Dr. Holly Hagan is a Professor in the Departments of Social Behavioral Sciences and Epidemiology at the College 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
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., Uchaneishvili, M., Sulaberidze, L., Sikharulidze, K., Hagan, H., & Van Devanter, N.
Journal titlePLoS ONE
Issue4Hepatitis 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.
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., Des Jarlais, D., Hagan, H., & Dombrowski, K.
Journal titlePLoS One
Issue11Hepatitis 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 hospitalCombellick, J. L., Shin, H., Shin, D., Cai, Y., Hagan, H., Lacher, C., Lin, D. L., McCauley, K., Lynch, S. V., & Dominguez-Bello, M. G.
Journal titleScientific Reports
Issue1Research on the neonatal microbiome has been performed mostly on hospital-born infants, who often undergo multiple birth-related interventions. Both the hospital environment and interventions around the time of birth may affect the neonate microbiome. In this study, we determine the structure of the microbiota in feces from babies born in the hospital or at home, and from vaginal samples of their mothers. We included 35 vaginally-born, breast-fed neonates, 14 of whom delivered at home (4 in water), and 21 who delivered in the hospital. Feces from babies and mothers and maternal vaginal swab samples were collected at enrollment, the day of birth, followed by days 1, 2, 7, 14, 21, and 28. At the time of birth, the diversity of the vaginal microbiota of mothers delivering in the hospital was higher than in mothers delivering at home, and showed higher proportion of Lactobacillus. Among 20 infants not exposed to perinatal maternal antibiotics or water birth, fecal beta diversity differed significantly by birth site, with hospital-born infants having lower Bacteroides, Bifidobacterium, Streptococcus, and Lactobacillus, and higher Clostridium and Enterobacteriaceae family (LDA > 3.0), than babies born at home. At 1 month of age, feces from infants born in the hospital also induced greater pro-inflammatory gene expression (TLR4, IL-8, occludin and TGFβ) in human colon epithelial HT-29 cells. The results of this work suggest that hospitalization (perinatal interventions or the hospital environment) may affect the microbiota of the vaginal source and the initial colonization during labor and birth, with effects that could persist in the intestinal microbiota of infants 1 month after birth. More research is needed to determine specific factors that alter bacterial transmission between mother and baby and the long-term health implications of these differences for the developing infant.
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)545-563Aims: 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., & D’Eramo Melkus, G.
Journal titleNutrition and Diabetes
Issue1Background/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.
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)66-75There 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)227-237MSM 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.
Check Hep C: A Community-Based Approach to Hepatitis C Diagnosis and Linkage to Care in High-Risk PopulationsFord, M. M., Johnson, N., Rude, E., Laraque, F., Varma, J. K., & Hagan, H.
Journal titleJournal of Public Health Management and PracticeCONTEXT:: 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 Healthʼs 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.
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 CareLinks 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 virusDes Jarlais, D., Arasteh, K., Feelemyer, J., Mcknight, C., Tross, S., Perlman, D. C., Campbell, A. N. C., Hagan, H., & Cooper, H. L. F.
Journal titleSexually Transmitted Diseases
Page(s)85-90Background: Herpes simplex virus type 2 (HSV-2) infection increases both susceptibility to and transmissibility of human immunodeficiency virus (HIV), and HSV-2 and HIV are often strongly associated in HIV epidemics. We assessed trends in HSV-2 prevalence among non-injecting drug users (NIDUs) when HIV prevalence declined from 16% to 8% among NIDUs in New York City. Methods: Subjects were current non-injecting users of heroin and/or cocaine and who had never injected illicit drugs. Three thousand one hundred fifty-seven NIDU subjects were recruited between 2005 and 2014 among persons entering Mount Sinai Beth Israel substance use treatment programs. Structured interviews, HIV, and HSV-2 testing were administered. Change over time was assessed by comparing 2005 to 2010 with 2011 to 2014 periods. Herpes simplex virus type 2 incidence was estimated among persons who participated in multiple years. Results: Herpes simplex virus type 2 prevalence was strongly associated with HIV prevalence (odds ratio, 3.9; 95% confidence interval, 2.9-5.1) from 2005 to 2014. Herpes simplex virus type 2 prevalence declined from 60% to 56% (P = 0.01). The percentage of NIDUs with neither HSV-2 nor HIVinfection increased from37% to 43%, (P < 0.001); the percentagewith HSV-2/HIV coinfection declined from 13% to 6% (P < 0.001). Estimated HSV-2 incidence was 1 to 2/100 person-years at risk. Conclusions: There were parallel declines in HIV and HSV-2 among NIDUs in New York City from 2005 to 2014. The increase in the percentage of NIDUs with neither HSV-2 nor HIV infection, the decrease in the percentage with HSV-2/HIV coinfection, and the low to moderate HSV-2 incidence suggest some population-level protection against resurgence of HIV. Prevention efforts should be strengthened to end the combined HIV/HSV-2 epidemic among NIDUs in New York City.
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
Past-year prevalence of prescription opioid misuse among those 11 to 30 years of age in the United States: A systematic review and meta-analysisJordan, A. E., Blackburn, N. A., Des Jarlais, D., & Hagan, H.
Journal titleJournal of Substance Abuse Treatment
Page(s)31-37Background There are high levels of prescription and consumption of prescription opioids in the US. Misuse of prescription opioids has been shown to be highly correlated with prescription opioid-related morbidity and mortality including fatal and non-fatal overdose. We characterized the past-year prevalence of prescription opioid misuse among those 11–30 years of age in the US. Methods A systematic review and meta-analysis were carried out following a published protocol and PRISMA guidelines. We searched electronic databases; reports were eligible if they were published between 1/1/1990–5/30/2014, and included data on individuals 11–30 years of age from the US. Study quality was assessed using the Newcastle-Ottawa Scale. Results A total of 3211 abstracts were reviewed for inclusion; after discarding duplicates and identifying non-eligible reports, a total of 19 unique reports, providing 34 estimates, were included in the final systematic review and meta-analysis. The range of past-year prescription opioid misuse prevalence the reports was 0.7%–16.3%. An increase in prevalence of 0.4% was observed over the years of data collection. Conclusions This systematic review and meta-analysis found a high prevalence of past-year prescription opioid misuse among individuals 11–30 years of age. Importantly, we identified an increase in past-year prevalence 1990–2014. Misuse of prescription opioids has played an important role in national increases of fatal and non-fatal drug overdose, heroin use and injection, and HIV and HCV infection among young people. The observed high and increasing prevalence of prescription opioid misuse is an urgent public health issue.
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)615-618Recent 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-analysisJordan, A. E., Perlman, D. C., Neurer, J., Smith, D. J., Des Jarlais, D., & Hagan, H.
Journal titleInternational Journal of STD and AIDS
Page(s)145-159Since 2000, an increase in hepatitis C virus infection among HIV-infected (HIV+) men who have sex with men has been observed. Evidence points to blood exposure during sex as the medium of hepatitis C virus transmission. Hepatitis C virus prevalence among HIV + MSM overall and in relation to injection drug use is poorly characterized. In this study, a systematic review and meta-analysis examining global hepatitis C virus antibody prevalence and estimating active hepatitis C virus prevalence among HIV + MSM were conducted; 42 reports provided anti-hepatitis C virus prevalence data among HIV + MSM. Pooled prevalence produced an overall anti-hepatitis C virus prevalence among HIV + MSM of 8.1%; active HCV prevalence estimate was 5.3%–7.3%. Anti-hepatitis C virus prevalence among injection drug use and non-injection drug use HIV + MSM was 40.0% and 6.7%, respectively. Among HIV + MSM, hepatitis C virus prevalence increased significantly over time among the overall and non-injection drug use groups, and decreased significantly among injection drug use HIV + MSM. We identified a moderate prevalence of hepatitis C virus among all HIV + MSM and among non-injection drug use HIV + MSM; for both, prevalence was observed to be increasing slightly. Pooled prevalence of hepatitis C virus among HIV + MSM was higher than that observed in the 1945–1965 US birth cohort. The modest but rising hepatitis C virus prevalence among HIV + MSM suggests an opportunity to control HCV among HIV + MSM; this combined with data demonstrating a rising hepatitis C virus incidence highlights the temporal urgency to do so.
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., Ritchie, A. S., & Kutnick, A.
Journal titleJournal of Acquired Immune Deficiency Syndromes
Page(s)499-507Identifying 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.
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)1-8Using 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 < 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 < 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.
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 (1999)
Page(s)S325-S332BACKGROUND: 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.
What happened to the HIV epidemic among non-injecting drug users in New York City?Des Jarlais, D., Arasteh, K., Mcknight, C., Feelemyer, J., Campbell, A. N. C., Tross, S., Cooper, H. L. F., Hagan, H., & Perlman, D. C.
Page(s)290-298Background and aims: HIV has reached high prevalence in many non-injecting drug user (NIDU) populations. The aims of this study were to (1) examine the trend in HIV prevalence among non-injecting cocaine and heroin NIDUs in New York City, (2) identify factors potentially associated with the trend and (3) estimate HIV incidence among NIDUs. Design: Serial-cross sectional surveys of people entering drug treatment programs. People were permitted to participate only once per year, but could participate in multiple years. Setting: Mount Sinai Beth Israel drug treatment programs in New York City, USA. Participants: We recruited 3298 non-injecting cocaine and heroin users from 2005 to 2014. Participants were 78.7% male, 6.1% white, 25.7% Hispanic and 65.8% African American. Smoking crack cocaine was the most common non-injecting drug practice. Measures: Trend tests were used to examine HIV prevalence, demographics, drug use, sexual behavior and use of antiretroviral treatment (ART) by calendar year; χ2 and multivariable logistic regression were used to compare 2005–10 versus 2011–14. Findings: HIV prevalence declined approximately 1% per year (P < 0.001), with a decline from 16% in 2005–10 to 8% in 2011–14 (P < 0.001). The percentages of participants smoking crack and having multiple sexual partners declined and the percentage of HIV-positive people on ART increased. HIV incidence among repeat participants was 1.2 per 1000 person-years (95% confidence interval = 0.03/1000–7/1000). Conclusions: HIV prevalence has declined and a high percentage of HIV-positive non-injecting drug users (NIDUs) are receiving antiretroviral treatment, suggesting an end to the HIV epidemic among NIDUs in New York City. These results can be considered a proof of concept that it is possible to control non-injecting drug use related sexual transmission HIV epidemics.
Associations of place characteristics with HIV and HCV risk behaviors among racial/ethnic groups of people who inject drugs in the United StatesFailed generating bibliography.Abstract
Journal titleAnnals of Epidemiology
Page(s)619-630.e2Purpose Investigate whether characteristics of geographic areas are associated with condomless sex and injection-related risk behavior among racial/ethnic groups of people who inject drugs (PWID) in the United States. Methods PWID were recruited from 19 metropolitan statistical areas for 2009 National HIV Behavioral Surveillance. Administrative data described ZIP codes, counties, and metropolitan statistical areas where PWID lived. Multilevel models, stratified by racial/ethnic groups, were used to assess relationships of place-based characteristics to condomless sex and injection-related risk behavior (sharing injection equipment). Results Among black PWID, living in the South (vs. Northeast) was associated with injection-related risk behavior (adjusted odds ratio [AOR] = 2.24, 95% confidence interval [CI] = 1.21–4.17; P =.011), and living in counties with higher percentages of unaffordable rental housing was associated with condomless sex (AOR = 1.02, 95% CI = 1.00–1.04; P =.046). Among white PWID, living in ZIP codes with greater access to drug treatment was negatively associated with condomless sex (AOR = 0.93, 95% CI = 0.88–1.00; P =.038). Conclusions Policies that increase access to affordable housing and drug treatment may make environments more conducive to safe sexual behaviors among black and white PWID. Future research designed to longitudinally explore the association between residence in the south and injection-related risk behavior might identify specific place-based features that sustain patterns of injection-related risk behavior.
Bisexual Behavior Among Male Injection Drug Users in New York CityReilly, K. H., Neaigus, A., Wendel, T., Marshall, D. M., & Hagan, H.
Journal titleAIDS and Behavior
Page(s)405-416Drug using men who have sex with men and women (MSMW) may be at high risk for HIV infection and transmitting HIV to sex partners. In 2012, injection drug users (IDUs) were sampled in New York City for the National HIV Behavioral Surveillance cross-sectional study using respondent-driven sampling. Logistic regression was used to calculate crude and adjusted odds ratios (aOR) and 95 % confidence intervals (95 %CI) to determine correlates of bisexual behavior in the past 12 months. Of 333 participants, 47(14.1 %) reported MSMW. Variables independently associated (p
Community Sexual Bridging Among Heterosexuals at High-Risk of HIV in New York CityNeaigus, A., Jenness, S. M., Reilly, K. H., Youm, Y., Hagan, H., Wendel, T., & Gelpi-Acosta, C.
Journal titleAIDS and Behavior
Page(s)722-736Community sexual bridging may influence the socio-geographic distribution of heterosexually transmitted HIV. In a cross-sectional study, heterosexual adults at high-risk of HIV were recruited in New York City (NYC) in 2010 for the Centers for Disease Control and Prevention-sponsored National HIV Behavioral Surveillance system. Eligible participants were interviewed about their HIV risk behaviors and sexual partnerships and tested for HIV. Social network analysis of the geographic location of participants’ recent sexual partnerships was used to calculate three sexual bridging measures (non-redundant ties, flow-betweenness and walk-betweenness) for NYC communities (defined as United Hospital Fund neighborhoods), which were plotted against HIV prevalence in each community. The analysis sample comprised 494 participants and 1534 sexual partnerships. Participants were 60.1 % male, 79.6 % non-Hispanic black and 19.6 % Hispanic race/ethnicity; the median age was 40 years (IQR 24–50); 37.7 % had ever been homeless (past 12 months); 16.6 % had ever injected drugs; in the past 12 months 76.7 % used non-injection drugs and 90.1 % engaged in condomless vaginal or anal sex; 9.6 % tested HIV positive (of 481 with positive/negative results). Sexual partnerships were located in 33 (78.6 %) of 42 NYC communities, including 13 “high HIV-spread communities”, 7 “hidden bridging communities”, 0 “contained high HIV prevalence communities”, and 13 “latent HIV bridging communities”. Compared with latent HIV bridging communities, the population racial/ethnic composition was more likely (p
Consistent estimates of very low HIV incidence among people who inject drugs: New York City, 2005-2014Des Jarlais, D., Arasteh, K., Mcknight, C., Feelemyer, J., Campbell, A. N. C., Tross, S., Smith, L., Cooper, H. L. F., Hagan, H., & Perlman, D.
Journal titleAmerican Journal of Public Health
Page(s)503-508Objectives. To compare methods for estimating low HIV incidence among persons who inject drugs. Methods. We examined 4 methods in New York City, 2005 to 2014: (1) HIV seroconversions among repeat participants, (2) increase of HIV prevalence by additional years of injection among new injectors, (3) the New York State and Centers for Disease Control and Prevention stratified extrapolation algorithm, and (4) newly diagnosed HIV cases reported to the New York City Department of Health and Mental Hygiene. Results. The 4 estimates were consistent: (1) repeat participants: 0.37 per 100 person-years (PY; 95% confidence interval [CI] = 0.05/100 PY, 1.33/100 PY); (2) regression of prevalence by years injecting: 0.61 per 100 PY (95% CI = 0.36/100 PY, 0.87/100 PY); (3) stratified extrapolation algorithm: 0.32 per 100 PY (95% CI = 0.18/100 PY, 0.46/100 PY); and (4)newly diagnosed cases of HIV: 0.14 per 100PY (95%CI = 0.11/100 PY, 0.16/100 PY). Conclusions. All methods appear to capture the same phenomenon of very low and decreasing HIV transmission among persons who inject drugs. Public Health Implications. If resources are available, the use ofmultiple methodswould provide better information for public health purposes.
Effectiveness of needle/syringe programmes and opiate substitution therapy in preventing HCV transmission among people who inject drugsPlatt, L., Reed, J., Minozzi, S., Vickerman, P., Hagan, H., French, C., Jordan, A., Degenhardt, L., Hope, V., Hutchinson, S., Maher, L., Palmateer, N., Taylor, A., & Hickman, M.
Journal titleCochrane database of systematic reviews (Online)
Issue1This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the impact of needle/syringe programmes with and without opiate substitution therapy (OST) on the incidence of HCV infection among people who inject drugs (PWID). To assess the effect of OST alone on the incidence of HCV infection among PWID. Research questions: How effective are needle/syringe programmes (NSP) with and without the use of OST for reducing HCV incidence among PWID? How effective is OST alone for reducing HCV incidence among PWID? How does the effect of NSP and OST vary according to duration of treatment (i.e. for NSPs weekly attendance versus monthly)? How does the effect of NSP vary according to the type of service (fixed site versus mobile; high coverage versus low coverage)? How does the effect of OST vary according to the dosage of OST, type of substitution used and adherence to treatment?
Estimates of global, regional, and national incidence, prevalence, and mortality of HIV, 1980-2015: The Global Burden of Disease Study 2015Wang, H., Wolock, T. M., Carter, A., Nguyen, G., Kyu, H. H., Gakidou, E., Hay, S. I., Mills, E. J., Trickey, A., Msemburi, W., Coates, M. M., Mooney, M. D., Fraser, M. S., Sligar, A., Salomon, J., Larson, H. J., Friedman, J., Abajobir, A. A., Abate, K. H., Abbas, K. M., Razek, M. M. A. E., Abd-Allah, F., Abdulle, A. M., Abera, S. F., Abubakar, I., Abu-Raddad, L. J., Abu-Rmeileh, N. M. E., Abyu, G. Y., Adebiyi, A. O., Adedeji, I. A., Adelekan, A. L., Adofo, K., Adou, A. K., Ajala, O. N., Akinyemiju, T. F., Akseer, N., Lami, F. H. A., Al-Aly, Z., Alam, K., Alam, N. K. M., Alasfoor, D., Aldhahri, S. F. S., Aldridge, R. W., Alegretti, M. A., Aleman, A. V., Alemu, Z. A., Alfonso-Cristancho, R., Ali, R., Alkerwi, A., Alla, F., Mohammad, R., Al-Raddadi, S., Alsharif, U., Abdulle, A., Alvis-Guzman, N., Amare, A. T., Amberbir, A., Amegah, A. K., Ammar, W., Amrock, S. M., Antonio, C. A. T., Anwari, P., Ärnlöv, J., Artaman, A., Asayesh, H., Asghar, R. J., Assadi, R., Atique, S., Atkins, L. S., Avokpaho, E. F. G. A., Awasthi, A., Quintanilla, B. P. A., Bacha, U., Badawi, A., Barac, A., Bärnighausen, T., Basu, A., Bayou, T. A., Bayou, Y. T., Bazargan-Hejazi, S., Beardsley, J., Bedi, N., Bennett, D. A., Bensenor, I. M., Betsu, B. D., Beyene, A. S., Bhatia, E., Bhutta, Z. A., Biadgilign, S., Bikbov, B., Birlik, S. M., Bisanzio, D., Brainin, M., Brazinova, A., Breitborde, N. J. K., Brown, A., Burch, M., Butt, Z. A., Campuzano, J. C., Cárdenas, R., Carrero, J. J., Ali, R., Rivas, J. C., Catalá-López, F., Chang, H. Y., Chang, J. C., Chavan, L., Chen, W., Chiang, P. P. C., Chibalabala, M., Chisumpa, V. H., Choi, J. Y. J., Christopher, D. J., Ciobanu, L. G., Cooper, C., Dahiru, T., Damtew, S. A., Dandona, L., Dandona, R., Das Neves, J., De Jager, P., De Leo, D., Degenhardt, L., Dellavalle, R. P., Deribe, K., Deribew, A., Des Jarlais, D. C., Dharmaratne, S. D., Ding, E. L., Doshi, P. P., Driscoll, T. R., Dubey, M., Elshrek, Y. M., Elyazar, I., Endries, A. Y., Ermakov, S. P., Eshrati, B., Esteghamati, A., Faghmous, I. D. A., Farinha, C. S. E. S., Faro, A., Farvid, M. S., Farzadfar, F., Fereshtehnejad, S. M., Fernandes, J. C., Fischer, F., Fitchett, J. R. A., Foigt, N., Fullman, N., Fürst, T., Gankpé, F. G., Gebre, T., Gebremedhin, A. T., Gebru, A. A., Geleijnse, J. M., Gessner, B. D., Gething, P. W., Ghiwot, T. T., Giroud, M., Gishu, M. D., Glaser, E., Goenka, S., Goodridge, A., Gopalani, S. V., Goto, A., Gugnani, H. C., Guimaraes, M. D. C., Gupta, R., Gupta, R., Gupta, V., Haagsma, J., Hafezi-Nejad, N., Hagan, H., Hailu, G. B., Hamadeh, R. R., Hamidi, S., Hammami, M., Hankey, G. J., Hao, Y., Harb, H. L., Harikrishnan, S., Haro, J. M., Harun, K. M., Havmoeller, R., Hedayati, M. T., Heredia-Pi, I. B., Hoek, H. W., Horino, M., Horita, N., Hosgood, H. D., Hoy, D. G., Hsairi, M., Hu, G., Huang, H., Huang, J. J., Iburg, K. M., Idrisov, B. T., Innos, K., Iyer, V. J., Jacobsen, K. H., Jahanmehr, N., Jakovljevic, M. B., Javanbakht, M., Jayatilleke, A. U., Des Jarlais, D., Jha, V., Jiang, G., Jiang, Y., Jibat, T., Jonas, J. B., Kabir, Z., Kamal, R., Kan, H., Karch, A., Karema, C. K., Karletsos, D., Kasaeian, A., Kaul, A., Kawakami, N., Kayibanda, J. F., Keiyoro, P. N., Kemp, A. H., Kengne, A. P., Kesavachandran, C. N., Khader, Y. S., Khalil, I., Khan, A. R., Khan, E. A., Khang, Y. H., Khubchandani, J., Kim, Y. J., Kinfu, Y., Kivipelto, M., Kokubo, Y., Kosen, S., Koul, P. A., Koyanagi, A., Defo, B. K., Bicer, B. K., Kulkarni, V. S., Kumar, G. A., Lal, D. K., Lam, H., Lam, J. O., Langan, S. M., Lansingh, V. C., Larsson, A., Leigh, J., Leung, R., Li, Y., Lim, S. S., Lipshultz, S. E., Hagan, H., Lloyd, B. K., Logroscino, G., Lotufo, P. A., Lunevicius, R., Razek, H. M. A. E., Mahdavi, M., Majdan, M., Majeed, A., Makhlouf, C., Malekzadeh, R., Mapoma, C. C., Marcenes, W., Martinez-Raga, J., Marzan, M. B., Masiye, F., Mason-Jones, A. J., Mayosi, B. M., McKee, M., Meaney, P. A., Mehndiratta, M. M., Mekonnen, A. B., Melaku, Y. A., Memiah, P., Memish, Z. A., Mendoza, W., Meretoja, A., Meretoja, T. J., Mhimbira, F. A., Miller, T. R., Mikesell, J., Mirarefin, M., Mohammad, K. A., Mohammed, S., Mokdad, A. H., Monasta, L., Moradi-Lakeh, M., Mori, R., Mueller, U. O., Murimira, B., Murthy, G. V. S., Naheed, A., Naldi, L., Nangia, V., Nash, D., Nawaz, H., Nejjari, C., Ngalesoni, F. N., De Dieu Ngirabega, J., Nguyen, Q. L., Nisar, M. I., Norheim, O. F., Norman, R. E., Nyakarahuka, L., Ogbo, F. A., Oh, I. H., Ojelabi, F. A., Olusanya, B. O., Olusanya, J. O., Opio, J. N., Oren, E., Ota, E., Padukudru, M. A., Park, H. Y., Park, J. H., Patil, S. T., Patten, S. B., Paul, V. K., Pearson, K., Peprah, E. K., Pereira, C. C., Perico, N., Pesudovs, K., Petzold, M., Phillips, M. R., Pillay, J. D., Plass, D., Polinder, S., Pourmalek, F., Prokop, D. 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Journal titleThe Lancet HIVBackground: Timely assessment of the burden of HIV/AIDS is essential for policy setting and programme evaluation. In this report from the Global Burden of Disease Study 2015 (GBD 2015), we provide national estimates of levels and trends of HIV/AIDS incidence, prevalence, coverage of antiretroviral therapy (ART), and mortality for 195 countries and territories from 1980 to 2015. Methods: For countries without high-quality vital registration data, we estimated prevalence and incidence with data from antenatal care clinics and population-based seroprevalence surveys, and with assumptions by age and sex on initial CD4 distribution at infection, CD4 progression rates (probability of progression from higher to lower CD4 cell-count category), on and off antiretroviral therapy (ART) mortality, and mortality from all other causes. Our estimation strategy links the GBD 2015 assessment of all-cause mortality and estimation of incidence and prevalence so that for each draw from the uncertainty distribution all assumptions used in each step are internally consistent. We estimated incidence, prevalence, and death with GBD versions of the Estimation and Projection Package (EPP) and Spectrum software originally developed by the Joint United Nations Programme on HIV/AIDS (UNAIDS). We used an open-source version of EPP and recoded Spectrum for speed, and used updated assumptions from systematic reviews of the literature and GBD demographic data. For countries with high-quality vital registration data, we developed the cohort incidence bias adjustment model to estimate HIV incidence and prevalence largely from the number of deaths caused by HIV recorded in cause-of-death statistics. We corrected these statistics for garbage coding and HIV misclassification. Findings: Global HIV incidence reached its peak in 1997, at 3·3 million new infections (95% uncertainty interval [UI] 3·1-3·4 million). Annual incidence has stayed relatively constant at about 2·6 million per year (range 2·5-2·8 million) since 2005, after a period of fast decline between 1997 and 2005. The number of people living with HIV/AIDS has been steadily increasing and reached 38·8 million (95% UI 37·6-40·4 million) in 2015. At the same time, HIV/AIDS mortality has been declining at a steady pace, from a peak of 1·8 million deaths (95% UI 1·7-1·9 million) in 2005, to 1·2 million deaths (1·1-1·3 million) in 2015. We recorded substantial heterogeneity in the levels and trends of HIV/AIDS across countries. Although many countries have experienced decreases in HIV/AIDS mortality and in annual new infections, other countries have had slowdowns or increases in rates of change in annual new infections. Interpretation: Scale-up of ART and prevention of mother-to-child transmission has been one of the great successes of global health in the past two decades. However, in the past decade, progress in reducing new infections has been slow, development assistance for health devoted to HIV has stagnated, and resources for health in low-income countries have grown slowly. Achievement of the new ambitious goals for HIV enshrined in Sustainable Development Goal 3 and the 90-90-90 UNAIDS targets will be challenging, and will need continued efforts from governments and international agencies in the next 15 years to end AIDS by 2030. Funding: Bill & Melinda Gates Foundation, and National Institute of Mental Health and National Institute on Aging, National Institutes of Health.
Experiences of discrimination and hiv risk among men who have sex with men in new york cityReilly, K. H., Neaigus, A., Jenness, S. M., Wendel, T., Marshall, D. M., & Hagan, H.
Journal titleAmerican Journal of Men's Health
Page(s)505-514The extent of gay-related discrimination in New York City (NYC) and the demographic and behavioral factors correlated with experiences of gay-related discrimination are not well understood. The Centers for Disease Control and Prevention–sponsored National HIV Behavioral Surveillance System, a cross-sectional study, was conducted in NYC in 2011. Men who have sex with men were venue-sampled, interviewed, and offered HIV testing. Frequencies of types of gay-related discrimination experienced in the past 12 months were calculated. Associations between types of discrimination and demographic and HIV risk variables were examined through the estimation of prevalence ratios (PRs) and 95% confidence intervals (CIs). More than half (53.2%) of all study participants reported having experienced any gay-related discrimination in the past 12 months; 45.0% reported that they had been called names or insulted; 23.6% reported receiving poorer services than other people in restaurants, stores, other businesses, or agencies; 22.0% reported being treated unfairly at work or school; 15.1% reported being physically attacked or injured; and 6.7% reported being denied or given lower quality health care. HIV-positive status (adjusted PR [aPR] = 2.9; 95% CI = 1.5, 5.6) and drug use in the past 12 months (aPR = 0.3; 95% CI = 0.1, 0.7) were independently associated with reports of having been denied or given lower quality health care. High rates of reported gay-related discrimination suggest that greater efforts are needed to reduce gay-related discrimination in affected communities. Future research is needed to better understand the extent of gay-related discrimination in NYC, particularly with regard to the relationship between HIV status and health care access.