Professor of Global Public Health
Dr. Holly Hagan is a Professor in the Departments of Social Behavioral Sciences and Epidemiology at the School of Global Public Health. Trained as an infectious disease epidemiologist, Dr. Hagan’s work has sought to understand the causes and consequences of substance use disorders. Her research has examined blood-borne and sexually-transmitted infections among people who use drugs. She is an internationally-recognized expert in the etiology, epidemiology, natural history, prevention and treatment of hepatitis C virus infection among PWUD, and in 2014 her work was recognized by the US Department of Health and Human Services with the President’s Award for Leadership in the Control of Viral Hepatitis in the United States. Dr. Hagan served on the Institute of Medicine Committee on the Prevention and Control of Viral Hepatitis in the United States, and she has been an advisor to the US Department of Health and Human Services, the CDC, and the Canadian Institutes of Health on national programs to detect, diagnose and treat HCV infections. She was recently appointed to the National Academy of Medicine Committee on the Examination of the Integration of Opioid and Infectious Disease Prevention Efforts in Select Programs.
Dr. Hagan is the Director of the NIDA P30 Center for Drug Use and HIV|HCV Research at Global Public Health, which provides research support to investigators throughout NYU and in two other NYC institutions. In 2017, she was selected by NIDA to chair the Executive Steering Committee for the Rural Opioid Initiative funded by NIH, CDC, SAMHSA and the Appalachian Regional Commission. Her research has shifted to examining the impact of the opioid crisis more broadly, to include studying the epidemiology of fatal and non-fatal overdose among PWUD. She was chosen by the American Foundation for AIDS Research to be the Principal Investigator for the New York State Opioid Prevention Center pilot study, which will examine the safety and effectiveness of the Supervised Consumption Sites to be implemented in New York City and in upstate NY.
PhD Epidemiology, University of Washington, Seattle, WAMPH Epidemiology, University of Massachusetts, Amherst, MABA Russian Studies, Evergreen State College, Olympia, WA
Nurses at the frontline of public health emergency preparedness and response: lessons learned from the HIV/AIDS pandemic and emerging infectious disease outbreaksGuilamo-Ramos, V., Thimm-Kaiser, M., Benzekri, A., Hidalgo, A., Lanier, Y., Tlou, S., De Lourdes Rosas López, M., Soletti, A. B., & Hagan, H.
Journal titleThe Lancet Infectious Diseases
Page(s)e326-e333AbstractThe years 2020–21, designated by WHO as the International Year of the Nurse and Midwife, are characterised by unprecedented global efforts to contain and mitigate the COVID-19 pandemic. Lessons learned from successful pandemic response efforts in the past and present have implications for future efforts to leverage the global health-care workforce in response to outbreaks of emerging infectious diseases such as COVID-19. Given its scale, reach, and effectiveness, the response to the HIV/AIDS pandemic provides one such valuable example, particularly with respect to the pivotal, although largely overlooked, contributions of nurses and midwives. This Personal View argues that impressive achievements in the global fight against HIV/AIDS would not have been attained without the contributions of nurses. We discuss how these contributions uniquely position nurses to improve the scale, reach, and effectiveness of response efforts to emerging infectious diseases with pandemic potential; provide examples from the responses to COVID-19, Zika virus disease, and Ebola virus disease; and discuss implications for current and future efforts to strengthen pandemic preparedness and response.
Cost-effectiveness of direct antiviral agents for hepatitis c virus infection and a combined intervention of syringe access and medication-assisted therapy for opioid use disorders in an injection drug use populationStevens, E. R., Nucifora, K. A., Hagan, H., Jordan, A. E., Uyei, J., Khan, B., Dombrowski, K., Des Jarlais, D., & Scott Braithwaite, R.
Journal titleClinical Infectious Diseases
Page(s)2652-2662AbstractBackground: There are too many plausible permutations and scale-up scenarios of combination hepatitis C virus (HCV) interventions for exhaustive testing in experimental trials. Therefore, we used a computer simulation to project the health and economic impacts of alternative combination intervention scenarios for people who inject drugs (PWID), focusing on direct antiviral agents (DAA) and medication-assisted treatment combined with syringe access programs (MAT+). Methods. We performed an allocative efficiency study, using a mathematical model to simulate the progression of HCV in PWID and its related consequences. We combined 2 previously validated simulations to estimate the cost-effectiveness of intervention strategies that included a range of coverage levels. Analyses were performed from a health-sector and societal perspective, with a 15-year time horizon and a discount rate of 3%. Results. From a health-sector perspective (excluding criminal justice system-related costs), 4 potential strategies fell on the cost-efficiency frontier. At 20% coverage, DAAs had an incremental cost-effectiveness ratio (ICER) of $27 251/quality-adjusted life-year (QALY). Combinations of DAA at 20% with MAT+ at 20%, 40%, and 80% coverage had ICERs of $165 985/QALY, $325 860/ QALY, and $399 189/QALY, respectively. When analyzed from a societal perspective (including criminal justice system-related costs), DAA at 20% with MAT+ at 80% was the most effective intervention and was cost saving. While DAA at 20% with MAT+ at 80% was more expensive (eg, less cost saving) than MAT+ at 80% alone without DAA, it offered a favorable value compared to MAT+ at 80% alone ($23 932/QALY). Conclusions. When considering health-sector costs alone, DAA alone was the most cost-effective intervention. However, with criminal justice system-related costs, DAA and MAT+ implemented together became the most cost-effective intervention.
Participation of the nursing workforce to address COVID-19 among people who use alcohol, tobacco, and drugs
What is a rural opioid risk and policy environment?
On the way to Hepatitis C elimination in the Republic of Georgia—Barriers and facilitators for people who inject drugs for engaging in the treatment program: A formative qualitative studyChikovani, I., Ompad, D. C., Uchaneishvili, M., Sulaberidze, L., Sikharulidze, K., Hagan, H., & Van Devanter, N. L.
Journal titlePloS one
Issue4AbstractHepatitis C virus (HCV) infection is a significant public health concern worldwide. Georgia is among the countries with a high burden of HCV infection. People who inject drugs (PWID) have the highest burden of infection in Georgia. In 2015, the Government of Georgia, with partners’ support, initiated one of the world’s first Hepatitis C Elimination Programs. Despite notable progress, challenges to achieving targets persist. This qualitative study is aimed to better understand some of the barriers and facilitators to HCV testing and treatment services for PWID to inform HCV treatment policies and practices. The study instrument examined social, structural, and individual factors influencing HCV testing and treatment practices. We started with key informant interviews to guide the study instrument development and compare the study findings against health care planners’ and health care providers’ views. Forty PWID with various HCV testing and treatment experiences were recruited through the snowball method. The study found that along with structural factors such as political commitment, co-financing of diagnostic and monitoring tests, and friendly clinic environments, knowledge about HCV infection and elimination program benefits, and support from family and peers also play facilitating roles in accessing testing and treatment services. On the other hand, inability to co-pay for diagnostic tests, fear of side effects associated with treatment, poor knowledge about HCV infection, and lack of social support hampered testing and treatment practices among PWID. Findings from this study are important for increasing the effectiveness of this unique program that targets a population at high risk of HCV infection.
Check Hep C: A Community-Based Approach to Hepatitis C Diagnosis and Linkage to Care in High-Risk PopulationsFord, M. M., Jordan, A. E., Johnson, N., Rude, E., Laraque, F., Varma, J. K., & Hagan, H.
Journal titleJournal of Public Health Management and Practice
Page(s)41-48AbstractContext: In New York City (NYC), an estimated 146 500 people, or 2.4% of the adult population, have chronic hepatitis C virus (HCV) infection and half may be unaware of their infection. Despite a 2014 state law requiring health care providers to screen for HCV infection in primary care settings, many high-risk HCV-positive persons are not, and a large proportion of those screened do not receive RNA testing to confirm infection, or antiviral therapies. Objective: The NYC Department of Health's Check Hep C program was designed to increase hepatitis C diagnosis and improve linkage to care at community-based organizations. Design: Coordinated, evidence-based practices were implemented at 12 sites, including HCV antibody testing, immediate blood draw for RNA testing, and patient navigation to clinical services. Results: From May 2012 through April 2013, a total of 4751 individuals were tested for HCV infection and 880 (19%) were antibody-positive. Of antibody-positive participants, 678 (77%) had an RNA test, and of those, 512 (76%) had current infection. Of all participants, 1901 were born between 1945 and 1965, and of those, 201 (11%) were RNA-positive. Ever having injected drugs was the strongest risk factor for HCV infection (40% vs 3%; adjusted odds ratio [AOR] = 19.1), followed by a history of incarceration (18% vs 4%; AOR = 2.2). Of the participants with current infection, 85% attended at least 1 follow-up hepatitis C medical appointment. Fourteen patients initiated hepatitis C treatment at a Check Hep C site and 6 initiators achieved cure. Conclusion: The community-based model successfully identified persons with HCV infection and linked a large proportion to care. The small number of patients initiating hepatitis C treatment in the program identified the need for patient navigation in high-risk populations. Results can be used to inform screening and linkage-to-care strategies and to support the execution of hepatitis C screening recommendations.
Combination interventions for Hepatitis C and Cirrhosis reduction among people who inject drugs: An agent-based, networked population simulation experimentKhan, B., Duncan, I., Saad, M., Schaefer, D., Jordan, A., Smith, D., Neaigus, A., Jarlais, D. D., Hagan, H., & Dombrowski, K.
Journal titlePloS one
Issue11AbstractHepatitis C virus (HCV) infection is endemic in people who inject drugs (PWID), with prevalence estimates above 60% for PWID in the United States. Previous modeling studies suggest that direct acting antiviral (DAA) treatment can lower overall prevalence in this population, but treatment is often delayed until the onset of advanced liver disease (fibrosis stage 3 or later) due to cost. Lower cost interventions featuring syringe access (SA) and medically assisted treatment (MAT) have shown mixed results in lowering HCV rates below current levels. However. little is known about the potential cumulative effects of combining DAA and MAT treatment. While simulation experiments can reveal likely long-term effects, most prior simulations have been performed on closed populations of model agents—a scenario quite different from the open, mobile populations known to most health agencies. This paper uses data from the Centers for Disease Control’s National HIV Behavioral Surveillance project, IDU round 3, collected in New York City in 2012 to parameterize simulations of open populations. To test the effect of combining DAA treatment with SA/MAT participation, multiple, scaled implementations of the two intervention strategies were simulated. Our results show that, in an open population, SA/MAT by itself has only small effects on HCV prevalence, while DAA treatment by itself can lower both HCV and HCV-related advanced liver disease prevalence. More importantly, the simulation experiments suggest that combinations of the two strategies can, when implemented together and at sufficient levels, dramatically reduce HCV incidence. We conclude that adopting SA/MAT implementations alongside DAA interventions can play a critical role in reducing the long-term consequences of ongoing HCV infection.
Differences in the fecal microbiota of neonates born at home or in the hospital
Needle and syringe programmes and opioid substitution therapy for preventing HCV transmission among people who inject drugs: findings from a Cochrane Review and meta-analysisPlatt, L., Minozzi, S., Reed, J., Vickerman, P., Hagan, H., French, C., Jordan, A., Degenhardt, L., Hope, V., Hutchinson, S., Maher, L., Palmateer, N., Taylor, A., Bruneau, J., & Hickman, M.
Page(s)545-563AbstractAims: To estimate the effects of needle and syringe programmes (NSP) and opioid substitution therapy (OST), alone or in combination, for preventing acquisition of hepatitis C virus (HCV) in people who inject drugs (PWID). Methods: Systematic review and meta-analysis. Bibliographic databases were searched for studies measuring concurrent exposure to current OST (within the last 6 months) and/or NSP and HCV incidence among PWID. High NSP coverage was defined as regular NSP attendance or ≥ 100% coverage (receiving sufficient or greater number of needles and syringes per reported injecting frequency). Studies were assessed using the Cochrane risk of bias in non-randomized studies tool. Random-effects models were used in meta-analysis. Results: We identified 28 studies (n = 6279) in North America (13), United Kingdom (five), Europe (four), Australia (five) and China (one). Studies were at moderate (two), serious (17) critical (seven) and non-assessable risk of bias (two). Current OST is associated with 50% [risk ratio (RR) =0.50, 95% confidence interval (CI) = 0.40–0.63] reduction in HCV acquisition risk, consistent across region and with low heterogeneity (I2 = 0, P = 0.889). Weaker evidence was found for high NSP coverage (RR = 0.79, 95% CI = 0.39–1.61) with high heterogeneity (I2 = 77%, P = 0.002). After stratifying by region, high NSP coverage in Europe was associated with a 56% reduction in HCV acquisition risk (RR = 0.44, 95% CI = 0.24–0.80) with low heterogeneity (I2 = 12.3%, P = 0.337), but not in North America (RR = 1.58, I2 = 89.5%, P = < 0.001). Combined OST/NSP is associated with a 74% reduction in HCV acquisition risk (RR = 0.26, 95% CI = 0.07–0.89, I2 = 80% P = 0.007). According to Grades of Recommendation Assessment, Development and Evaluation (GRADE) criteria, the evidence on OST and combined OST/NSP is low quality, while NSP is very low. Conclusions: Opioid substitution therapy reduces risk of hepatitis C acquisition and is strengthened in combination with needle and syringe programmes (NSP). There is weaker evidence for the impact of needle syringe programmes alone, although stronger evidence that high coverage is associated with reduced risk in Europe.
Racial and ethnic disparities in predictors of glycemia: a moderated mediation analysis of inflammation-related predictors of diabetes in the NHANES 2007–2010Nowlin, S., Cleland, C. M., Parekh, N., Hagan, H., & Melkus, G.
Journal titleNutrition and Diabetes
Issue1AbstractBackground/Objective: Racial/ethnic disparities in type 2 diabetes (T2D) outcomes exist, and could be explained by nutrition- and inflammation-related differences. The objective of this study is to identify associations between race/ethnicity and glucose control among participants from NHANES 2007–2010, as influenced by diet quality, body mass, and inflammation and grouped by T2D status. Subjects/Methods: The following is a cross-sectional, secondary data analysis of two NHANES data cycles spanning 2007–2010. The association between race/ethnicity and hemoglobin A1c (HbA1c) as mediated by dietary intake score, body mass index (BMI), and C-reactive protein (CRP) was assessed, as was the strength of the difference of that association, or moderation, by T2D status. The sample included n = 7850 non-pregnant adult participants ≥ 20 years of age who had two days of reliable dietary recall data, and no missing data on key variables included in the analysis. The primary outcome examined was HbA1c. Results: The model accurately explained the variation in HbA1c measures in participants without T2D, as mediated by diet quality, BMI, and CRP. However, significant variation in HbA1c remained after accounting for aforementioned mediators when contrasting non-Hispanic White to non-Hispanic Black participants without T2D. The model was not a good fit for explaining racial/ethnic disparities in HbA1c in participants with T2D. A test of the index of moderated mediation for this model was not significant for the differences in the effect of race/ethnicity on HbA1c by T2D status (moderator). Conclusions: This study demonstrated that diet quality, BMI, and CRP mediated the effect of race/ethnicity on HbA1c in persons without T2D, but not in persons with T2D. Further research should include additional inflammatory markers, and other inflammation- and T2D-related health outcomes, and their association with racial/ethnic disparities in diabetes.
Sex Practices by HIV Awareness and Engagement in the Continuum of Care Among MSM: A National HIV Behavioral Surveillance Analysis in 21 U.S. CitiesFailed generating bibliography.Abstract
Journal titleAIDS and Behavior
Page(s)840-847AbstractUsing National HIV Behavioral Surveillance (NHBS) cross-sectional survey and HIV testing data in 21 U.S. metropolitan areas, we identify sex practices among sexually active men who have sex with men (MSM) associated with: (1) awareness of HIV status, and (2) engagement in the HIV care continuum. Data from 2008, 2011, and 2014 were aggregated, yielding a sample of 5079 sexually active MSM living with HIV (MLWH). Participants were classified into HIV status categories: (1) unaware; (2) aware and out of care; (3) aware and in care without antiretroviral therapy (ART); and (4) aware and on ART. Analyses were conducted examining sex practices (e.g. condomless sex, discordant condomless sex, and number of sex partners) by HIV status. Approximately 30, 5, 10 and 55% of the sample was classified as unaware, aware and out of care, aware and in care without ART, and aware and on ART, respectively. Unaware MLWH were more likely to report condomless anal sex with a last male partner of discordant or unknown HIV status (25.9%) than aware MLWH (18.0%, p value OpenSPiltSPi 0.0001). Unaware MLWH were 3 times as likely to report a female sex partner in the prior 12 months as aware MLWH (17.3 and 5.6%, p-value OpenSPiltSPi 0.0001). When examining trends across the continuum of care, reports of any condomless anal sex with a male partner in the past year (ranging from 65.0 to 70.0%), condomless anal sex with a male partner of discordant or unknown HIV status (ranging from 17.7 to 21.3%), and median number of both male and female sex partners were similar. In conclusion, awareness of HIV and engagement in care was not consistently associated with protective sex practices, highlighting the need for continued prevention efforts.
Use of the PRECIS-II instrument to categorize reports along the efficacy-effectiveness spectrum in an hepatitis C virus care continuum systematic review and meta-analysisJordan, A. E., Perlman, D. C., Smith, D. J., Reed, J. R., & Hagan, H.
Journal titleJournal of Clinical Epidemiology
Page(s)66-75AbstractThere is increasing recognition of the importance of the distinction between efficacy and effectiveness research in the design, conduct, and evaluation of interventions and program outcomes. There is a concurrent increase in the application of systematic reviews and meta-analyses. These two lines of inquiry are only beginning to meet. There is an emerging need for systematic reviews and meta-analyses to account for differences in degrees to which included studies reflect either efficacy or effectiveness design. Based on ongoing work on a formal systematic review of the hepatitis C virus care continuum, this paper describes and discusses the rationale for, and how the PRECIS-II instrument can be used on, and modestly adapted to, studies included in the systematic review examining the extent to which studies include elements of efficacy or effectiveness or a combination of the two. We also highlight that use of such an instrument may have general applicability to and value in the conduct of systematic reviews and meta-analysis.
Association Between Enacted Stigma and HIV-Related Risk Behavior Among MSM, National HIV Behavioral Surveillance System, 2011Failed generating bibliography.Abstract
Journal titleAIDS and Behavior
Page(s)227-237AbstractMSM bear a disproportionate burden of the HIV epidemic. Enacted stigma (overt negative actions) against sexual minorities may play an important role in increasing HIV risk among this population. Using data from the 2011 National HIV Behavioral Surveillance system, MSM cycle, we examined the independent associations between three measures of enacted stigma (verbal harassment, discrimination, physical assault) and engagement in each of four HIV-related risk behaviors as outcomes: condomless anal intercourse (CAI) at last sex with a male partner of HIV discordant or unknown status and, in the past 12 months, CAI with a male partner, ≥4 male sex partners, and exchange sex. Of 9819 MSM, 32% experienced verbal harassment in the past 12 months, 23% experienced discrimination, and 8% experienced physical assault. Discordant CAI at last sex with a male partner was associated with previous discrimination and physical assault. Past 12 month CAI with a male partner, ≥4 male sex partners, and exchange sex were each associated with verbal harassment, discrimination, and physical assault. These findings indicate that a sizable proportion of MSM report occurrences of past 12 month enacted stigma and suggest that these experiences may be associated with HIV-related risk behavior. Addressing stigma towards sexual minorities must involve an integrated, multi-faceted approach, including interventions at the individual, community, and societal level.
Continuing Links Between Substance Use and HIV Highlight the Importance of Nursing RolesDeren, S., Naegle, M., Hagan, H., & Ompad, D. C.
Journal titleJournal of the Association of Nurses in AIDS Care
Page(s)622-632AbstractLinks between HIV and substance use were identified early in the U.S. HIV epidemic. People who use drugs are at risk of HIV infection through shared injection equipment and risky sexual behaviors. In addition, substance use has negative health consequences for people living with HIV. The prescription opioid misuse epidemic, linked to injection drug use, hepatitis C infection, and HIV, poses a new threat to declining HIV rates. We reviewed evidence-based interventions that decrease HIV risk in people who use drugs (needle/syringe programs, medication-assisted treatment, engagement in HIV care, and preexposure prophylaxis/postexposure prophylaxis). The critical roles of nurses in HIV prevention/care for this population are described, including applying the principles of harm reduction, screening for substance use, and undertaking implementation and research efforts. As the nation's largest health care profession, nurses are positioned to contribute to the quality of HIV-related prevention/care for people who use drugs and to lead practice initiatives.
Decline in herpes simplex virus type 2 among non-injecting heroin and cocaine users in New York City, 2005 to 2014: Prospects for avoiding a resurgence of human immunodeficiency virus
Decline in HSV-2 among non-injecting Heroin and Cocaine users in New York City, 2005-2014: potential protection against HIV resurgenceDes Jarlais, D., Arasteh, K., Feelemyer, J., Mcknight, C., Tross, S., Perlman, D., Campbell, A. N. C., Hagan, H., & Cooper, H. L. F.
Journal titleSexually Transmitted Diseases
Epidemiology of hepatitis c virus among people who inject drugs: Protocol for a systematic review and meta-analysisSmith, D. J., Neurer, J., Jordan, A. E., & Hagan, H.
Journal titleJMIR Research Protocols
Issue10AbstractBackground: Hepatitis C virus (HCV) is a persistent epidemic among people who inject drugs (PWID), and PWID remain as the population experiencing the most significant impact of HCV-related morbidity and mortality worldwide. Objective: The purpose of this systematic review and meta-analysis is to synthesize data on the epidemiology of HCV infection among PWID. Our main objectives are to characterize the global and regional distribution and determinants of HCV infection among PWID. Methods: A search strategy is conducted that involves both the electronic and manual retrievals of literature. Reports are included in this review if they present data published between 2006 and 2015 on prevalent or incident HCV infection among current or former PWID. Standard meta-analytic techniques are performed to synthesize the pooled data and identify correlates of HCV infection. Results: The search strategy has been performed, and data collection is in progress. Data analysis will follow, and the final results of this systematic review/meta-analysis are expected by December 2017. Conclusions: This article describes the protocol for the systematic review and meta-analysis of epidemiology of HCV among PWID. We aim to provide synthesized data on HCV incidence and prevalence as well as to identify factors associated with HCV transmission. Our research contributes empirical evidence that informs scholarly, medical, and policy discussions concerning HCV.
Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugsPlatt, L., Minozzi, S., Reed, J., Vickerman, P., Hagan, H., French, C., Jordan, A., Degenhardt, L., Hope, V., Hutchinson, S., Maher, L., Palmateer, N., Taylor, A., Bruneau, J., & Hickman, M.
Journal titleCochrane Database of Systematic Reviews
Issue9AbstractBackground: Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs Needle syringe programmes (NSP) and opioid substitution therapy (OST) are the primary interventions to reduce hepatitis C (HCV) transmission in people who inject drugs. There is good evidence for the effectiveness of NSP and OST in reducing injecting risk behaviour and increasing evidence for the effectiveness of OST and NSP in reducing HIV acquisition risk, but the evidence on the effectiveness of NSP and OST for preventing HCV acquisition is weak. Objectives: To assess the effects of needle syringe programmes and opioid substitution therapy, alone or in combination, for preventing acquisition of HCV in people who inject drugs. Search methods: We searched the Cochrane Drug and Alcohol Register, CENTRAL, the Cochrane Database of Systematic Reviews (CDSR), the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment Database (HTA), the NHS Economic Evaluation Database (NHSEED), MEDLINE, Embase, PsycINFO, Global Health, CINAHL, and the Web of Science up to 16 November 2015. We updated this search in March 2017, but we have not incorporated these results into the review yet. Where observational studies did not report any outcome measure, we asked authors to provide unpublished data. We searched publications of key international agencies and conference abstracts. We reviewed reference lists of all included articles and topic-related systematic reviews for eligible papers. Selection criteria: We included prospective and retrospective cohort studies, cross-sectional surveys, case-control studies and randomised controlled trials that measured exposure to NSP and/or OST against no intervention or a reduced exposure and reported HCV incidence as an outcome in people who inject drugs. We defined interventions as current OST (within previous 6 months), lifetime use of OST and high NSP coverage (regular attendance at an NSP or all injections covered by a new needle/syringe) or low NSP coverage (irregular attendance at an NSP or less than 100% of injections covered by a new needle/syringe) compared with no intervention or reduced exposure. Data collection and analysis: We followed the standard Cochrane methodological procedures incorporating new methods for classifying risk of bias for observational studies. We described study methods against the following 'Risk of bias' domains: confounding, selection bias, measurement of interventions, departures from intervention, missing data, measurement of outcomes, selection of reported results; and we assigned a judgment (low, moderate, serious, critical, unclear) for each criterion. Main results: We identified 28 studies (21 published, 7 unpublished): 13 from North America, 5 from the UK, 4 from continental Europe, 5 from Australia and 1 from China, comprising 1817 incident HCV infections and 8806.95 person-years of follow-up. HCV incidence ranged from 0.09 cases to 42 cases per 100 person-years across the studies. We judged only two studies to be at moderate overall risk of bias, while 17 were at serious risk and 7 were at critical risk; for two unpublished datasets there was insufficient information to assess bias. As none of the intervention effects were generated from RCT evidence, we typically categorised quality as low. We found evidence that current OST reduces the risk of HCV acquisition by 50% (risk ratio (RR) 0.50, 95% confidence interval (CI) 0.40 to 0.63, I2 = 0%, 12 studies across all regions, N = 6361), but the quality of the evidence was low. The intervention effect remained significant in sensitivity analyses that excluded unpublished datasets and papers judged to be at critical risk of bias. We found evidence of differential impact by proportion of female participants in the sample, but not geographical region of study, the main drug used, or history of homelessness or imprisonment among study samples. Overall, we found very low-quality evidence that high NSP coverage did not reduce risk of HCV acquisition (RR 0.79, 95% CI 0.39 to 1.61) with high heterogeneity (I2 = 77%) based on five studies from North America and Europe involving 3530 participants. After stratification by region, high NSP coverage in Europe was associated with a 76% reduction in HCV acquisition risk (RR 0.24, 95% CI 0.09 to 0.62) with less heterogeneity (I2 =0%). We found low-quality evidence of the impact of combined high coverage of NSP and OST, from three studies involving 3241 participants, resulting in a 74% reduction in the risk of HCV acquisition (RR 0.26 95% CI 0.07 to 0.89). Authors' conclusions: OST is associated with a reduction in the risk of HCV acquisition, which is strengthened in studies that assess the combination of OST and NSP. There was greater heterogeneity between studies and weaker evidence for the impact of NSP on HCV acquisition. High NSP coverage was associated with a reduction in the risk of HCV acquisition in studies in Europe.
Past-year prevalence of prescription opioid misuse among those 11 to 30 years of age in the United States: A systematic review and meta-analysis
Patterns and Gaps Identified in a Systematic Review of the Hepatitis C Virus Care Continuum in Studies among People Who Use DrugsJordan, A. E., Perlman, D. C., Reed, J., Smith, D. J., & Hagan, H.
Journal titleFrontiers in Public Health
Volume5AbstractIntroduction: Systematic reviews are useful for synthesizing data on various health conditions and for identifying gaps in available data. In the US, the main risk group for hepatitis C virus (HCV) infection is people who use drugs (PWUD); as a group, PWUD have the highest prevalence of chronic HCV. While the care continuum construct has been increasingly applied to studies of HCV care among PWUD, what constitutes the steps in an HCV care continuum is not standardized. We sought to examine the range of HCV care continuum outcomes that studies reported on, to identify gaps in the literature, and to develop strategies that allowed for valuable syntheses of care continuum data. Methods: We conducted searches of electronic databases for published literature. Reports were eligible if they provided original data from 1990 to 2016 from the US, presented data on one or more HCV care continuum outcomes, and provided outcome data on PWUD as a distinct group. Results: A total of 313 full-text reports were assessed for eligibility. Of 212 potentially eligible reports, 32 (15.1%) did not present outcomes for PWUD separately from those who were non-PWUD. Among 101 eligible reports, a total of 166 care continuum outcomes were extracted; outcomes could be grouped into three categories that represent the HCV care continuum: testing (39.8%, n = 66/166); linkage to care (16.9%, n = 28/166); and treatment (43.4%, n = 72/166). Seventy-four reports (73.3%, n = 74/101) presented data on only one step. Linkage to care occurred variably after only antibody, or after antibody and viral load (VL) testing. Six (5.9%, n = 6/101) reports presented data on all three steps. Conclusion: Reports examined a variety of HCV care continuum outcomes that could be grouped into the three steps of testing, linkage to care, and treatment. The application of this care continuum model would facilitate subsequent data synthesis for program comparison and public health evaluation. Given the two-step nature of HCV testing, analyses also need to account for variation in whether linkage to care occurred after antibody testing or after sequential antibody and VL testing. Additional data are needed on the progression of PWUD through the entire care continuum.
Policy Changes and Improvements in Health Insurance Coverage Among MSM: 20 U.S. Cities, 2008–2014Failed generating bibliography.Abstract
Journal titleAIDS and Behavior
Page(s)615-618AbstractRecent policy changes have improved the ability of gay, bisexual, and other men who have sex with men (MSM) to secure health insurance. We wanted to assess changes over time in self-reported health insurance status among MSM participating in CDC’s National HIV Behavioral Surveillance (NHBS) in 2008, 2011, and 2014. We analyzed NHBS data from sexually active MSM interviewed at venues in 20 U.S. cities. To determine if interview year was associated with health insurance status, we used a Poisson model with robust standard errors. Among included MSM, the overall percentage of MSM with health insurance rose 16 % from 2008 (68 %) to 2014 (79 %) (p value for trend < 0.001). The change in coverage over time was greatest in key demographic segments with lower health insurance coverage all three interview years, by age, education, and income. Corresponding with recent policy changes, health insurance improved among MSM participating in NHBS, with greater improvements in historically underinsured demographic segments. Despite these increases, improved coverage is still needed. Improved access to health insurance could lead to a reduction in health disparities among MSM over time.
Prevalence of hepatitis C virus infection among HIV+ men who have sex with men: a systematic review and meta-analysis
Public health benefit of peer-referral strategies for detecting undiagnosed HIV infection among high-risk heterosexuals in New York CityGwadz, M., Cleland, C. M., Perlman, D. C., Hagan, H., Jenness, S. M., Leonard, N. R., Ritchie, A. S., & Kutnick, A.
Journal titleJournal of Acquired Immune Deficiency Syndromes
Page(s)499-507AbstractIdentifying undiagnosed HIV infection is necessary for the elimination of HIV transmission in the United States. The present study evaluated the efficacy of 3 community-based approaches for uncovering undiagnosed HIV among heterosexuals at high-risk (HHR), who are mainly African American/Black and Hispanic. Heterosexuals comprise 24% of newly reported HIV infections in the United States, but experience complex multilevel barriers to HIV testing. We recruited African American/Black and Hispanic HHR in a discrete urban area with both elevated HIV prevalence and poverty rates. Approaches tested were (1) respondent-driven sampling (RDS) and confidential HIV testing in 2 sessions (n = 3116); (2) RDS and anonymous HIV testing in one session (n = 498); and (3) venuebased sampling (VBS) and HIV testing in a single session (n = 403). The main outcome was newly diagnosed HIV infection. RDS with anonymous testing and one session reached HHR with less HIV testing experience and more risk factors than the other approaches. Furthermore, RDS with anonymous (4.0%) and confidential (1.0%) testing yielded significantly higher rates of newly diagnosed HIV than VBS (0.3%). Thus peer-referral approaches were more efficacious than VBS for uncovering HHR with undiagnosed HIV, particularly a single-session/anonymous strategy, and have a vital role to play in efforts to eliminate HIV transmission.
The Interaction of Risk Network Structures and Virus Natural History in the Non-spreading of HIV Among People Who Inject Drugs in the Early Stages of the EpidemicDombrowski, K., Khan, B., Habecker, P., Hagan, H., Friedman, S. R., & Saad, M.
Journal titleAIDS and Behavior
Page(s)1004-1015AbstractThis article explores how social network dynamics may have reduced the spread of HIV-1 infection among people who inject drugs during the early years of the epidemic. Stochastic, discrete event, agent-based simulations are used to test whether a “firewall effect” can arise out of self-organizing processes at the actor level, and whether such an effect can account for stable HIV prevalence rates below population saturation. Repeated simulation experiments show that, in the presence of recurring, acute, and highly infectious outbreaks, micro-network structures combine with the HIV virus’s natural history to reduce the spread of the disease. These results indicate that network factors likely played a significant role in the prevention of HIV infection within injection risk networks during periods of peak prevalence. They also suggest that social forces that disturb network connections may diminish the natural firewall effect and result in higher rates of HIV.
Trends in HIV and HCV Risk Behaviors and Prevalent Infection Among People Who Inject Drugs in New York City, 2005-2012Neaigus, A., Reilly, K. H., Jenness, S. M., Hagan, H., Wendel, T., Gelpi-Acosta, C., & Marshall, D. M.
Journal titleJournal of Acquired Immune Deficiency Syndromes
Page(s)S325-S332AbstractBackground: We assess trends in HIV and hepatitis C virus (HCV) risk behaviors and prevalent infection among people who inject drugs (PWID) in New York City (NYC). Methods: PWID in NYC were sampled using respondent-driven sampling in 2005, 2009, and 2012 (serial cross sections) for the Centers for Disease Control and Prevention-sponsored National HIV Behavioral Surveillance study. Participants were interviewed about their current (≤12 months) risk behaviors and tested for HIV and HCV. The crude and adjusted risk ratio (RR) and 95% confidence interval (95% CI) for linear time trends were estimated using generalized estimating equations regression with a modified Poisson model. Results: The sample comprised 500, 514, and 525 participants in 2005, 2009, and 2012, respectively. Significant (P< 0.05) linear trends in risk behaviors included a decline in unsafe syringe sources (60.8%, 31.3%, 46.7%; RR = 0.86, 95% CI: 0.81 to 0.92), an increase in all syringes from syringe exchanges or pharmacies (35.4%, 67.5%, 50.3%; RR = 1.15, 95% CI: 1.09 to 1.22), and an increase in condomless vaginal or anal sex (53.6%, 71.2%, 70.3%; RR = 1.14, 95% CI: 1.09 to 1.19). Receptive syringe sharing (21.4%, 27.0%, 25.1%), sharing drug preparation equipment (45.4%, 43.4%, 46.7%), and having ≥2 sex partners (51.2%, 44.0%, 50.7%) were stable. Although HIV seroprevalence declined (18.1%, 12.5%, 12.2%), HCV seroprevalence was high (68.2%, 75.8%, 67.1%). In multivariate analysis, adjusting for sample characteristics significantly associated with time, linear time trends remained significant, and the decline in HIV seroprevalence gained significance (adjusted RR = 0.76, 95% CI: 0.64 to 0.91, P = 0.003). Conclusions: This trend analysis suggests declining HIV prevalence among NYC PWID. However, HCV seroprevalence was high and risk behaviors were considerable. Longitudinal surveillance of HIV and HCV risk behaviors and infections is needed to monitor trends and for ongoing data-informed prevention among PWID.