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Risk networks, infectious diseases, social norms, risk behaviors and health activism

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Title: Hepatitis B (HBV) Vaccination in a High-risk Community Author: Sam Friedman Last modified by: Sam Friedman Created Date: 3/2/2004 8:34:35 PM – PowerPoint PPT presentation

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Title: Risk networks, infectious diseases, social norms, risk behaviors and health activism


1
Risk networks, infectious diseases, social norms,
risk behaviors and health activism intravention
  • Samuel R Friedman
  • Melissa Bolyard
  • Carey Maslow
  • Pedro Mateu-Gelabert
  • Milagros Sandoval
  • National Development and Research Institutes,
    Inc., New York, NY
  • Friedman is also a Senior Associate, Department
    of Epidemiology, Bloomberg School of Public
    Health, Johns Hopkins University
  • Sunbelt Social Networks Conference, Redondo
    Beach, California, February 19, 2005 .

2
Acknowledgements
  • This presentation was supported by
  • NIDA grant R01 DA13128, Networks, norms and HIV
    risk among youth
  • NIMH grant RO1 MH62280 Local Context, Social
    Control Actions and HIV Risk
  • We want to thank the busy men and women who took
    part in this study by answering some very
    personal questions and letting us take specimens.

3
Background
  • Both sexual activity and injection drug use can
    spread diseases such as HIV, hepatitis B and C,
    and syphilis.
  • The relative probabilities of sexual versus
    injection transmission varies among these
    diseases.
  • Although STIs such as herpes simplex virus Type 1
    (HSV-1) and Type 2 (HSV-2), gonorrhea, and
    chlamydia seem not to be spread by injection,
    HSV-1 and HSV-2 seem to be more prevalent among
    young adult injection drug users (IDUs) than
    among young adults who do not use hard drugs.
  • Similarly, men who have sex with men (MSM) tend
    to be more likely to be infected with many of
    these disease agents.

4
Objective
  • To study
  • Ties among IDUs, other drug users, MSM, WSW, and
    others.
  • how risk network locations are related to
  • infection with various diseases
  • vaccination against hepatitis B
  • participation in group sex activities
  • health activism intravention

5
MethodsSetting
  • Bushwick is in Brooklyn, NY.
  • Population about 100,000
  • Mainly Latino/a, sizeable percent African
    American
  • Impoverished, but beginning to be gentrified
  • Many IDUs and other drug users
  • Large HIV/AIDS and HCV epidemics centered among
    IDUs began in 1980s

6
Sample
  • 465 subjects were recruited in 2002 - 2004 in a
    sexual and injection network serosurvey in
    Bushwick.
  • Links were defined as having injected or had sex
    with each other, or having attended a groups sex
    event together, in the prior three months.
  • 111 index cases (see next slide)
  • 355 subjects were sexual and/or injection
    partners of 1 or more of the index cases or were
    partners of such partners or their partners.
  • The next slide also shows network ties by gender
    and drug use.

7
Index Cases by Gender/Sexuality (MSMup triangle,
WSWdown triangle, other femalecircle, other
malesquare) by Hardest Drug Use Ever (from dark
red to light pink IDU, Crack, NI Heroin or
Cocaine blueother)
8
Classification (1)
  • Youths aged lt 25 approximately define those
    under 18 when youth vaccination against hepatitis
    B was recommended.

9
18-24 Year-Olds by Gender/Sexuality (MSMup
triangle, WSWdown triangle, other femalecircle,
other malesquare) by Hardest Drug Use Ever (from
dark red to light pink IDU, Crack, NI Heroin or
Cocaine blueother)
10
Classification (2) Core, Sex Partners, and
Distance
  • Core Men who have sex with men (MSM) and
    injection drug users (IDUs) are a core for HIV
    and HBV infection. n 230
  • Sex partners (SPs) are defined as sex partners of
    one or more core members. n 75
  • D2 (distance 2) are sex partners of sex
    partners. n 26
  • D3 are sex partners of D2 members, or sex
    partners of other D3 sex partners. n 15
  • Unlinked are non-core subjects who are not
    sexually linked to a core group member by a path
    of any length. n 119

11
Blood-borne virus infection by network distance
from core
  • HIV HCV HBVª
  • Core (MSM /or IDU) 18 58 57
  • SPs 7 6 26
  • D2 0 0 13
  • D3 0 0 20
  • Unlinked to core 0 1 4
  • ª HBV exposure among the unvaccinated.
  • p chi-sq test for trend) lt .001.

12
Percent testing positive by proximity to core
group of IDU or MSM, younger than 25 years
Tested positive IDU or MSM (n26) Sex partner (n19) 2 links (n31) Not linked (n80) p-value p-value (no core)
HIV 13 0 0 0 .0014 -----
HCV 42 0 0 1 lt.0001 -----
HBV 25 17 13 8 .1058 .4852
HSV-2 46 26 17 22 .0344 .8740
Note Ns may differ due to invalid infection
data. Mantel-Haenszel used to compute p-values,
unless otherwise noted asterisk indicates
Fishers exact test.
13
Percent testing positive by proximity to core
group of IDU or MSM, 25 years old
Tested positive IDU or MSM (n204) Sex partner (n56) 2 links (n10) Not linked (n39) p-value p-value (no core)
HIV 19 10 0 0 .0009 .0410 (.1351)
HCV 60 7 0 0 lt.0001 .0784 (.2977)
HBV 60 27 22 0 lt.0001 .0016
HSV-2 62 63 70 58 .8583 .6855
Note Ns may differ due to invalid infection
data. Mantel-Haenszel used to compute p-values,
unless otherwise noted asterisk indicates
Fishers exact test.
14
Sexually-transmitted infections by network
distance from core
  • Nt HSV2 HSV1 Syph. GC CT
  • Core (MSM or IDU) 230 60 85 5 1 6
  • SPs 75 53 86 3 1 5
  • D2 26 35 80 4 4 8
  • D3 15 21 71 0 0 36
  • Unlinked to core 119 33 71 0 0 6
  • p (chi-sq test for trend) lt .001.
  • t Ns differ for infections due to missing data

15
HIV Positive by Gender/Sexuality (MSMup
triangle, WSWdown triangle, other femalecircle,
other malesquare) by Hardest Drug Use Ever (from
dark red to light pink IDU, Crack, NI Heroin or
Cocaine blueother)
16
HCV Positive by Gender/Sexuality (MSMup
triangle, WSWdown triangle, other femalecircle,
other malesquare) by Hardest Drug Use Ever (from
dark red to light pink IDU, Crack, NI Heroin or
Cocaine blueother)
17
HBV Status (Exposed, VVaccinated) by
Gender/Sexuality (MSMup triangle, WSWdown
triangle, other femalecircle, other malesquare)
by Hardest Drug Use Ever (from dark red to light
pink IDU, Crack, NI Heroin or Cocaine
blueother)
18
HSV2 Positive by Gender/Sexuality (MSMup
triangle, WSWdown triangle, other femalecircle,
other malesquare) by Hardest Drug Use Ever (from
dark red to light pink IDU, Crack, NI Heroin or
Cocaine blueother)
19
Immunization among 156 youth lt 25 years old
  • 7 have been exposed to hepatitis B
  • Among the 137 unexposed, 53 have induced
    immunity.
  • Independent significant predictors of induced
    immunity
  • Attended church more than once in last year (AOR
    3.73)
  • Younger Age (AOR per year 0.80)

20
Immunization among 166 IDUs aged 25
  • 57 have been exposed to hepatitis B
  • Among the 72 unexposed, 15 have induced
    immunity.

21
As the next slide shows, high-risk communities
contain health activists who are willing to
urge others to reduce risk behaviors.
  • This suggests that efforts might be made to win
    them to urge others to get vaccinated.
  • Outreach methods have been developed to do this
    for prevention.
  • Research is needed to see if vaccine-oriented
    outreach would be effective in these communities.

22
Star Urgers by Gender/Sexuality (MSMup triangle,
WSWdown triangle, other femalecircle, other
malesquare) by Hardest Drug Use Ever (from dark
red to light pink IDU, Crack, NI Heroin or
Cocaine blueother)
23
Group sex and health activism by proximity to
core group of IDU or MSM by age
Mantel-Haenszel p-values, unless otherwise noted asterisk indicates Fishers exact test. IDU or MSM Sex partner 2 links Not linked p-value p-value (no core)
lt25 years old n26 n19 n31 n80
Sex at group sex event L12M 46 21 32 14 .0016 .1541
Health activist 38 21 13 6 lt.0001 .0435 .0958

25 years old n204 n56 n10 n39
Sex at group sex event L12M 31 16 50 18 .1053 .7169
Health activist 32 39 10 28 .5191 .2236
24
Sex at Group Sex Party by Gender/Sexuality
(MSMup triangle, WSWdown triangle, other
femalecircle, other malesquare) by Hardest Drug
Use Ever (from dark red to light pink IDU,
Crack, NI Heroin or Cocaine blueother)
25
Correlation coefficients with distance from core
group
Includes core Includes core Excludes core Excludes core
Pearson r p-value Pearson r p-value
lt25 years old
Peers object to high-risk sex (factor scale) .27 lt.0001 -.01 .9020
Peers object to drug use (factor) .35 lt.0001 .06 .5634
Peers use drugs (factor scale) -.31 lt.0001 -.24 .0127
Number sex partners L3M -.05 .3842 -.09 .3484

25 years old
Peers object to high-risk sex (factor scale) .24 .0030 .03 .7256
Peers object to drug use (factor) .41 lt.0001 .12 .1894
Peers use drugs (factor scale) -.50 lt.0001 -.24 .0065
Number sex partners L3M -.40 lt.0001 -.36 lt.0001
26
Conclusions (1) Hepatitis B vaccination rate is
low
  • Even if we apply Lums young-IDU-based 33
    expansion factor on immunization estimates to
    estimate the rate of completed 3-dose
    vaccination, many youth have not received their
    indicated vaccinations.
  • Few members of core groups and few of their sex
    partners (in the 25 age group) have been
    immunized.
  • AJPH 2003 93919-923.

27
Conclusions (2) Infections
  • For HSV-2, IDUs and MSM may be a core group for
    wider sexual transmission. Among those less than
    25 years of age, the virus is concentrated among
    MSM and IDUs and has lower prevalence with
    greater network distance from this core. It has
    become more widespread among those 25 years old
    or older. Hypothesis HSV-2 tends to infect IDUs
    and MSM first among an age cohort, and they
    operate to an extent as a core group for further
    spread.
  • Risk network position is associated with
    infection with HIV, hepatitis B, and perhaps
    HSV-1 and syphilis.
  • The probability of current infection with
    chlamydia and gonorrhea, two curable bacterial
    infections, is NOT associated with distance from
    the MSM/IDU core.

28
Conclusions (3) Sex, norms, and health activism
  • Group sex is widespread. It is most common in the
    core for youth.
  • The number of sex partners decreases with
    distance from the core.
  • There are lots of sexual links among MSM and
    IDUs, and of WSW with both of these groups. This
    may be one reason why WSW get infected with HIV
    and other infections.
  • The norms of those with closer sexual ties to the
    core seem to be less protective.
  • Health activism (defined in terms of urging
    others to engage in safer behaviors) is more
    common in or near the core for youth, suggesting
    that those at highest risk engage in
    other-directed prevention efforts.

29
Question for you
  • Given the strong associations of age with network
    position (and other variables)which is at least
    partially methodologically produced by our
    sampling of so many over-25 IDUswhat are some
    ways to tease out the connections between network
    properties and dependent variables like
    infections, behaviors, and norms?

30
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31
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32
Chlamydia by Gender/Sexuality (MSMup triangle,
WSWdown triangle, other femalecircle, other
malesquare) by Hardest Drug Use Ever (from dark
red to light pink IDU, Crack, NI Heroin or
Cocaine blueother)
33
Cat or Dog as Pet by Gender/Sexuality (MSMup
triangle, WSWdown triangle, other femalecircle,
other malesquare) by Hardest Drug Use Ever (from
dark red to light pink IDU, Crack, NI Heroin or
Cocaine blueother)
34
Attended Group Sex Party by Gender/Sexuality
(MSMup triangle, WSWdown triangle, other
femalecircle, other malesquare) by Hardest Drug
Use Ever (from dark red to light pink IDU,
Crack, NI Heroin or Cocaine blueother)
35
Unsafe Sex at Group Sex Party by Gender/Sexuality
(MSMup triangle, WSWdown triangle, other
femalecircle, other malesquare) by Hardest Drug
Use Ever (from dark red to light pink IDU,
Crack, NI Heroin or Cocaine blueother)
36
HCV/HIV Co-infection by Gender/Sexuality (MSMup
triangle, WSWdown triangle, other femalecircle,
other malesquare) by Hardest Drug Use Ever (from
dark red to light pink IDU, Crack, NI Heroin or
Cocaine blueother)
37
HSV2/HCV Co-infection by Gender/Sexuality (MSMup
triangle, WSWdown triangle, other femalecircle,
other malesquare) by Hardest Drug Use Ever (from
dark red to light pink IDU, Crack, NI Heroin or
Cocaine blueother)
38
HSV2/HIV Co-infection by Gender/Sexuality (MSMup
triangle, WSWdown triangle, other femalecircle,
other malesquare) by Hardest Drug Use Ever (from
dark red to light pink IDU, Crack, NI Heroin or
Cocaine blueother)
39
Urge IDUs to be Safe by Gender/Sexuality (MSMup
triangle, WSWdown triangle, other femalecircle,
other malesquare) by Hardest Drug Use Ever (from
dark red to light pink IDU, Crack, NI Heroin or
Cocaine blueother)
40
Urge Others to be Safe by Gender/Sexuality
(MSMup triangle, WSWdown triangle, other
femalecircle, other malesquare) by Hardest Drug
Use Ever (from dark red to light pink IDU,
Crack, NI Heroin or Cocaine blueother)
41
Syphilis Positive by Gender/Sexuality (MSMup
triangle, WSWdown triangle, other femalecircle,
other malesquare) by Hardest Drug Use Ever (from
dark red to light pink IDU, Crack, NI Heroin or
Cocaine blueother)
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