STI among males (AOR 6.85, 95% CI 1.99, 23.53), a finding which is in contrast to our hypotheses. The findings suggest that neighborhood social organizational factors such as informal social control have an independent relationship with sexual health among U.S. urban youth. The causality of the relationship remains to be determined.

Background: Inaccurate perceptions about whether a partner has concurrent sexual partners are associated with current sexually transmitted infections status. Despite high sexually transmitted infection rates among pregnant adolescents, studies have not investigated the accuracy of perceptions about sexual concurrency among young pregnant adolescents. The objectives were to assess (1) the accuracy of perceptions about whether one's partner ever had concurrent sexual partners during the relationship and (2) whether self-reported concurrency and relationship factors are related to inaccurate perceptions. Methods: Sociodemographic, psychosocial, and sexual behavior data were collected from 296 couples recruited from antenatal clinics. Couples included pregnant adolescents, aged 14 to 21 years, and the father of the baby, aged ≥14 years. Percentage agreement and κ statistics assessed the accuracy of perceptions about whether one's partner ever had concurrent sexual partners during the relationship. Logistic regression models using generalized estimating equations assessed associations between respondents' self-reported concurrency, relationship factors, and inaccurate perceptions. Results: Among participants whose partner was concurrent (n = 171), 60% did not accurately report their partner's concurrency, and greater relationship satisfaction (adjusted odds ratio [AOR]: 1.54) increased the likelihood of inaccuracy. Among participants with a nonconcurrent partner (n = 418), 17% were inaccurate; self-reported concurrency (AOR: 2.69) and greater partnership duration (AOR: 1.25) increased the likelihood of inaccuracy, whereas greater relationship satisfaction decreased the likelihood of inaccuracy (AOR: 0.68). Conclusions: Many pregnant adolescents and their partners inaccurately perceived their partner's concurrency status. Self-reported concurrency and relationship factors were associated with inaccuracy, reinforcing the need to improve sexual communication among this population.

Background The objective of this analysis was to compare measurement methods—counts, proximity, mean distance, and spatial access—of calculating alcohol outlet density and violent crime using data from Baltimore, Maryland. Methods Violent crime data ( n = 11,815) were obtained from the Baltimore City Police Department and included homicides, aggravated assaults, rapes, and robberies in 2016. We calculated alcohol outlet density and violent crime at the census block (CB) level ( n = 13,016). We then weighted these CB‐level measures to the census tract level ( n = 197) and conducted a series of regressions. Negative binomial regression was used for count outcomes and linear regression for proximity and spatial access outcomes. Choropleth maps, partial R 2 , Akaike's Information Criterion, and root mean squared error guided determination of which models yielded lower error and better fit. Results The inference depended on the measurement methods used. Eight models that used a count of alcohol outlets and/or violent crimes failed to detect an association between outlets and crime, and 3 other count‐based models detected an association in the opposite direction. Proximity, mean distance, and spatial access methods consistently detected an association between outlets and crime and produced comparable model fits. Conclusions Proximity, mean distance, and spatial access methods yielded the best model fits and had the lowest levels of error in this urban setting. Spatial access methods may offer conceptual strengths over proximity and mean distance. Conflicting findings in the field may be in part due to error in the way that researchers measure alcohol outlet density.

Abstract Background Human immunodeficiency virus pre-exposure prophylaxis (PrEP) clinical guidelines recommend men who have sex with men (MSM) PrEP users be screened biannually for syphilis and gonorrhea/chlamydia at all anatomic sites. We sought to determine the proportion screened and positive by STI and anatomic site at PrEP initiation and PrEP-care visits and patient-level characteristics associated with screening among MSM PrEP users in Baltimore City, Maryland. Methods Medical records among MSM initiating PrEP between 30 September 2015 and 31 March 2018 were abstracted. STI screening (syphilis and gonorrhea/chlamydia at all anatomic sites) and positivity at PrEP visits ≤12 months following initiation were calculated. Poisson regression with cluster robust SEs was used to assess associations with STI screening. Results Among 290 MSM initiating PrEP, 43.1% (n = 125) were screened per guidelines at PrEP initiation; 79.3% (230), 69.3% (201), 55.9% (162), and 69.3% (201) were screened for syphilis, urogenital, rectal, and oropharyngeal gonorrhea/chlamydia, respectively. Positivity among those screened was syphilis, 7.8% (n = 18/230); gonorrhea, 5.0% urogenital (10/201), 11.1% rectal (18/162), and 7.5% oropharyngeal (15/201); chlamydia, 5.0% urogenital (10/201), 11.7% rectal (19/162), and 1.5% oropharyngeal (3/201). Reported anal and oral sex (vs neither) was independently associated with STI screening (aPR, 2.11; 1.05–4.27) at PrEP initiation. At biannual PrEP-care visits, STI screening was lower and syphilis and rectal gonorrhea/chlamydia positivity was higher. Conclusions Observed STI screening levels and disease burden suggest the effectiveness of STI screening in PrEP care for STI prevention may be limited. Our results suggest providers may be offering screening based on sexual practices; clarification of STI screening guidelines for PrEP users is needed.

Purpose Epidemic levels of sexually transmitted infections (STIs) among urban youth have drawn attention to the potential role of sex partner selection in creating risk for STIs. The objectives of this study were to describe the ideal preferences and real selection of sex partners, to evaluate sex partner ideal versus real discordance using quantitative methods, and to determine the association between discordance and STI risk behaviors. Methods Data are obtained from an urban, household sample of 429 individuals aged 15–24 years. Trait clusters were developed for participants' ratings of their real and ideal sex partners and tested for reliability. Discordance between the ratings of real and ideal partners was measured. Logistic regression was used to assess associations between sex partner discordance and STI risk behaviors. Results Ratings of the real sex partners were often lower than participants' ideal sex partner ratings. A total of 33% of male adolescents and young men and 66% of female adolescents and young women were discordant on at least one trait cluster. Male adolescents and young men who were discordant on the emotional support they expected of their partner were more likely to report more than two sex partners in the past 90 days (odds ratio = 2.13, 95% confidence interval: 1.06–4.26) and perceived partner concurrency (odds ratio = 3.85, 95% confidence interval: 1.53–9.72). For female adolescents and young women, discordance on fidelity or emotional support significantly increased the odds of all risk behaviors. Conclusion Male and female adolescents with discordant real and ideal sex partner ratings were more likely to report STI-related risk behaviors. Further steps should involve identification of factors associated with ideal versus real sex partner discordance, such as features of the social context.

Background Syphilis incidence is increasing across the United States among men who have sex with men (MSM). Early latent (EL) versus primary and secondary (P&amp;S) syphilis may be an indicator of delayed diagnosis and increased opportunity for transmission. To inform syphilis control strategies and identify potential gaps in case finding, we described recent syphilis trends among MSM and compared characteristics of syphilis cases by diagnosis stage. Methods We used public health surveillance data on P&amp;S and EL syphilis diagnoses reported to the Baltimore City Health Department between 2009 and 2015. Differences across diagnosis stage were assessed using Cochran-Armitage and χ 2 tests. Results Between 2009 and 2015, Baltimore City Health Department received 2436 reports of P&amp;S and EL diagnoses. The majority (61%) of reports were among MSM, among whom 86% were black and 67% were human immunodeficiency virus (HIV)-infected. During this period, P&amp;S and EL syphilis increased by 85% and 245%, respectively ( P &lt; 0.0001). MSM with EL versus P&amp;S syphilis were similarly likely to be Black, more likely to be older ( P &lt; 0.05), HIV coinfected ( P &lt; 0.001), and diagnosed in private health care settings ( P &lt; 0.0001), but less likely to report multiple ( P &lt; 0.001) and anonymous sex partners ( P &lt; 0.001). Conclusions In Baltimore City, syphilis diagnoses, particularly EL diagnoses, are increasing rapidly and are concentrated among Black HIV-infected MSM. Significant gaps in identifying MSM with P&amp;S syphilis may exist, specifically among HIV-infected MSM, and those diagnosed in private health care settings. Strategies to address these gaps may include local guidelines and provider education to screen MSM more frequently than CDC currently recommends and regardless of HIV status or risk.

&lt;b&gt;&lt;i&gt;Introduction:&lt;/i&gt;&lt;/b&gt; The optimal method to detect impairments in cerebrovascular pressure autoregulation in neonates with hypoxic-ischemic encephalopathy (HIE) is unclear. Improving autoregulation monitoring methods would significantly advance neonatal neurocritical care. &lt;b&gt;&lt;i&gt;Methods:&lt;/i&gt;&lt;/b&gt; We tested several mathematical algorithms from the frequency and time domains in a piglet model of HIE, hypothermia, and hypotension. We used laser Doppler flowmetry and induced hypotension to delineate the gold standard lower limit of autoregulation (LLA). Receiver operating characteristics curve analyses were used to determine which indices could distinguish blood pressure above the LLA from that below the LLA in each piglet. &lt;b&gt;&lt;i&gt;Results:&lt;/i&gt;&lt;/b&gt; Phase calculation in the frequency band with maximum coherence, as well as the correlation between mean arterial pressure (MAP) and near-infrared spectroscopy relative total tissue hemoglobin (HbT) or regional oxygen saturation (rSO&lt;sub&gt;2&lt;/sub&gt;), accurately discriminated functional from dysfunctional autoregulation. Neither hypoxia-ischemia nor hypothermia affected the accuracy of these indices. Coherence alone and gain had low diagnostic value relative to phase and correlation. &lt;b&gt;&lt;i&gt;Conclusion:&lt;/i&gt;&lt;/b&gt; Our findings indicate that phase shift is the most accurate component of autoregulation monitoring in the developing brain, and it can be measured using correlation or by calculating phase when coherence is maximal. Phase and correlation autoregulation indices from MAP and rSO&lt;sub&gt;2&lt;/sub&gt; and vasoreactivity indices from MAP and HbT are accurate metrics that are suitable for clinical HIE studies.

Places are an important determinant of risk for sexually transmitted infection (STI) acquisition and transmission. We sought to identify social places that are critical for targeted STI control activities. The objective of this study was to determine whether sex partner meeting places characterized by drug markets, sex markets, and separately, drug and/or sex markets were more likely to have potential core transmitters as compared with other sex partner meeting places in one urban setting.In 2008-2009, heterosexual sex partner places or venues were identified in Baltimore, MD using a venue-based study approach.A total of 1334 participants aged 18 to 35 years were enrolled at 85 venues. In those participants, 39 potential core transmitters were identified and 31% of venues had at least one potential core transmitter. In final age-adjusted and gender-adjusted models, core transmitters were significantly more likely to be identified at drug markets (OR = 1.37; 95% CI = 1.23-1.53), sex markets (OR = 1.27; 95% CI = 1.14-1.41), and drug and/or sex markets (OR = 1.49; 95% CI = 1.32-1.68).This study identified key characteristics of venues, such as drug and sex market activity, that may be important in identifying places for the targeted control of STI transmission.

The objective of this study was to evaluate the satisfaction with, and the feasibility and effectiveness of, a public health detailing project focused on increasing routine human immunodeficiency virus (HIV) screening of people aged 13-64 by primary care providers working in areas of Baltimore City, Maryland, with high rates of HIV transmission (defined as a mean geometric viral load of ≥1500 copies/mL per census tract). In public health detailing, trained public health professionals (ie, detailers) visit medical practice sites to meet with providers and site staff members, with the intention of influencing changes in clinical practice policy and/or behavior. During 2014, detailers made personal visits and gave HIV Testing Action Kits containing maps, educational and guideline documents, and resource lists to 166 providers and office managers at 85 primary care sites. At follow-up, 88 of 91 (96.7%) providers and 37 of 38 (97.4%) clinic managers were very satisfied or satisfied with the project. Of the 79 sites eligible at follow-up (ie, those that had not closed or merged with another practice), 76 (96.2%) had accepted at least 1 HIV Testing Action Kit, and 67 of 90 (74.4%) providers had increased their HIV screening. Public health detailing projects can be used to educate and support providers, establish relationships between providers and local health departments, and disseminate public health messages.

Young Black gay, bisexual and other men who have sex with men (YBMSM) carry a disproportionate HIV burden perpetuated by exposure to sexual networks with higher untreated HIV prevalence and incidence. In Baltimore, these sexual networks include high utilization of geosocial networking apps (GSN-apps). Our prior work suggests these apps can be important access points for targeted interventions like PrEP. To inform online PrEP outreach we explored YBMSM GSN-app users' exposure to and discussions about PrEP while navigating apps. We actively recruited YBMSM (n = 17) age 18–24 from the GSN-app most frequently reported by MSM newly diagnosed with HIV in Baltimore. Participants were recruited through direct messaging within the GSN-app while logged-on in high HIV transmission areas. Participants completed 60–90 minute semi-structured interviews, which were analyzed using a 3-stage analytic coding strategy. While some participants had not heard of PrEP, the majority described mentions or conversations about PrEP on GSN-apps. Three themes emerged: (1) Mistrust of PrEP, (2) Association with sexual promiscuity, and (3) Concerns about lack of protection from other STIs. Proper messaging, accurate information, and education are needed to account for the negative perceptions that surround PrEP; otherwise, continued underuse among YBMSM will expand rather than reduce HIV disparities.

This study explored the influence of STI history on childbearing motivations, fertility beliefs, current childbearing desires, and contraception use among urban African-American adolescents and young adults (AYA). Secondary data were from the Neighborhood Influences on Adolescent and Young Adult Health (NIAAH) study, conducted from 2004 to 2007. Sample included 517 AYA ages 15-24 years (male: n = 199, female: n = 318). Linear and logistic regression models examined gender differences in childbearing motivations (CBM) and desires, fertility beliefs, condom, and contraception use. Logistic regression models were constructed to examine age, pregnancy history, and STI fertility knowledge as potential confounders. AYA men (3.29) and AYA women (3.23) had similar CBM mean scores. AYA women had more positive CBM and used condoms less. Condom use was not associated with CBM among AYA men (OR = 0.71, p = 0.069). Low beliefs about fertility (OR = 0.52, p = 0.003) and prior pregnancy (OR = 5.27, p = 0.002) were associated with current childbearing desires among AYA women. AYA men's low fertility beliefs were only associated with current childbearing desires (OR = 0.56, p = 0.044). AYA men reported more contraception use (67.46 vs. 55.04%), especially with no partner pregnancy history (OR = 0.26, p = 0.017). Younger men (15 to 18 years old) reported more contraception or condom use compared to older AYA men (19-25 years old) (OR = 0.40, p = 0.016). Young men reporting a partner's prior pregnancy used fewer condoms or contraception (OR = 0.23, p = 0.028). STI history did not influence CBM in this sample of urban youth. Prior pregnancy experiences and chronological age, however, were important milestones shaping proximal motivations and desires to bear children, beliefs about fertility, and contraception behaviors.

LGBTQ populations, particularly Black men who have sex with men and transgender women, experience significant HIV disparities; public health messages may inadvertently stigmatize LGBTQ populations. We sought to use qualitative methods to inform a PrEP campaign. Unstructured focus groups were conducted among predominantly Black LGBTQ persons recruited through social media and events. Discussions were audio-recorded, transcribed, and analyzed in NVivo using categorical analysis. Eighty individuals participated in 13 focus groups; 80% (64) identified as sexual or gender minorities. Eighty-eight percent (70) identified as Black/African American. Four themes emerged: (1) culturally competent, community-informed, locally relevant messaging, (2) avoiding stigmatizing language or images, (3) inaccessibility of clinical language, and (4) using identity labels representing local communities and their diversity. Findings suggest PrEP campaigns need to be developed through community-informed processes to engage and avoid stigmatizing priority populations. Ongoing partnerships between public health and LGBTQ communities can facilitate development of campaigns with engaging, acceptable language.

Abstract Background Syphilis and gonorrhea reached an all-time high in 2018. The resurgence of syphilis and gonorrhea requires innovative methods of sexual contact tracing that encourage disclosure of same-sex sexual contacts that might otherwise be suppressed. Over 75% of Grindr mobile phone application users report seeking “friendship,” so this study asked people diagnosed with syphilis and gonorrhea to identify their friends. Methods Patients at the two Baltimore sexually transmitted infection (STI) clinics and the Baltimore City Health Department were asked 12 questions to elicit members of their friendship networks before eliciting sexual networks. The study included 353 index cases and 172 friendship contacts, yielding a friendship network of 331 non-isolates ( n = 331) and sexual-only network of 140 non-isolates. The data were plotted and analyzed using exponential family random graph analysis. Results Eliciting respondents’ in-person social contacts yielded 12 syphilis cases and 6 gonorrhea cases in addition to the 16 syphilis cases and 4 gonorrhea cases that would have been found with sexual contacts alone. Syphilis is clustered within sexual (odds ratio = 2.2, 95% confidence interval (1.36, 3.66)) and social contacts (OR = 1.31, 95% CI (1.02, 1.68)). Gonorrhea is clustered within reported social (OR = 1.56, 95% CI (1.22, 2.00)) but not sexual contacts (OR = 0.98, 95% CI (0.62, 1.53)). Conclusions Eliciting friendship networks of people diagnosed with syphilis and gonorrhea may find members of their sexual networks, drug use networks, or people of similar STI risk. Friendship networks include more diagnosed cases of syphilis and gonorrhea than sexual networks alone, especially among populations with many non-disclosing men who have sex with men (MSM) and women who have sex with women (WSW). Future research should evaluate whether this friendship network method of contact tracing can be implemented by adapting automated mobile phone COVID-19 contact tracing protocols, if these COVID-19 contact tracing methods are able to maintain anonymity and public trust.

To explore young men's perceived experience of coercive pregnancy behaviors by female partners, and engagement in and behavioral overlap of these occurrences in this sample.Heterosexually active young men aged 15 to 24 (n = 39), recruited from 3 primary care and 2 sexually transmitted disease clinics in Baltimore, MD city over a 2-week period, were surveyed on their perceived experience of and engagement in coercive pregnancy behaviors, attitudes about women, and background characteristics.Of 130 invited, 66 (51%) agreed to participate, 39 of whom were heterosexual young men; 87% were non-Hispanic Black and 59% were aged 20 to 24. Eleven (28%) perceived one or more coercive pregnancy behaviors by a partner and nine (23%) engaged in one or more coercive behavior. Most (58%) agreed women are responsible for birth control decisions, but 55% believed women could not be trusted to tell the truth about contraceptive use and 68% believe women would like to get pregnant.Over one-third of young men in this sample perceived experience of coercive pregnancy behaviors by partners and/or engaged in these behaviors. Findings have implications for promoting healthy relationships among young people.This study found over one-third of young men perceived experience of coercive pregnancy behaviors by partners and/or engaged in these behaviors. Findings highlight the need for research to include young men in examining coercive pregnancy behaviors. Findings also highlight the need to develop strategies to support educational and clinical approaches to address young men's role as partners in healthy contraceptive practices.

<b>Objectives:</b> To determine the prevalence of age-bridgers among urban males aged 14–24 years, asymptomatically infected with chlamydia and to determine factors that distinguish age-bridgers from non age-bridgers. An index was defined as an age-bridger if within 2 months, he had had at least two sexual partners who differed from him in age by ⩾2 years. <b>Methods:</b> Infected males provided data about themselves and up to four sexual partners in the past 2 months. Bivariate and multivariable logistic regression was used in the analysis. <b>Results:</b> The prevalence of age bridging was 21% in Baltimore and 26% in Denver. In both cities, in bivariate analysis, age-bridgers and their partners engaged in significantly more risky sexual behaviours. In adjusted multivariable analysis after controlling for number of sexual partners, age bridging was associated with having a sexual partner in the past 2 months, who, at time of last sexual intercourse, was drinking. <b>Conclusion:</b> Age-bridgers represented major proportions of the study populations and, along with their sexual partners, were more likely to engage in risky sexual behaviours. Male age-bridgers may be key players in the transmission of sexually transmitted infections among youth linking age-disparate sexual networks.

Integrated infectious disease surveillance information systems have the potential to provide important new surveillance capacities and business efficiencies for local health departments. We conducted a case study at a large city health department of the primary computer-based infectious disease surveillance information systems during a 10-year period to identify the major challenges for information integration across the systems.The assessment included key informant interviews and evaluations of the computer-based surveillance information systems used for acute communicable diseases, human immunodeficiency virus/acquired immunodeficiency syndrome, sexually transmitted diseases, and tuberculosis. Assessments were conducted in 1998 with a follow-up in 2008. Assessments specifically identified and described the primary computer-based surveillance information system, any duplicative information systems, and selected variables collected.Persistent challenges to information integration across the information systems included the existence of duplicative data systems, differences in the variables used to collect similar information, and differences in basic architecture.The assessments identified a number of challenges for information integration across the infectious disease surveillance information systems at this city health department. The results suggest that local disease control programs use computer-based surveillance information systems that were not designed for data integration. To the extent that integration provides important new surveillance capacities and business efficiencies, we recommend that patient-centric information systems be designed that provide all the epidemiologic, clinical, and research needs in one system. In addition, the systems should include a standard system of elements and fields across similar surveillance systems.