Extant analyses of the relation between economic conditions and population health were often based on annualized data and were susceptible to confounding by nonlinear time trends. In the present study, the authors used generalized additive models with nonparametric smoothing splines to examine the association between economic conditions, including levels of economic activity in New York State and the degree of volatility in the New York Stock Exchange, and monthly rates of death by suicide in New York City. The rate of suicide declined linearly from 8.1 per 100,000 people in 1990 to 4.8 per 100,000 people in 1999 and then remained stable from 1999 to 2006. In a generalized additive model in which the authors accounted for long-term and seasonal time trends, there was a negative association between monthly levels of economic activity and rates of suicide; the predicted rate of suicide was 0.12 per 100,000 persons lower when economic activity was at its peak compared with when it was at its nadir. The relation between economic activity and suicide differed by race/ethnicity and sex. Stock market volatility was not associated with suicide rates. Further work is needed to elucidate pathways that link economic conditions and suicide.
economic recession; economics; longitudinal studies; mental health; New York City; suicide
In multilevel studies, strong correlations of neighbourhood exposures with individual and neighbourhood confounders may generate problems with non-positivity (ie, inferences that are `off-support'). The authors used propensity restriction and matching to (1) assess the utility of propensity restriction to ensure analyses are `on-support' and (2) examine the relation between collective efficacy and violence in a previously unstudied city.
Associations between neighbourhood collective efficacy and violent victimisation were estimated in data from New York City in 2005 (n=4000) using marginal models and propensity matching.
In marginal models adjusted for individual confounders and limited to observations `on-support', under conditions of high collective efficacy, the estimated prevalence of violent victimisation was 3.5/100, while under conditions of low collective efficacy, it was 7.5/100, resulting in a difference of 4.0/100 (95% CI 2.6 to 5.8). In propensity-matched analysis, the comparable difference was 4.0/100 (95% CI 2.1 to 5.9). In analyses adjusted for individual and neighbourhood confounders and limited to observations 'on-support', the difference in violent victimisation associated with collective efficacy was 3.1/100 (95% CI 1.2 to 5.2) in marginal models and 2.4/100 (95% CI 0.2 to 4.5) in propensity-matched analysis. Analyses without support restrictions produced surprisingly similar results.
Under conditions of high collective efficacy, there was about half the prevalence of violence compared with low collective efficacy. The results contribute to a growing body of evidence that suggests collective efficacy may shape violence, and illustrate how careful techniques can be used to disentangle exposures from highly correlated confounders without relying on model extrapolation.
Little is known about material resources among drug users beyond income. Income measures can be insensitive to variation among the poor, do not account for variation in cost-of-living, and are subject to non-response bias and underreporting. Further, most do not include illegal income sources that may be relevant to drug-using populations.
We explored the reliability and validity of an 18-item material resource scale and describe correlates of adequate resources among 1593 current, former and non-drug users recruited in New York City. Reliability was determined using coefficient α, ωh, and factor analysis. Criterion validity was explored by comparing item and mean scores by income and income source using ANOVA; content validity analyses compared scores by drug use. Multiple linear regression was used to describe correlates of adequate resources.
The coefficient α and ωh for the overall scale were 0.91 and 0.68, respectively, suggesting reliability was at least adequate. Legal income >$5000 (vs. ≤ $5000) and formal (vs. informal) income sources were associated with more resources, supporting criterion validity. We observed decreasing resources with increasing drug use severity, supporting construct validity. Three factors were identified: basic needs, economic resources and services. Many did not have their basic needs met and few had adequate economic resources. Correlates of adequate material resources included race/ethnicity, income, income source, and homelessness.
The 18-item material resource scale demonstrated reliability and validity among drug users. These data provide a different view of poverty, one that details specific challenges faced by low-income communities.
injection drug users; non-injection drug users; former drug users; poverty; material deprivation; factor analysis
For 18 months in 2009–2010, the Rockefeller Foundation provided support to establish the Roundtable on Urban Living Environment Research (RULER). Composed of leading experts in population health measurement from a variety of disciplines, sectors, and continents, RULER met for the purpose of reviewing existing methods of measurement for urban health in the context of recent reports from UN agencies on health inequities in urban settings. The audience for this report was identified as international, national, and local governing bodies; civil society; and donor agencies. The goal of the report was to identify gaps in measurement that must be filled in order to assess and evaluate population health in urban settings, especially in informal settlements (or slums) in low- and middle-income countries. Care must be taken to integrate recommendations with existing platforms (e.g., Health Metrics Network, the Institute for Health Metrics and Evaluation) that could incorporate, mature, and sustain efforts to address these gaps and promote effective data for healthy urban management. RULER noted that these existing platforms focus primarily on health outcomes and systems, mainly at the national level. Although substantial reviews of health outcomes and health service measures had been conducted elsewhere, such reviews covered these in an aggregate and perhaps misleading way. For example, some spatial aspects of health inequities, such as those pointed to in the 2008 report from the WHO’s Commission on the Social Determinants of Health, received limited attention. If RULER were to focus on health inequities in the urban environment, access to disaggregated data was a priority. RULER observed that some urban health metrics were already available, if not always appreciated and utilized in ongoing efforts (e.g., census data with granular data on households, water, and sanitation but with little attention paid to the spatial dimensions of these data). Other less obvious elements had not exploited the gains realized in spatial measurement technology and techniques (e.g., defining geographic and social urban informal settlement boundaries, classification of population-based amenities and hazards, and innovative spatial measurement of local governance for health). In summary, the RULER team identified three major areas for enhancing measurement to motivate action for urban health—namely, disaggregation of geographic areas for intra-urban risk assessment and action, measures for both social environment and governance, and measures for a better understanding of the implications of the physical (e.g., climate) and built environment for health. The challenge of addressing these elements in resource-poor settings was acknowledged, as was the intensely political nature of urban health metrics. The RULER team went further to identify existing global health metrics structures that could serve as platforms for more granular metrics specific for urban settings.
Urban living is the new reality for the majority of the world’s population. Urban change is taking place in a context of other global challenges—economic globalization, climate change, financial crises, energy and food insecurity, old and emerging armed conflicts, as well as the changing patterns of communicable and noncommunicable diseases. These health and social problems, in countries with different levels of infrastructure and health system preparedness, pose significant development challenges in the 21st century. In all countries, rich and poor, the move to urban living has been both good and bad for population health, and has contributed to the unequal distribution of health both within countries (the urban–rural divide) and within cities (the rich–poor divide). In this series of papers, we demonstrate that urban planning and design and urban social conditions can be good or bad for human health and health equity depending on how they are set up. We argue that climate change mitigation and adaptation need to go hand-in-hand with efforts to achieve health equity through action in the social determinants. And we highlight how different forms of governance can shape agendas, policies, and programs in ways that are inclusive and health-promoting or perpetuate social exclusion, inequitable distribution of resources, and the inequities in health associated with that. While today we can describe many of the features of a healthy and sustainable city, and the governance and planning processes needed to achieve these ends, there is still much to learn, especially with respect to tailoring these concepts and applying them in the cities of lower- and middle-income countries. By outlining an integrated research agenda, we aim to assist researchers, policy makers, service providers, and funding bodies/donors to better support, coordinate, and undertake research that is organized around a conceptual framework that positions health, equity, and sustainability as central policy goals for urban management.
Urban health; Health inequity; Climate change; Social inclusion; Urban planning and design; Governance
Substantial progress has been made in reducing HIV among injection drug users (IDUs) in the United States, despite political and social resistance that reduced resources and restricted access to services. The record for HIV prevention among noninjecting drug users is less developed, although they are more numerous than IDUs. Newer treatments for opiate and alcohol abuse can now be integrated into primary HIV care; treatment for stimulant abuse is less developed. All drug users present challenges for newer HIV prevention strategies (eg, “test and treat,” nonoccupational postexposure prophylaxis and pre-exposure prophylaxis, contingency management, and conditional cash transfer). A comprehensive HIV prevention program that includes multicomponent, multilevel approaches (ie, individual, network, structural) has been effective in HIV prevention among IDUs. Expanding these approaches to noninjecting drug users, especially those at highest risk (eg, minority men who have sex with men) and incorporating these newer approaches is a public health priority.
HIV; noninjection drug use; injection drug use; prevention; contingency management; treatment; epidemiology
We evaluated the association of alcohol consumption and depression, and their effects on HIV disease progression among women with HIV. The study included 871 women with HIV who were recruited from 1993–1995 in four US cities. The participants had physical examination, medical record extraction, and venipuncture, CD4+ T-cell counts determination, measurement of depression symptoms (using the self-report Center for Epidemiological Studies-Depression Scale), and alcohol use assessment at enrollment, and semiannually until March 2000. Multilevel random coefficient ordinal models as well as multilevel models with joint responses were used in the analysis. There was no significant association between level of alcohol use and CD4+ T-cell counts. When participants were stratified by antiretroviral therapy (ART) use, the association between alcohol and CD4+ T-cell did not reach statistical significance. The association between alcohol consumption and depression was significant (p<0.001). Depression had a significant negative effect on CD4+ T-cell counts over time regardless of ART use. Our findings suggest that alcohol consumption has a direct association with depression. Moreover, depression is associated with HIV disease progression. Our findings have implications for the provision of alcohol use interventions and psychological resources to improve the health of women with HIV.
alcohol use; HIV/AIDS; multilevel longitudinal models; CD4+T-cells; depression
(See the editorial commentary by Grebely and Dore, on pages 571–4.)
Background. Population-level hepatitis C virus (HCV) infection incidence is a surrogate for community drug-related risk.
Methods. We characterized trends in human immunodeficiency virus (HIV) and HCV infection incidence and HCV infection prevalence among injection drug users (IDUs) recruited over 4 periods: 1988–1989, 1994–1995, 1998, and 2005–2008. We calculated HIV and HCV infection incidence within the first year of follow-up among IDUs whose test results were negative for these viruses at baseline (n = 2061 and n = 373, respectively). We used Poisson regression to compare trends across groups.
Results. HIV infection incidence declined significantly from 5.5 cases/100 person-years (py) in the 1988–1989 group to 2.0 cases/100 py in the 1994–1995 group to 0 cases/100 py in the 1998 and 2005–2008 groups. Concurrently, HCV infection incidence declined but remained robust (22.0 cases/100 py in the 1988–1989 cohort to 17.2 cases/100 py in the 1994–1995 cohort, 17.9 cases/100 py in the 1998 cohort, and 7.8 cases/100 py in the 2005–2008 cohort; P = .07). Likewise, HCV infection prevalence declined, but chiefly in younger IDUs. For persons aged <39 years, relative to the 1988–1989 cohort, all groups exhibited significant declines (adjusted prevalence ratio [PR] for the 2005–08 cohort, .73; 95% confidence interval [CI], .65–.81). However, for persons aged ≥39 years, only the 2005–2008 cohort exhibited declining prevalence compared with the 1988–1989 cohort (adjusted PR, .87; 95% CI, .77–.99).
Conclusions. Although efforts to reduce blood-borne infection incidence have had impact, this work will need to be intensified for the most transmissible viruses, such as HCV.
Accidental drug overdose is a major cause of mortality among drug users. Fears of police arrest may deter witnesses of drug overdose from calling for medical help and may be a determinant of drug overdose mortality. To our knowledge, no studies have empirically assessed the relation between levels of policing and drug overdose mortality. We hypothesized that levels of police activity, congruent with fears of police arrest, are positively associated with drug overdose mortality.
We assembled cross-sectional time-series data for 74 New York City (NYC) police precincts over the period 1990–1999 using data collected from the Office of the Chief Medical Examiner of NYC, the NYC Police Department, and the US Census Bureau. Misdemeanor arrest rate—reflecting police activity—was our primary independent variable of interest, and overdose rate our primary dependent variable of interest.
The mean overdose rate per 100,000 among police precincts in NYC between 1990 and 1999 was 10.8 (standard deviation = 10.0). In a Bayesian hierarchical model that included random spatial and temporal effects and a space-time interaction, the misdemeanor arrest rate per 1,000 was associated with higher overdose mortality (posterior median = 0.003, 95% Credible Interval = 0.001, 0.005) after adjustment for overall drug use in the precinct and demographic characteristics.
Levels of police activity in a precinct are associated with accidental drug overdose mortality. Future research should examine aspects of police-community interactions that contribute to higher overdose mortality.
drug use; overdose; cocaine; opiates; spatial; policing
This study assesses the impact of REAL MEN, an intervention designed to reduce drug use, risky sexual behavior and criminal activity among 16 to 18 year old males leaving New York City jails.
Participants (N=552) were recruited in city jails and randomly assigned to receive an intensive 30-hour jail/community-based intervention or a single jail-based discharge planning session. All participants were also referred to optional services at a community-based organization (CBO). One year after release from jail, 397 (72%) participants completed a follow-up interview. Logistic and OLS regression were used to evaluate the impact of the intervention on drug use, risky sexual behavior, criminal justice involvement, and school/work involvement post release.
Assignment to REAL MEN and, independently, use of CBO services, significantly reduced the odds of substance dependence (OR=.52, p≤.05; OR=.41, p≤.05, respectively) one year after release. Those assigned to the intervention spent 29 fewer days in jail compared with the comparison group (p≤.05). Compared to non-CBO visitors, those who visited the CBO were more likely to have attended school or found work in the year after release (OR=2.02, p≤.01).
Jail and community services reduced drug dependence one year after release and the number of days spent in jail after the index arrest. While these findings suggest that multi-faceted interventions can improve outcomes for young men leaving jail, rates of drug use, risky sexual behavior, and recidivism remained high for all participants after release from jail, suggesting the need for additional policy and programmatic interventions.
Incarcerated youth; Drug abuse; Sexual behavior; Randomized controlled trial
A nascent HIV epidemic and high prevalence of risky drug practices were detected among injecting drug users (IDUs) in Kabul, Afghanistan from 2005-2006. We assessed prevalence of HIV, hepatitis C virus (HCV), hepatitis B surface antigen (HBsAg), syphilis, and needle and syringe program (NSP) use among this population.
IDUs were recruited between June, 2007 and March, 2009 and completed questionnaires and rapid testing for HIV, HCV, HBsAg, and syphilis; positive samples received confirmatory testing. Logistic regression was used to identify correlates of HIV, HCV, and current NSP use.
Of 483 participants, all were male and median age, age at first injection, and duration of injection were 28, 24, and 2.0 years, respectively. One-fifth (23.0%) had initiated injecting within the last year. Reported risky injecting practices included ever sharing needles/syringes (16.9%) or other injecting equipment (38.4%). Prevalence of HIV, HCV Ab, HBSAg, and syphilis was 2.1% (95% CI: 1.0-3.8), 36.1% (95% CI: 31.8-40.4), 4.6% (95% CI: 2.9-6.9), and 1.2% (95% CI: 0.5-2.7), respectively. HIV and HCV infection were both independently associated with sharing needles/syringes (AOR = 5.96, 95% CI: 1.58 - 22.38 and AOR = 2.33, 95% CI: 1.38 - 3.95, respectively). Approximately half (53.8%) of the participants were using NSP services at time of enrollment and 51.3% reported receiving syringes from NSPs in the last three months. Current NSP use was associated with initiating drug use with injecting (AOR = 2.58, 95% CI: 1.22 - 5.44), sharing injecting equipment in the last three months (AOR = 1.79, 95% CI: 1.16 - 2.77), prior incarceration (AOR = 1.57, 95% CI: 1.06 - 2.32), and greater daily frequency of injecting (AOR = 1.40 injections daily, 95% CI: 1.08 - 1.82).
HIV and HCV prevalence appear stable among Kabul IDUs, though the substantial number having recently initiated injecting raises concern that transmission risk may increase over time. Harm reduction programming appears to be reaching high-risk drug user populations; however, monitoring is warranted to determine efficacy of prevention programming in this dynamic environment.
injection drug user; Afghanistan; HIV; hepatitis C; harm reduction
To evaluate the effects of longitudinal patterns and types of non-injection drug use (NIDU) on HIV progression in the highly active antiretroviral therapy (HAART) era.
Women’s Interagency HIV Study (WIHS), a prospective cohort study conducted at six US sites.
Data were collected semi-annually from 1994 to 2002 on 1046 HIV+ women. Multivariate Cox proportional hazards modeling was used to estimate relative hazards for developing AIDS and for death by pattern and type of NIDU.
During follow-up, 285 AIDS events and 287 deaths, of which 177 were AIDS-related, were reported. At baseline, consistent and former NIDU was associated with CD4+ counts of < 200 cells/μl (43% and 46%, respectively) and viral load > 40 000 copies/ml (53% and 55%, respectively). Consistent NIDU reported less HAART use (53%) compared with other NIDU patterns. Stimulant use was associated with CD4+ cell counts of < 200 cells/μl (53%) and lower HAART initiation (63%) compared with other NIDU types. In multivariate analyses, progression to AIDS was significantly higher among consistent (RH = 2.52), inconsistent (RH = 1.63) and former (RH = 1.56) users compared with never users; and for stimulant (RH = 2.04) and polydrug (RH = 1.65) users compared with non-users. Progression to all-cause death was higher only among former users (RH = 1.48) compared with never users in multivariate analysis. NIDU behaviors were not associated with progression to AIDS-related death.
In this study, pattern and type of NIDU were associated with HIV progression to AIDS and all-cause mortality. These differences were associated with lower HAART utilization among consistent NIDU and use of stimulants, and poor baseline immunological and virological status among former users.
Acquired immunodeficiency syndrome; highly active anti-retroviral therapy; human immunodeficiency virus; mortality; non-injection drug use
Injection drug use contributes to considerable global morbidity and mortality associated with human immunodeficiency virus (HIV) infection and AIDS and other infections due to blood-borne pathogens through the direct sharing of needles, syringes, and other injection equipment. Of ~16 million injection drug users (IDUs) worldwide, an estimated 3 million are HIV infected. The prevalence of HIV infection among IDUs is high in many countries in Asia and eastern Europe and could exacerbate the HIV epidemic in sub- Saharan Africa. This review summarizes important components of a comprehensive program for prevention of HIV infection in IDUs, including unrestricted legal access to sterile syringes through needle exchange programs and enhanced pharmacy services, treatment for opioid dependence (i.e., methadone and buprenorphine treatment), behavioral interventions, and identification and treatment of noninjection drug and alcohol use, which accounts for increased sexual transmission of HIV. Evidence supports the effectiveness of harm-reduction programs over punitive drug-control policies.
Mortality increases as ambient temperature increases. Because cocaine affects core body temperature, ambient temperature may play a role in cocaine-related mortality in particular. The present study examined the association between ambient temperature and fatal overdoses over time in New York City (NYC).
Mortality data were obtained from the Office of the Chief Medical Examiner for 1990 through 2006, and temperature data from the National Oceanic and Atmospheric Association. We used Generalized Additive Models to test the relationship between weekly average temperatures and counts of accidental overdose deaths in NYC, controlling for year and average length of daylight hours.
We found a significant relation between ambient temperature and accidental overdose fatality for all models where the overdoses were due in whole or in part to cocaine (all p < 0.05), but not for non-cocaine overdoses. Risk of accidental overdose deaths increased for weeks when the average temperature was above 24 degrees Celsius.
These results suggest a strong relation between temperature and accidental overdose mortality that is driven by cocaine-related overdoses rising at temperatures above 24 degrees Celsius; this is a substantially lower temperature than prior estimates. To put this in perspective, approximately seven weeks a year between 1990 and 2006 had an average weekly temperature of 24 or above in NYC. Heat-related mortality presents a considerable public health concern, and cocaine users constitute a high-risk group.
cocaine; climate; generalized additive models; heat; mortality; overdose
The present study examined the associations of relationship factors, partner violence, relationship power, and condom-use related factors with condom use with a main male partner among drug-using women. Over two visits, 244 heterosexual drug-using women completed a cross-sectional survey. Multivariate logistic regression models indicated that women who expected positive outcomes and perceived lower condom-use barriers were more likely to report condom use with their intimate partners. The findings suggest that future interventions aiming at reducing HIV risk among drug-using women should focus on women’s subjective appraisals of risks based on key relationship factors in addition to the occurrence of partner violence.
Partner violence; condom use; heterosexual women; HIV; intimate relationship; drugs
Neighborhood socioeconomic environment may be a determinant of injection drug use cessation. The authors used data from a prospective cohort study of Baltimore City, Maryland, injection drug users assessed between 1990 and 2006. The study examined the relation between living in a poorer neighborhood and the probability of injection cessation among active injectors, independent of individual characteristics and while respecting the temporality of potential confounders, exposure, and outcome. Participants’ residences were geocoded, and the crude, adjusted, and inverse probability of exposure weighted associations between neighborhood poverty and injection drug use cessation were estimated. Weighted models showed a strong association between neighborhood poverty and injection drug use cessation; living in a neighborhood with fewer than 10%, compared with more than 30%, of residents in poverty was associated with a 44% increased odds of not injecting in the prior 6 months (odds ratio = 1.44, 95% confidence interval: 1.14, 1.82). Results show that neighborhood environment may be an important determinant of drug injection behavior independent of individual-level characteristics.
drug users; epidemiologic methods; heroin; poverty; residence characteristics; social environment; substance-related disorders
To identify and understand the patterns and predictors of depressive symptom trajectories over time after mass traumatic events.
Data was used from a prospective, representative sample of adult residents of the New York City metropolitan area (n=2282) followed across four survey waves between 2001(after the September 11 attacks), and 2004. Semi-parametric group-based modeling was used to identify trajectories, as well as the time-fixed and time-varying predictors of distinct depressive trajectories.
Five distinct trajectories of depression were characterized: minimal symptomatology at all time points (group 1, 39% of sample), mild delayed depression (group 2, 34% of sample), recovery (group 3, 6% of sample), severe delayed depression (group 4, 13% of sample), and chronic severe depression (group 5, 8% of sample). Among members of distinct trajectories, lower household income, exposure to ongoing stressors, and exposure to traumatic events were commonly associated with an increased number of depressive symptoms.
Ongoing socioeconomic adversity appears to be centrally associated with a worse course of depression after exposure to traumatic events. Identifying distinct trajectories of depression and the preventable factors that are associated with them may facilitate the development of interventions that aim to promote better mental health.
depression; mental disorders; disasters
Researchers have reported adverse health effects among rescue/recovery workers and people living near the World Trade Center on September 11, 2001. The authors investigated the occurrence of respiratory symptoms among persons living outside of Lower Manhattan in areas affected by the World Trade Center particulate matter plume. Using a novel atmospheric dispersion model, they estimated relative cumulative plume intensity in areas surrounding the World Trade Center site over a 5-day period following the collapse of the buildings. Using data from a telephone survey of residents (n = 2,755) conducted approximately 6 months after the event, the authors evaluated associations between the estimated plume intensities at individual residence locations and self-reported respiratory symptoms among nonasthmatics, as well as symptoms and nonroutine care among asthmatics. Comparing persons at or above the 75th percentile of cumulative plume intensity with those below it, there was no statistically significant difference in self-reported new-onset wheezing/cough after September 11 (16.1% vs. 13.3%; adjusted odds ratio = 1.0, 95% confidence interval: 0.7, 1.7) and no worsening of asthma from before September 11 to the 4 weeks prior to the survey (13.9% vs. 16.6%; odds ratio = 1.0, 95% confidence interval: 0.3, 2.8). These results suggest that the plume was not strongly associated with respiratory symptoms outside of Lower Manhattan, within the limitations of this retrospective study.
air pollution; asthma; inhalation exposure; New York City; particulate matter; respiratory tract diseases; September 11 terrorist attacks
We assessed whether New York City’s gun-related homicide rates in the 1990s were associated with a range of social determinants of homicide rates.
We used cross-sectional time-series data for74 New York City police precincts from 1990 through 1999, and we estimated Bayesian hierarchical models with a spatial error term. Homicide rates were estimated separately for victims aged 15–24 years (youths), 25–34 years (young adults), and 35 years or older (adults).
Decreased cocaine consumption was associated with declining homicide rates in youths (posterior median [PM] = 0.25; 95% Bayesian confidence interval [BCI] = 0.07, 0.45) and adults (PM = 0.07; 95% BCI = 0.02, 0.12), and declining alcohol consumption was associated with fewer homicides in young adults (PM = 0.14; 95% BCI = 0.02, 0.25). Receipt of public assistance was associated with fewer homicides for young adults (PM=−104.20; 95% BCI=−182.0, −26.14) and adults (PM=−28.76; 95% BCI=−52.65, −5.01). Misdemeanor policing was associated with fewer homicides in adults (PM=−0.01; 95% BCI=−0.02, −0.001).
Substance use prevention policies and expansion of the social safety net may be able to cause major reductions in homicide among age groups that drive city homicide trends.
Hazardous alcohol consumption among women with human immunodeficiency virus (HIV) infection is associated with several adverse health and behavioral outcomes, but the proportion of HIV-positive women who engage in hazardous drinking over time is unclear. The authors sought to determine rates of hazardous alcohol consumption among these women over time and to identify factors associated with this behavior. Subjects were 2,770 HIV-positive women recruited from 6 US cities who participated in semiannual follow-up visits in the Women's Interagency HIV Study from 1995 to 2006. Hazardous alcohol consumption was defined as exceeding daily (≥4 drinks) or weekly (>7 drinks) consumption recommendations. Over the 11-year follow-up period, 14%–24% of the women reported past-year hazardous drinking, with a slight decrease in hazardous drinking over time. Women were significantly more likely to report hazardous drinking if they were unemployed, were not high school graduates, had been enrolled in the original cohort (1994–1995), had a CD4 cell count of 200–500 cells/mL, were hepatitis C-seropositive, or had symptoms of depression. Approximately 1 in 5 of the women met criteria for hazardous drinking. Interventions to identify and address hazardous drinking among HIV-positive women are urgently needed.
alcohol drinking; HIV; longitudinal studies; women
To characterize the influence of the residential neighborhood of older adults on the prevalence of disability.
We combined Census data on disability in older adults living in New York City with environmental information from a comprehensive geospatial database. We used factor analysis to derive dimensions of compositional and physical neighborhood characteristics and linear regression to model their association with levels of disability. Measures of neighborhood collective efficacy were added to these models to explore the impact of the social environment.
Low neighborhood socioeconomic status, residential instability, living in areas with low proportions of foreign born and high proportions of Black residents, and negative street characteristics were associated with higher prevalence of both “physical” disability and “going outside the home” disability. High crime levels were additionally associated with physical disability, although this relationship disappeared when misdemeanor arrests were removed from the crime variable. Low levels of collective efficacy were associated with more going-outside-the-home disability, with racial/ethnic composition dropping out of this model to be replaced by an interaction term.
The urban environment may have a substantial impact on whether an older adult with a given level of functional impairment is able to age actively and remain independent.
Disability; Elderly; Environment; Neighborhood
The increased burden of chronic kidney and end-stage kidney diseases (ESKD) in populations of African ancestry has been largely unexplained. To identify genetic variants predisposing to idiopathic and HIV-1–associated focal segmental glomerulosclerosis (FSGS), we carried out an admixture-mapping linkage-disequilibrium genome scan on 190 African American individuals with FSGS and 222 controls. We identified a chromosome 22 region with a genome-wide logarithm of the odds (lod) score of 9.2 and a peak lod of 12.4 centered on MYH9, a functional candidate gene expressed in kidney podocytes. Multiple MYH9 SNPs and haplotypes were recessively associated with FSGS, most strongly a haplotype spanning exons 14 through 23 (OR = 5.0, 95% CI = 3.5–7.1; P = 4 × 10−23, n = 852). This association extended to hypertensive ESKD (OR = 2.2, 95% CI = 1.5–3.4; n = 433), but not type 2 diabetic ESKD (n = 476). Genetic variation at the MYH9 locus substantially explains the increased burden of FSGS and hypertensive ESKD among African Americans.
We consider the problem of comparing cumulative incidence functions of non-mortality events in the presence of informative coarsening and the competing risk of death. We extend frequentist-based hypothesis tests previously developed for non-informative coarsening and propose a novel Bayesian method based on comparing a posterior parameter transformation to its expected distribution under the null hypothesis of equal cumulative incidence functions. Both methods use estimates derived by extending previously published estimation procedures to accommodate censoring by death. The data structure and analysis goal are exemplified by the AIDS Link to the Intravenous Experience (ALIVE) study, where researchers are interested in comparing incidence of human immunodeficiency virus seroconversion by risk behavior categories. Coarsening in the forms of interval and right censoring and censoring by death in ALIVE are thought to be informative, thus we perform a sensitivity analysis by incorporating elicited expert information about the relationship between seroconversion and censoring into the model.
Bayesian Analysis; Frequentist Analysis; Hypothesis Test; Interval Censoring; Markov Chain Monte Carlo; Sensitivity Analysis
In this paper, the authors use the rubric of “coarsened data,” of which missing and censored data are special cases, to motivate the elicitation and use of expert information for performing sensitivity analyses of censored event-time data. Elicited information is important because observed data are insufficient to estimate how study participants with coarsened data compare with participants with uncoarsened data, and misspecifying this comparison may produce biased analysis results. In the presence of coarsening, performing a sensitivity analysis over a range of plausible assumptions is the best one can do. Here the authors illustrate an approach for eliciting expert information for use in sensitivity analyses to compare cumulative incidence functions of censored nonmortality outcomes. An example of such data is the AIDS Link to Intravenous Experience (ALIVE) Study, where the authors aim to estimate and compare cumulative incidence functions for human immunodeficiency virus between risk factor categories. The interval and right-censoring and censoring due to death found in the ALIVE data (1988–1998) are thought to be informative; thus, a sensitivity analysis is performed using information elicited from 2 ALIVE scientists and an expert in acquired immunodeficiency syndrome epidemiology about the relation between seroconversion and censoring.
Bayesian analysis; frequentist approach; HIV; hypothesis test; incidence; interval censoring; sensitivity analysis