Saba Rouhani

Washington Square Park
Saba Rouhani

Assistant Professor of Epidemiology

Professional overview

Dr. Saba Rouhani is an Assistant Professor in the Department of Epidemiology at GPH, and joins the school as inaugural faculty at its Center for Anti-racism, Social Justice and Public Health.

Her research is focused on characterizing the structural environment that influences the risk of overdose and other drug-related harms; she investigates the impact of harm reduction and overdose prevention initiatives, using results to identify gaps in implementation and to inform policy. Dr. Rouhani is especially interested in how drug policy has fueled mass incarceration and impacted racial and ethnic minorities in the United States, and she studies how changes to the policy and policing landscape may promote or hinder equity in health and social outcomes. Her current research is focused on characterizing emerging drug decriminalization policies and modeling their impacts on equity in criminal legal involvement and health outcomes.

Prior to joining NYU Dr. Rouhani worked as research faculty in the Department of Health, Behavior and Society at the Johns Hopkins Bloomberg School of Public Health. She also completed a fellowship funded by the National Institutes of Health/National Institute on Drug Abuse. Her research has been published in the International Journal of Drug Policy, Drug and Alcohol Dependence, the Journal of Urban Health, and the American Journal of Public Health and Preventive Medicine.

Dr. Rouhani received her PhD in global disease epidemiology and control from the Johns Hopkins Bloomberg School of Public Health. She holds an MSc in the control of infectious diseases from the London School of Hygiene and Tropical Medicine, and a BSc in medical microbiology from the University of Edinburgh.

Education

PhD Global Disease Epidemiology & Control, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
MS Control of Infectious Diseases, The London School of Hygiene & Tropical Medicine, London, United Kingdom
BS Medical Microbiology, University of Edinburgh, Edinburgh, United Kingdom

Honors and awards

Drug Dependency Epidemiology Training (T32) Fellowship, National Institute of Drug Abuse, National Institutes of Health (2018)
The R. Bradley Sack Family Scholarship Award, Johns Hopkins Bloomberg School of Public Health (2016)
Global Health Established Field Placement Scholarship, Johns Hopkins Bloomberg School of Public Health (2014)
Save the Children Program Management Award, Save the Children International (2012)
Royal Society of Tropical Medicine and Hygiene Award for Best Poster Presentation of Research in Progress (2012)

Publications

Publications

Increased solitary drug use during COVID-19: An unintended consequence of social distancing

Schneider, K. E., Allen, S. T., Rouhani, S., Morris, M., Haney, K., Saloner, B., & Sherman, S. G. (n.d.).

Publication year

2023

Journal title

International Journal of Drug Policy

Volume

111
Abstract
Abstract
Background: During the COVID-19 pandemic, overdose rates substantially increased in the United States. One possible contributor to this phenomenon may be solitary drug use resulting from social distancing efforts to prevent COVID-19 transmission. Methods: We surveyed 458 people who use drugs (PWUD) who were recruited from harm reduction and drug treatment providers located in nine states and the District of Columbia. We assessed if solitary drug use had increased since the start of COVID-19. Associations between increased solitary drug use and sociodemographic characteristics, drug use characteristics, and COVID-19 prevention behaviors were examined using multiple logistic regression. Results: Half the sample identified as men (52.7%), White (49.7%), and single (49.3%). The average age was 43.2 (SD:11.8) years. Two-thirds (66.8%) recently injected drugs. 44% reported increased solitary drug use since COVID-19. Significant correlates of increased solitary drug use included being single (adjusted Odds Ratio [aOR]=1.99, 95% Confidence Interval [CI]: 1.33, 2.98), increasing drug use (aOR=2.74, 95% CI: 1.72, 4.37), using more in private locations (aOR=1.91, 95% CI: 1.34, 2.72), and social distancing behaviors (aOR=1.31, 95% CI: 1.11, 1.54). Experiencing homelessness (aOR=0.45, 95% CI: 0.31, 0.65) and identifying as a sexual minority (aOR=0.53, 95% CI: 0.31, 0.93) were associated with being less likely to increase solitary drug use. Conclusions: Solitary drug use increased during the COVID-19 pandemic. Increases in solitary drug use, in the context of a drug market increasingly permeated by fentanyl, indicates an urgent need for comprehensive harm reduction interventions to reduce overdose mortality.

Acceptability of Overdose Prevention Sites in the Business Community in Baltimore, Maryland

Sherman, S. G., Rouhani, S., White, R. H., Weicker, N., Morris, M., Schneider, K., Park, J. N., & Barry, C. (n.d.).

Publication year

2022

Journal title

Journal of Urban Health

Volume

99

Issue

4

Page(s)

723-732
Abstract
Abstract
Intervetions are urgently needed to reduce the trajectory of the US opioid overdose epidemic, yet implementation is often hampered by resistance or opposition from key community stakeholders. While businesses are economically and physically impacted by the opioid epidemic, they are rarely engaged in efforts to reduce its impact. The establishment of overdose prevention sites (OPS) is being discussed throughout many US jurisdictions with limited attention to the potential positive role of businesses in that process. We surveyed business owners and employees of businesses located in neighborhoods with concentrated drug markets. The study’s primary aim was to examine their attitudes to locally-placed OPS. An iterative, two-phase sampling strategy was used to identify recruitment zones. In person (December 2019–March 2020) and telephone-based (April–July 2020) surveys were administered to distinct business owners and employees (N = 149). Sixty-five percent of participants supported OPS in their neighborhood and 47% had recently witnessed an overdose in or around their workplace. While 70% had heard of naloxone, and 38% reported having it on the premises. Correlates of supporting an OPS locally included living in the same neighborhood as work (adjusted odds ratio (aOR) 1.99, 95% confidence intervals (CI): 1.30–3.05); having a more positive attitude towards people who use drugs (aOR 1.33, 95% CI: 1.13–1.58); and having recently seen an overdose in/around the workplace (aOR 2.86, 95% CI: 1.11–7.32). Lack of support being an owner (aOR 0.35, 95% CI: 0.15–0.83). These data indicate the extent to which businesses are directly impacted by the opioid epidemic and the power of personal experience in shaping OPS support in advocacy efforts.

Alternative use of buprenorphine among people who use opioids in three U.S. Cities

Gandhi, P., Rouhani, S., Park, J. N., Urquhart, G. J., Allen, S. T., Morales, K. B., Green, T. C., & Sherman, S. G. (n.d.).

Publication year

2022

Journal title

Substance Abuse

Volume

43

Issue

1

Page(s)

364-370
Abstract
Abstract
Background: Buprenorphine is an effective treatment for opioid use disorder, yet some persons are concerned with its “alternative use” (i.e., any use unintended by the prescriber). There is limited evidence on the factors associated with alternative use of buprenorphine (AUB); in this study, we examined correlates of recent (past 6 months) AUB. Methods: Multivariable logistic regression was used to analyze survey data from a multi-site, cross-sectional study of people who use drugs (PWUD) (N = 334) in Baltimore, Maryland; Boston, Massachusetts; and Providence, Rhode Island. Results: One-fifth (20%) of the sample reported recent AUB. In adjusted analyses, significant negative correlates of AUB were female gender (adjusted odds ratio [aOR] 0.48, 95% confidence intervals [CI] 0.24–0.95), recent emergency room visit (aOR 0.45, 95% CI 0.23–0.89), and recent injection drug use (aOR 0.41, 95% CI 0.19–0.88). Significant positive correlates were alternative use of other prescription opioids (aOR 8.32, 95% CI 4.22–16.38), three or more overdoses in the past year (aOR 3.74, 95% CI 1.53–9.17), recent buprenorphine use as prescribed (aOR 2.50, 95% CI 1.12–5.55), and recent residential rehabilitation treatment (aOR 3.71, 95% CI 1.50–9.16). Conclusions: Structural and behavioral correlates of AUB may help identify PWUD at high risk of overdose with unmet treatment needs.

Businesses in high drug use areas as potential sources of naloxone during overdose emergencies

Schneider, K. E., Rouhani, S., Weicker, N. P., Morris, M., & Sherman, S. G. (n.d.).

Publication year

2022

Journal title

Drug and alcohol dependence

Volume

233
Abstract
Abstract
Introduction: Naloxone distribution remains a cornerstone of a public health approach to combating the ongoing opioid overdose crisis. Most distribution programs focus on providing naloxone to individuals who use drugs or those closely associated with them (e.g., family). Utilizing businesses as fixed location sources of naloxone could be a valuable supplemental strategy to preventing fatal overdoses that is underexplored in the literature. Methods: We surveyed business owners and employees (N = 149) located in neighborhoods characterized by high rates of drug use in Baltimore City. Participants reported their interactions with people who use drugs as well as if they had heard of naloxone, if the business had naloxone on the premises, and how many employees were trained to use naloxone. Results: Most participants reported seeing individuals under the influence of drugs (93%), public drug use (80%), and overdose (66%) while at work. 66% of participants had heard of naloxone. Among those who had heard of naloxone, only 39% reported that there was a naloxone kit in the business and 28% of businesses had multiple employees trained to use naloxone. Conclusions: Businesses are underutilized as potential reliable sources of naloxone. While study participants reported high levels of exposure to drug use and overdose in and around their businesses, their ability to intervene was limited. Efforts to train employees to respond to overdoses and to keep naloxone on site are warranted to supplement existing naloxone distribution efforts and can help empower business staff to help prevent overdose mortality in their communities.

Discordance between Self-reported and Biologically Tested Exposure to Fentanyl among People at Risk of Opioid Overdose

Park, J. N., Urquhart, G., Morris, M., Dahal, R., Rouhani, S., & Sherman, S. G. (n.d.).

Publication year

2022

Journal title

Journal of Addiction Medicine

Volume

16

Issue

6

Page(s)

722-724
Abstract
Abstract
Drug overdose remains a leading cause of death in the US, and the majority of opioid overdose fatalities involve fentanyl. This study aims to measure the degree of concordance between self-reported and biologically tested exposure to fentanyl. We conducted a cross-sectional analysis using survey and urinalysis data collected between 2019 and 2020 from Anne Arundel County, Maryland. Among urinalysis participants (n =113), 30% reported daily fentanyl use, and among this group, only 54% had a fentanyl-positive result. Cohen Kappa between self-reported and biologically detected fentanyl use was 0.26, indicating minimal agreement between the 2 markers. Limitations to interpreting self-reported and urinalysis data are discussed in this report.

HIV Risk Among Urban and Suburban People Who Inject Drugs: Elevated Risk Among Fentanyl and Cocaine Injectors in Maryland

Park, J. N., Owczarzak, J., Urquhart, G., Morris, M., Weicker, N. P., Rouhani, S., & Sherman, S. G. (n.d.).

Publication year

2022

Journal title

AIDS and Behavior

Volume

26

Issue

1

Page(s)

277-283
Abstract
Abstract
Drug overdose remains a leading cause of death in the US, with growing rates attributable to illicit fentanyl use. Recent HIV outbreaks among people who inject drugs (PWID) and service disruptions from COVID-19 have renewed concerns on HIV resurgence. We examined the relationship between fentanyl use and three injection-related HIV risk behaviors among PWID in Baltimore City (BC) and Anne Arundel Country (AAC), Maryland. PWID (N = 283) were recruited to the study through targeted sampling at street-based locations in BC and AAC from July 2018 to March 2020. Receptive syringe sharing (RSS) [adjusted odds ratio (AOR): 2.8, 95% confidence interval (CI): 1.2–6.3] and daily injecting (AOR: 1.9, 95% CI: 1.0–3.6) were associated with injecting fentanyl and cocaine together. Fentanyl availability and COVID-19 bring new HIV prevention challenges, particularly among those who inject fentanyl with cocaine, highlighting the importance to expand and sustain harm reduction, prevention, and treatment services for PWID to reduce HIV and overdose burden.

Identifying pathways to recent non-fatal overdose among people who use opioids non-medically: How do psychological pain and unmet mental health need contribute to overdose risk?

Tomko, C., Schneider, K. E., Rouhani, S., Urquhart, G. J., Nyeong Park, J., Morris, M., & Sherman, S. G. (n.d.).

Publication year

2022

Journal title

Addictive Behaviors

Volume

127
Abstract
Abstract
Background: Significant associations exist between psychological pain, unmet mental health need, and frequency and severity of substance use among people who use drugs (PWUD), but no studies have analyzed the relationship of these variables to non-fatal overdose. Methods: We conducted a cross-sectional survey of people who used opioids non-medically in Baltimore, Maryland (n = 563) as part of a broader harm reduction-focused evaluation (PROMOTE). The outcome was self-reported recent (past 6 months) non-fatal overdose; exposures of interest were recent self-reported unmet mental health need, experiencing daily “long-lasting psychological or mental pain” (vs. < daily), and daily multi-opioid use (vs. none/one opioid used). Path analysis was used to model direct relationships between these variables, personal characteristics (race, gender, experiencing homelessness, drug injection) and overdose. Results: 30% of the sample had experienced a recent non-fatal overdose, 46% reported unmet mental health need, 21% reported daily psychological pain, and 62% used multiple types of opioids daily. After adjusting for covariates, daily multi-opioid use (aOR = 1.78, p = 0.03) and unmet mental health need (aOR = 2.05, p = 0.01) were associated with direct, significant increased risk of recent overdose. Significant pathways associated with increased odds of unmet mental health need included woman gender (aOR = 2.23, p = 0.003) and daily psychological pain (aOR = 4.14, p = 0.002). In turn, unmet mental health need associated was with greater odds of daily multi-opioid use (aOR = 1.57, p = 0.05). Discussion: Unmet mental heath need and daily psychological pain are common experiences in this sample of PWUD. Unmet mental health need appears on several pathways to overdose and associated risk factors; improving access to mental healthcare for PWUD (particularly women) expressing need may be an important harm reduction measure.

NIMBYism and Harm Reduction Programs: Results from Baltimore City

Rouhani, S., Schneider, K. E., Weicker, N., Whaley, S., Morris, M., & Sherman, S. G. (n.d.).

Publication year

2022

Journal title

Journal of Urban Health

Volume

99

Issue

4

Page(s)

717-722

PWUD Experiences of Criminal Justice Reform: Enduring Tensions Between Policing and Harm Reduction in Baltimore, MD

Footer, K. H., Urquhart, G. J., Silberzahn, B., Rouhani, S., Weicker, N. P., Owczarzak, J., Park, J. N., Morris, M., & Sherman, S. G. (n.d.).

Publication year

2022

Journal title

Contemporary Drug Problems
Abstract
Abstract
In this paper we explore people who use drugs (PWUD) perceptions and experiences of drug-related law enforcement in a major U.S. city. Maryland recently implemented several harm reduction policies/interventions aiming to improve PWUD-police relationships, such as the Good Samaritan Law (GSL), intended to avoid criminalizing police encounters with PWUD in cases of overdose. PWUD, though most impacted by these efforts, are seldom included in the decision making process. Data collection occurred in Baltimore City, a majority-Black city with a history of structural racism, where high overdose fatalities necessitate collaborative interventions, but where over-policing and abusive practices have generated widespread community mistrust of police. Between October 2018 and December 2019, we conducted in-depth interviews with 20 PWUD in Baltimore City to understand their perspectives of policing and its impact on harm reduction practices (specifically willingness to seek overdose assistance) in the context of the GSL. PWUD reported ongoing police mistrust, which impacted their harm reduction practices and experiences of laws such as the GSL. Results question whether police, as first responders to overdose, can ever avoid criminalizing the encounter. Findings intend to guide future public health-law enforcement collaboration efforts in the context of the current de-policing debate.

Racial resentment and support for decriminalization of drug possession in the United States

Rouhani, S., McGinty, E. E., Weicker, N. P., White, R. H., LaSalle, L., Barry, C. L., & Sherman, S. G. (n.d.).

Publication year

2022

Journal title

Preventive Medicine

Volume

163
Abstract
Abstract
Drug criminalization creates significant barriers to prevention and treatment of substance use disorders and racial equity objectives, and removal of criminal penalties for drug possession is increasingly being endorsed by health and justice advocates. We present empirical data estimating the share of U.S. adults who support eliminating criminal penalties for possession of all illicit drugs, and examine factors associated with public support. Data from the Johns Hopkins COVID-19 Civic Life and Public Health Survey, a probability-based nationally representative sample of 1222 U.S. adults, was collected from November 11–30, 2020. Support for decriminalizing drug possession was assessed overall and by sociodemographic factors and attitudes towards politics and race. Correlates of support were examined using multivariable logistic regression. Thirty-five percent of adults supported eliminating criminal penalties for drug possession in the U.S. In adjusted regression models, respondents who were younger or identified as politically liberal were more likely to support decriminalization relative to other groups, and respondents who were Hispanic or identified strongly with their religious beliefs were less likely to support decriminalization. Among white respondents, greater racial resentment was strongly associated with reduced support for drug decriminalization. Support for drug decriminalization varies considerably by beliefs about politics and race, with racial resentment among white Americans potentially comprising a barrier to drug policy reform. Findings can inform communication and advocacy efforts to promote drug policy reform in the United States.

Safety in solitude? Competing risks and drivers of solitary drug use among women who inject drugs and implications for overdose detection

Rosen, J. G., Glick, J. L., Zhang, L., Cooper, L., Olatunde, P. F., Pelaez, D., Rouhani, S., Sue, K. L., & Park, J. N. (n.d.).

Publication year

2022

Journal title

Addiction
Abstract
Abstract
Background and aims: Solitary drug use (SDU) can amplify risks of fatal overdose. We examined competing risks and drivers of SDU, as well as harm reduction strategies implemented during SDU episodes, among women who inject drugs (WWID). Design: A cross-sectional qualitative study, including telephone and face-to-face in-depth interviews. Setting: Baltimore City, MD, USA. Participants: Twenty-seven WWID (mean age = 39 years, 67% white, 74% injected drugs daily) recruited via outreach and street intercept (April–September 2021). Measurements: Interviews explored the physical (i.e. indoor/private, outdoor/public) and social (i.e. alone, accompanied) risk environments in which drug use occurred. Guided by the principles of emergent design, we used thematic analysis to interrogate textual data, illuminating women's preferences/motivations for SDU and strategies for minimizing overdose risks when using alone. Findings: Many participants reported experiences with SDU, despite expressed preferences for accompanied drug use. SDU motivations clustered around three primary drivers: (1) avoiding opioid withdrawal, (2) preferences for privacy when using drugs and (3) safety concerns, including threats of violence. Participants nevertheless acknowledged the dangers of SDU and, at times, took steps to mitigate overdose risk, including naloxone possession, communicating to peers when using alone (‘spotting’) and using drugs in public spaces. Conclusions: WWID appear to engage frequently in SDU due to constraints of the physical and social environments in which they use drugs. They express a preference for accompanied drug use in most cases and report implementing strategies to mitigate their overdose risk, especially when using drugs alone.

Selling sex in the context of substance use: social and structural drivers of transactional sex among men who use opioids in Maryland

Rosen, J. G., Schneider, K. E., Allen, S. T., Morris, M., Urquhart, G. J., Rouhani, S., & Sherman, S. G. (n.d.).

Publication year

2022

Journal title

Harm Reduction Journal

Volume

19

Issue

1
Abstract
Abstract
Background: Transactional sex is an important driver of HIV risk among people who use drugs in the USA, but there is a dearth of research characterizing men’s selling and trading of sex in the context of opioid use. To identify contextually specific factors associated with selling or trading sex in a US population of men who use drugs, we cross-sectionally examined social and structural correlates of transactional sex among men who use opioids (MWUO) in Anne Arundel County and Baltimore City, Maryland. Methods: Between July 2018 and March 2020, we used targeted sampling to recruit men reporting past-month opioid use from 22 street-level urban and suburban recruitment zones. MWUO completed a 30-min self-administered interview eliciting substance use histories, experiences with hunger and homelessness, criminal justice interactions, and transactional sex involvement. We identified correlates of recent (past 3 months) transactional sex using multivariable log-binomial regression with cluster-robust standard errors. Results: Among 422 MWUO (mean age 47.3 years, 73.4% non-Hispanic Black, 94.5% heterosexual), the prevalence of recent transactional sex was 10.7%. In multivariable analysis, younger age (adjusted prevalence ratio [aPR] 0.98, 95% confidence interval [95% CI] 0.97–0.99, p < 0.001), identifying as gay/bisexual (aPR = 5.30, 95% CI 3.81–7.37, p < 0.001), past-month food insecurity (aPR = 1.77, 95% CI 1.05–3.00, p = 0.032), and injection drug use in the past 3 months (aPR = 1.75, 95% CI 1.02–3.01, p = 0.043) emerged as statistically significant independent correlates of transactional sex. Conclusions: Synergistic sources of social and structural marginalization—from sexuality to hunger, homelessness, and injection drug use—are associated with transactional sex in this predominantly Black, heterosexual-identifying sample of MWUO. Efforts to mitigate physical and psychological harms associated with transactional sex encounters should consider the racialized dimensions and socio-structural drivers of transactional sex among MWUO.

Understanding the longitudinal relationship between substance use and violent victimization among street-based women who exchange sex in Baltimore, Maryland

Schneider, K. E., Tomko, C., Nestadt, D. F., Rouhani, S., White, R. H., Decker, M. R., Galai, N., & Sherman, S. G. (n.d.).

Publication year

2022

Journal title

International Journal of Drug Policy

Volume

109
Abstract
Abstract
Background: Women who exchange sex (WES) experience extensive interpersonal violence from multiple perpetrators. Violence towards WES contributes to poor mental and behavioral health outcomes, including high rates of drug use. However, it is difficult to disentangle the temporal relationship between drug use and violence among WES. Methods: We used data from 251 WES, who completed baseline and 6-month follow up surveys. WES reported baseline sociodemographic characteristics, including homelessness and hunger. Participants reported their drug use by type and violent experiences by perpetrator at each time point. We conducted a path analysis examining the associations between drug use and violent victimization over time. Results: Participants were on average 37.8 years old, non-Hispanic White (57.4%) and experiencing high levels of structural vulnerability (59.4% homelessness; 58.6% weekly hunger). Drug use and violence were significantly correlated within each time point. Prospectively, baseline violent victimization was significantly associated with drug use (ß (SE) = 0.13 (0.06)) and violence (ß (SE) = 0.47 (0.05)) at follow up. Baseline drug use was associated with drug use at follow up (ß (SE) = 0.45 (0.05)) but was not significantly associated with violence at follow up (ß (SE) = 0.10 (0.06)). Conclusions: Violence and drug use are closely linked in this population; and violence appears to facilitate sustained drug use. Interventions to address the dual epidemics of violence and substance use in this population should address underlying trauma as well as socio-structural drivers of violence as well as tailored harm reduction services for this population.

Confirmatory Factor Analysis and Construct Validity of the Internalized Sex Work Stigma Scale among a Cohort of Cisgender Female Sex Workers in Baltimore, Maryland, United States

Tomko, C., Nestadt, D. F., Rouhani, S., Silberzahn, B. E., Haney, K., Park, J. N., Galai, N., Logie, C. H., & Sherman, S. G. (n.d.).

Publication year

2021

Journal title

Journal of Sex Research

Volume

58

Issue

6

Page(s)

713-723
Abstract
Abstract
Internalized sex work stigma among cisgender female sex workers (FSW) is produced within contexts of social marginalization and associated with a range of ill-effects, including psychological distress, and lower rates of healthcare-seeking. This study seeks to uncover latent domains of the new Internalized Sex Work Stigma Scale (ISWSS) using data from 367 FSW in Baltimore, Maryland, USA. The sample was 56% white with high substance use (82% smoked crack cocaine, 58% injected any drug). The average ISWSS score was 34.8 (s.d. = 5.8, possible range: 12–48) and internal consistency was high (0.82). Confirmatory factor analysis revealed four subscales: worthlessness, guilt and shame, stigma acceptance, and sex work illegitimacy. Internal consistency of subscales was high (0.69–0.90); the scale also demonstrated construct validity with depression and agency. In bivariate logistic regressions, higher ISWSS, worthlessness, shame and guilt, and acceptance scores predicted higher odds of rushing client negotiations due to police. In unadjusted multinomial regressions, feeling respected by police predicted lower ISWSS, worthlessness, guilt and shame, acceptance, and illegitimacy scores. Identified factors are congruent with existing literature about how FSW manage sex work-specific stigma. Understanding the unique dimensions and impacts of internalized sex work stigma can inform interventions and policy to reduce morbidities experienced by FSW.

Food access among people who inject drugs in West Virginia

Rouhani, S., Allen, S. T., Whaley, S., White, R. H., O’Rourke, A., Schneider, K. E., Kilkenny, M. E., Weir, B. W., & Sherman, S. G. (n.d.).

Publication year

2021

Journal title

Harm Reduction Journal

Volume

18

Issue

1
Abstract
Abstract
Background: The substance use epidemic in the United States continues to drive high levels of morbidity and mortality, particularly among people who inject drugs (PWID). Poor access to food often co-occurs with drug use and contributes to associated sequelae, such as risks for HIV and diabetes. The objective of this study was to examine factors associated with adequate food access among PWID in a rural Appalachian community. Methods: Cross-sectional surveys were used to collect data among PWID aged 18 and older in Cabell County, West Virginia. Frequency of hunger and sociodemographic, structural and drug use characteristics were measured. Adequate food access was defined as reporting ‘never’ going to bed hungry at night in the past six months. Pearson’s χ2 and t-tests and multivariable logistic regression were used to identify factors associated with food access. Results: Only 71 individuals (17%) reported never going to bed hungry at night in the past six months. Adjusted odds of having adequate food access were higher among PWID who completed high school (aOR 2.94; P = 0.010) and usually used drugs alone (aOR 1.97; P = 0.025), and lower among PWID who were female (aOR 0.51; P = 0.037), experienced homelessness (aOR 0.23, P < 0.001), were recently arrested (aOR 0.50 P = 0.047), and engaged in receptive sharing of injection equipment (aOR 0.52, P = 0.035). Conclusions: We found extremely low food access in a population of PWID in Appalachia who are vulnerable to overdose and infectious disease transmission. Integrated interventions promoting food access are needed to improve the public health and wellbeing of people who inject drugs in Appalachia.

Homotypic and Heterotypic Protection and Risk of Reinfection following Natural Norovirus Infection in a Highly Endemic Setting

Chhabra, P., Rouhani, S., Browne, H., Peñataro Yori, P., Siguas Salas, M., Paredes Olortegui, M., Moulton, L. H., Kosek, M. N., & Vinjé, J. (n.d.).

Publication year

2021

Journal title

Clinical Infectious Diseases

Volume

72

Issue

2

Page(s)

222-229
Abstract
Abstract
Background: Norovirus is a leading cause of acute gastroenteritis worldwide, yet there is limited information on homotypic or heterotypic protection following natural infection to guide vaccine development. Methods: A total of 6020 stools collected from 299 Peruvian children between 2010 and 2014 were tested by norovirus real-time reverse-transcription polymerase chain reaction followed by sequence-based genotyping. Cox proportional hazards models were used to derive adjusted hazard ratios (HRs) of infection among children with vs without prior exposure. Results: Norovirus was detected in 1288 (21.3%) samples. GII.4 (26%), GII.6 (19%), and GI.3 (9%) viruses accounted for 54% of infections. Homotypic protection for GI.3 (HR, 0.35; P=.015), GI.7 (HR, 0.19; P=.022), GII.4 (HR, 0.39; P<.001), and GII.6 (HR, 0.52; P=.006) infections was observed. Hazard analysis showed that children with prior GII.4 infection exhibited heterotypic protection with a 48% reduction of subsequent GI.3 infection (HR, 0.52; P=.005). Prior exposure to GI.3, GII.2, and GII.17 infections enhanced susceptibility to subsequent infections with several other norovirus genotypes. Conclusions: Children up to 2 years of age infected with GII.4 noroviruses demonstrated both homotypic and heterotypic protection to reinfection with other genotypes. These data support the need for ongoing vaccine development efforts with GII.4 as the main component and caution the inclusion of genotypes that may enhance susceptibility to infections.

Implications of attitudes and beliefs about COVID-19 vaccines for vaccination campaigns in the United States: A latent class analysis

Schneider, K. E., Dayton, L., Rouhani, S., & Latkin, C. A. (n.d.).

Publication year

2021

Journal title

Preventive Medicine Reports

Volume

24
Abstract
Abstract
Unprecedented global efforts in vaccine development have resulted in effective vaccines for COVID-19. The pandemic response in the US has been highly politicized, resulting in significant opposition to public health efforts, including vaccines. We aimed to understand patterns of attitudes and beliefs about the COVID-19 vaccine to inform vaccination campaigns. 583 English speaking United States adults were surveyed November 18–29, 2020. Participants answered 11 questions about their attitudes and beliefs about a COVID-19 vaccine, including perceived vaccine effectiveness, likelihood of getting vaccinated, and concerns that vaccine development was rushed/influenced by politics. We conducted a latent class analysis to identify profiles of attitudes/beliefs about a COVID-19 vaccine. We identified four classes of COVID-19 vaccine beliefs. The pro-vaccine class (28.8%) was willing to get vaccinated and had broadly positive beliefs about the vaccine. The development concerns class (27.8%) was willing to get vaccinated but was concerned about the development process. The third class (22.6%) was largely unsure if they would get vaccinated and if their peer groups would be vaccinated. The forth class (anti-vaccine, 20.8%) was dominated by an unwillingness to get vaccinated, vaccine distrust, vaccine development concerns, and peers groups with negative vaccine intentions. Given the large proportion of individuals who were concerned about the COVID-19 vaccine development process, messaging about rigor and approval processes may be critical to securing this group's commitment to vaccination. Having scientific and cultural leaders endorse vaccination may also be influential.

Incidence and predictors of violence from clients, intimate partners and police in a prospective US-based cohort of women in sex work

Decker, M., Rouhani, S., Park, J. N., Galai, N., Footer, K., White, R., Allen, S., & Sherman, S. (n.d.).

Publication year

2021

Journal title

Occupational and Environmental Medicine

Volume

78

Issue

3

Page(s)

160-166
Abstract
Abstract
Objective Gender-based violence threatens women's health and safety. Female sex workers (FSWs) experience violence disproportionately, yet prospective data on violence predictors is lacking. In the first US-based prospective FSW cohort study, we examine incidence rates (IRs) and predictors of violence from distinct perpetrators: paying clients, non-paying intimate partners and police. Methods The parent cohort (Sex Workers and Police Promoting Health In Risky Environments) recruited street-based cisgender FSWs in urban Baltimore, MD (n=250) with 5 assessments at 3-month intervals through 12-month follow-up. Stratifying by violence perpetrator, we characterise violence at baseline, IR over the study period and time-varying predictors using Poisson models. Results The violence IR per person year was highest for client-perpetrated violence (0.78), followed by intimate partner violence (IPV; IR 0.39), and police violence (IR 0.25). Prevalence over the 12-month follow-up period among participants with complete visit data (n=103), was 42% for client violence, 22% for IPV and 16% for police violence. In adjusted analyses, risk factors for incident violence varied across perpetrators and included entry to sex work through force or coercion (adjusted IR ratio (aIRR) IPV 2.0; 95% CI 1.2 to 3.6), homelessness (aIRR IPV 2.0; 95% CI 1.3 to 2.9; aIRR police 2.7; 95% CI 1.3 to 5.8) and daily injection drug use (aIRR client 1.9; 95% CI 1.2 to 3.0). Risk of incident client violence and IPV was elevated by past abuse from each respective perpetrator. Help-seeking following abuse was limited. Conclusions FSWs face profound, enduring risk for violence from a range of perpetrators, likely enabled by criminalisation-related barriers to justice and perpetrator impunity. FSWs represent a priority population for access to justice, trauma-informed healthcare and violence-related support services. Structural vulnerabilities including homelessness and addiction represent actionable priorities for improving safety and health.

Perceived vulnerability to overdose-related arrests among people who use drugs in Maryland

Rouhani, S., Schneider, K. E., Rao, A., Urquhart, G. J., Morris, M., LaSalle, L., & Sherman, S. G. (n.d.).

Publication year

2021

Journal title

International Journal of Drug Policy

Volume

98
Abstract
Abstract
Background: People who use drugs (PWUD) must weigh complex legal scenarios when seeking help during overdose events. Good Samaritan laws (GSL) offer limited immunity for certain low-level drug crimes to encourage PWUD to call 911. Drug-induced homicide laws (DHL) allow for criminal prosecution of people delivering drugs that result in overdose death and may exert opposing effects on the decision-making process. We examined whether perceptions of these laws were related to overall perceived vulnerability to overdose-related arrests, which can impact help-seeking and overdose mortality. Methods: We conducted a cross-sectional study of PWUD (N = 173) in Anne Arundel County, Maryland and measured sociodemographic characteristics, structural vulnerabilities, and knowledge of GSL and DHL. Perceived vulnerability to overdose-related arrest was defined as self-reported concern arising from calling 911, receiving medical help, or supplying drugs in the event of an overdose. Multivariable logistic regression was used to identify significant correlates of perceived vulnerability to overdose-related arrest. Results: Most participants were aware of DHL (87%) and half were aware of GSL (53%). Forty-seven percent of PWUD expressed concern about arrest during or due to an overdose. After adjustment, positive correlates of perceived vulnerability to arrest were non-white race (aOR 2.0, 95% CI 1.5-2.5) and hearing of somebody charged with DHL (aOR 3.1, 95%CI 1.9-5.0), and negative correlates were history of drug treatment (aOR 0.6, 95%CI 0.4-1.0), receiving naloxone (aOR 0.6, 95% CI 0.4-1.0), and having made, sold or traded drugs in the past 3 months (aOR 0.4, 95% CI 0.2-0.9). Conclusions: We report persisting concern about arrest during overdose events among street-based PWUD facing a complicated landscape of legal protections and liabilities. Findings demonstrate clear racial disparities in concern outside of an urban centre, where impacts of policing on health are less studied, and present evidence that DHL may compromise overdose prevention efforts. Changes to drug policy and enforcement including police nonattendance at overdose scenes may be necessary to promote help-seeking among PWUD and reduce overdose fatalities.

Practical implications of naloxone knowledge among suburban people who use opioids

Schneider, K. E., Urquhart, G. J., Rouhani, S., Park, J. N., Morris, M., Allen, S. T., & Sherman, S. G. (n.d.).

Publication year

2021

Journal title

Harm Reduction Journal

Volume

18

Issue

1
Abstract
Abstract
Background: Naloxone distribution programs have been a cornerstone of the public health response to the overdose crisis in the USA. Yet people who use opioids (PWUO) continue to face a number of barriers accessing naloxone, including not knowing where it is available. Methods: We used data from 173 PWUO from Anne Arundel County, Maryland, which is located between Baltimore City and Washington, DC. We assessed the prevalence of recently (past 6 months) receiving naloxone and currently having naloxone, the type(s) of the naloxone kits received, and the perceived ease/difficultly of accessing naloxone. We also assessed participants knowledge of where naloxone was available in the community. Results: One third (35.7%) of participants had recently received naloxone. Most who had received naloxone received two doses (72.1%), nasal naloxone (86.9%), and education about naloxone use (72.1%). Most currently had naloxone in their possession (either on their person or at home; 78.7%). One third (34.4%) believed naloxone was difficult to obtain in their community. Only half (56.7%) knew of multiple locations where they could get naloxone. The health department was the most commonly identified naloxone source (58.0%). Identifying multiple sources of naloxone was associated with being more likely to perceive that naloxone is easy to access. Discussion: Our results suggest that additional public health efforts are needed to make PWUO aware of the range of sources of naloxone in their communities in order to ensure easy and continued naloxone access to PWUO.

Resilience among Cisgender and Transgender Women in Street-Based Sex Work in Baltimore, Maryland

Rouhani, S., Decker, M. R., Tomko, C., Silberzahn, B., Allen, S. T., Park, J. N., Footer, K. H., & Sherman, S. G. (n.d.).

Publication year

2021

Journal title

Women's Health Issues

Volume

31

Issue

2

Page(s)

148-156
Abstract
Abstract
Introduction: Resilience represents adaptability and empowerment and can buffer against the consequences of traumatic events. Cisgender and transgender women in street-based sex work are at high risk for trauma, yet data on their resilience are sparse. A clearer understanding of resilience and its correlates is useful for informing sex worker-centered interventions. Methods: Using the Connor-Davidson 10-item Resilience Scale (range, 0–40), we describe resilience among 165 cisgender and 42 transgender street-based women sex workers in Baltimore, Maryland. Longitudinal cohort data were used to examine correlates of resilience in each population. Analyses are conducted using multiple linear regression. Results: The mean resilience score was 24.2 (95% confidence interval, 23.6–24.8) among cisgender women sex workers and 32.2 among transgender women sex workers (95% confidence interval, 30.8–32.7). Among cisgender participants, positive correlates of resilience were being Black, Hispanic, or other race (ß = 2.7; p = .004), having housing (ß = 1.9; p = .034), social cohesion score (ß = 0.18; p = .047), and daily drug injection (ß = 3.7; p < .001); negative correlates of resilience were sexual violence (ß = –4.8; p = .006) and exposure to egregious police acts (ß = –0.6; p = .015). Among transgender participants, higher education level (ß = 8.8; p < .001), food security (ß = 3.5; p = .005), and housing stability (ß = 2.0; p < .001) were associated with increased resilience, and daily noninjection drug use (excluding marijuana; ß = –3.3; p < .001) and physical violence (ß = –2.9; p < .001) were associated with reduced resilience. Conclusions: This study is the first to characterize factors that may influence resilience among cisgender and transgender women sex workers. Results highlight tangible intervention targets for promoting mental health and safety among a uniquely vulnerable population of women.

Agency in the fentanyl era: Exploring the utility of fentanyl test strips in an opaque drug market

Weicker, N. P., Owczarzak, J., Urquhart, G., Park, J. N., Rouhani, S., Ling, R., Morris, M., & Sherman, S. G. (n.d.).

Publication year

2020

Journal title

International Journal of Drug Policy

Volume

84
Abstract
Abstract
Background: In Baltimore, the emergence of fentanyl and its analogues exacerbated an existing heroin crisis and increased uncertainty about drug composition and potency. In an effort to reduce overdoses, harm reduction organizations and health departments across the U.S. began distributing fentanyl test strips, a low barrier, inexpensive drug checking strategy. Studies show that people who use drugs (PWUD) frequently suspect that their drugs contain fentanyl and are interested in using fentanyl test strips to check their drugs; however, some people question their usefulness in regions where fentanyl presence is assumed. Understanding the utility of fentanyl test strips in fentanyl-saturated markets is a priority to best tailor interventions. Methods: In-depth interviews (N = 20) were conducted with individuals who reported recent (past 30 days) opioid use in Baltimore, MD. Results: Fentanyl was viewed as pervasive, dangerous, and difficult to avoid in the local drug supply. This dominant narrative characterized PWUD as disempowered by the heightened unpredictability of the drug market. While several strategies are used to navigate the drug market, respondents wanted more information about their drugs. In this context, fentanyl test strips were used in unique and unexpected ways to empower PWUD to be savvier market consumers, including avoiding fentanyl when there could be negative social or legal consequences, negotiating with dealers, and helping others in their social network navigate the opaque drug market. Conclusion: These findings add nuance and place fentanyl preference and use in the context of the drug market. When fentanyl presence is assumed, people used fentanyl test strips in unexpected ways to gain some control over their drug use. Novel uses for fentanyl test strips strengthen existing strategies used to navigate the drug market and mitigate overdose risk, and highlight their potential to quickly disseminate valuable information about the local drug supply.

Diarrhea as a potential cause and consequence of reduced gut microbial diversity among undernourished children in peru

Rouhani, S., Griffin, N. W., Yori, P. P., Gehrig, J. L., Olortegui, M. P., Salas, M. S., Trigoso, D. R., Moulton, L. H., Houpt, E. R., Barratt, M. J., Kosek, M. N., & Gordon, J. I. (n.d.).

Publication year

2020

Journal title

Clinical Infectious Diseases

Volume

71

Issue

4

Page(s)

989-999
Abstract
Abstract
Background. Detrimental effects of diarrhea on child growth and survival are well documented, but details of the underlying mechanisms remain poorly understood. Recent evidence demonstrates that perturbations to normal development of the gut microbiota in early life may contribute to growth faltering and susceptibility to related childhood diseases. We assessed associations between diarrhea, gut microbiota configuration, and childhood growth in the Peruvian Amazon. Methods. Growth, diarrhea incidence, illness, pathogen infection, and antibiotic exposure were assessed monthly in a birth cohort of 271 children aged 0-24 months. Gut bacterial diversity and abundances of specific bacterial taxa were quantified by sequencing 16S rRNA genes in fecal samples collected at 6, 12, 18, and 24 months. Linear and generalized linear models were used to determine whether diarrhea was associated with altered microbiota and, in turn, if features of the microbiota were associated with the subsequent risk of diarrhea. Results. Diarrheal frequency, duration, and severity were negatively associated with bacterial diversity and richness (P < .05). Children born stunted (length-for-age z-score [LAZ] ≤ -2) who were also severely stunted (LAZ ≤ -3) at the time of sampling exhibited the greatest degree of diarrhea-associated reductions in bacterial diversity and the slowest recovery of bacterial diversity after episodes of diarrhea. Increased bacterial diversity was predictive of reduced subsequent diarrhea from age 6 to 18 months. Conclusions. Persistent, severe growth faltering may reduce the gut microbiota's resistance and resilience to diarrhea, leading to greater losses of diversity and longer recovery times. This phenotype, in turn, denotes an increased risk of future diarrheal disease and growth faltering.

Gut microbiota features associated with campylobacter burden and postnatal linear growth deficits in a peruvian birth cohort

Rouhani, S., Griffin, N. W., Yori, P. P., Olortegui, M. P., Salas, M. S., Trigoso, D. R., Moulton, L. H., Houpt, E. R., Barratt, M. J., Kosek, M. N., & Gordon, J. I. (n.d.).

Publication year

2020

Journal title

Clinical Infectious Diseases

Volume

71

Issue

4

Page(s)

1000-1007
Abstract
Abstract
Background. Campylobacter infection is associated with impaired growth of children, even in the absence of symptoms. To examine the underlying mechanisms, we evaluated associations between Campylobacter infection, linear growth, and fecal microbial community features in a prospective birth cohort of 271 children with a high burden of diarrhea and stunting in the Amazonian lowlands of Peru. Methods. Campylobacter was identified using a broadly reactive, genus-specific enzyme-linked immunosorbent assay. 16S rRNAbased analyses were used to identify bacterial taxa in fecal samples at ages 6, 12, 18, and 24 months (N = 928). Associations between infection, growth, and gut microbial community composition were investigated using multiple linear regression adjusting for withinchild correlations, age, and breastfeeding. Indicator species analyses identified taxa specifically associated with Campylobacter burden. Results. Ninety-three percent (251) of children had Campylobacter present in asymptomatic fecal samples during the follow-up period. A 10% increase in the proportion of stools infected was associated with mean reductions of 0.02 length-for-age z scores (LAZ) at 3, 6, and 9 months thereafter (P < .01). We identified 13 bacterial taxa indicative of cumulative Campylobacter burden and 14 taxa significantly associated with high or low burden of enteroaggregative Escherichia coli, norovirus, or Giardia. Conclusions. Campylobacter infection is common in this cohort and associated with changes in microbial community composition. These results support the notion that disruptions to the fecal microbiota may help explain the observed effects of asymptomatic infections on growth in early life.

High willingness to use overdose prevention sites among female sex workers in Baltimore, Maryland

Rouhani, S., White, R. H., Park, J. N., & Sherman, S. G. (n.d.).

Publication year

2020

Journal title

Drug and alcohol dependence

Volume

212
Abstract
Abstract
Background: Overdose Prevention Sites (OPS) operate worldwide as spaces where people can consume previously purchased drugs under supervision, and are linked to reductions in HIV/HCV transmission and fatal overdoses. As the United States weighs their merits and legality, research is needed to estimate acceptability and use among populations at high risk for overdose. We examine willingness to use OPS among street-based female sex workers (FSW) with prevalent drug use and associated morbidities. Methods: We describe self-reported willingness, barriers and conditions around use of a hypothetical OPS among 141 FSW engaged in active drug use in Baltimore City, and describe trends using Pearson's χ2 and Fisher's exact tests. Results: Most women had history of overdose (55 %) and were likely to use OPS (77 %). Willingness was higher among women who: were sexual minorities (97 %;P=0.002),experienced homelessness (82 %;P=0.019), injected drugs (82 %;P=0.013), shared syringes (82 %;P=0.007), experienced sexual violence (92 %;P=0.045) or reported heroin use (83 %;P=0.039) in the past 3 months. Common anticipated barriers included transportation (45 %) and fear of arrest (41 %). Conclusions: This study highlights a population of uniquely high-risk women who would benefit from an OPS integrated with other services. Conditions and barriers discussed are informative for planning and implementation.

Contact

saba.rouhani@nyu.edu 708 Broadway New York, NY, 10003