On epidemiology and geographic information systems: a review and discussion of future directions

Geographic information systems are powerful automated systems for the capture, storage, retrieval, analysis, and display of spatial data. While the systems have been in development for more than 20 years, recent software has made them substantially easier to use for those outside the field. The systems offer new and expanding opportunities for epidemiology because they allow an informed user to choose between options when geographic distributions are part of the problem. Even when used minimally, these systems allow a spatial perspective on disease. Used to their optimum level, as tools for analysis and decision making, they are indeed a new information management vehicle with a rich potential for public health and epidemiology

Distance Traveled and Cross-State Commuting to Opioid Treatment Programs in the United States

This study examined commuting patterns among 23,141 methadone patients enrolling in 84 opioid treatment programs (OTPs) in the United States. Patients completed an anonymous one-page survey. A linear mixed model analysis was used to predict distance traveled to the OTP. More than half (60%) the patients traveled <10 miles and 6% travelled between 50 and 200 miles to attend an OTP; 8% travelled across a state border to attend an OTP. In the multivariate model (n = 17,792), factors significantly (P < .05) associated with distance were, residing in the Southeast or Midwest, low urbanicity, area of the patient's ZIP code, younger age, non-Hispanic white race/ethnicity, prescription opioid abuse, and no heroin use. A significant number of OTP patients travel considerable distances to access treatment. To reduce obstacles to OTP access, policy makers and treatment providers should be alert to patients' commuting patterns and to factors associated with them

Trends in the Population Prevalence of People Who Inject Drugs in US Metropolitan Areas 1992–2007

Background: People who inject drugs (PWID) have increased risk of morbidity and mortality. We update and present estimates and trends of the prevalence of current PWID and PWID subpopulations in 96 US metropolitan statistical areas (MSAs) for 1992–2007. Current estimates of PWID and PWID subpopulations will help target services and help to understand long-term health trends among PWID populations. Methodology: We calculated the number of PWID in the US annually from 1992–2007 and apportioned estimates to MSAs using multiplier methods. We used four types of data indicating drug injection to allocate national annual totals to MSAs, creating four distinct series of component estimates of PWID in each MSA and year. The four component estimates are averaged to create the best estimate of PWID for each MSA and year. We estimated PWID prevalence rates for three subpopulations defined by gender, age, and race/ethnicity. We evaluated trends using multi-level polynomial models. Results: PWID per 10,000 persons aged 15–64 years varied across MSAs from 31 to 345 in 1992 (median 104.4) to 34 to 324 in 2007 (median 91.5). Trend analysis indicates that this rate declined during the early period and then was relatively stable in 2002–2007. Overall prevalence rates for non-Hispanic black PWID increased in 2005 as compared to other racial/ethnic groups. Hispanic prevalence, in contrast, declined across time. Importantly, results show a worrisome trend in young PWID prevalence since HAART was initiated – the mean prevalence was 90 to 100 per 10,000 youth in 1992–1996, but increased to >120 PWID per 10,000 youth in 2006–2007. Conclusions: Overall, PWID rates remained constant since 2002, but increased for two subpopulations: non-Hispanic black PWID and young PWID. Estimates of PWID are important for planning and evaluating public health programs to reduce harm among PWID and for understanding related trends in social and health outcomes

Metropolitan Social Environments and Pre-HAART/HAART Era Changes in Mortality Rates (per 10,000 Adult Residents) among Injection Drug Users Living with AIDS

Background Among the largest US metropolitan areas, trends in mortality rates for injection drug users (IDUs) with AIDS vary substantially. Ecosocial, risk environment and dialectical theories suggest many metropolitan areas characteristics that might drive this variation. We assess metropolitan area characteristics associated with decline in mortality rates among IDUs living with AIDS (per 10,000 adult MSA residents) after highly active antiretroviral therapy (HAART) was developed. Methods This is an ecological cohort study of 86 large US metropolitan areas from 1993–2006. The proportional rate of decline in mortality among IDUs diagnosed with AIDS (as a proportion of adult residents) from 1993–1995 to 2004–2006 was the outcome of interest. This rate of decline was modeled as a function of MSA-level variables suggested by ecosocial, risk environment and dialectical theories. In multiple regression analyses, we used 1993–1995 mortality rates to (partially) control for pre-HAART epidemic history and study how other independent variables affected the outcomes. Results In multivariable models, pre-HAART to HAART era increases in ‘hard drug’ arrest rates and higher pre-HAART income inequality were associated with lower relative declines in mortality rates. Pre-HAART per capita health expenditure and drug abuse treatment rates, and pre- to HAART-era increases in HIV counseling and testing rates, were weakly associated with greater decline in AIDS mortality. Conclusions Mortality among IDUs living with AIDS might be decreased by reducing metropolitan income inequality, increasing public health expenditures, and perhaps increasing drug abuse treatment and HIV testing services. Given prior evidence that drug-related arrest rates are associated with higher HIV prevalence rates among IDUs and do not seem to decrease IDU population prevalence, changes in laws and policing practices to reduce such arrests while still protecting public order should be considered

A needle in the haystack – the dire straits of needle exchange in Hungary

Abstract Background The two largest needle exchange programs (NEPs) in Hungary were forced to close down in the second half of 2014 due to extreme political attacks and related lack of government funding. The closures occurred against a background of rapid expansion in Hungary of injectable new psychoactive substances, which are associated with very frequent injecting episodes and syringe sharing. The aim of our analysis was to predict how the overall Hungarian NEP syringe supply was affected by the closures. Methods We analyzed all registry data from all NEPs in Hungary for all years of standardized NEP data collection protocols currently in use (2008–2014) concerning 22 949 client enrollments, 9 211 new clients, 228 167 client contacts, 3 160 560 distributed syringes, and 2 077 676 collected syringes. Results We found that while the combined share of the two now closed NEPs decreased over time, even in their partial year 2014 they still distributed and collected about half of all syringes, and attended to over half of all clients and client contacts in Hungary. The number of distributed syringes per PWID (WHO minimum target = 100) was 81 in 2014 in Hungary, but 39 without the two now closed NEPs. Conclusions There is a high probability that the combination of decreased NEP coverage and the increased injection risk of new psychoactive substances may lead in Hungary to a public health disaster similar to the HIV outbreaks in Romania and Greece. This can be avoided only by an immediate change in the attitude of the Hungarian government towards harm reduction

Predictors of historical change in drug treatment coverage among people who inject drugs in 90 large metropolitan areas in the USA, 1993–2007

Background Adequate access to effective treatment and medication assisted therapies for opioid dependence has led to improved antiretroviral therapy adherence and decreases in morbidity among people who inject drugs (PWID), and can also address a broad range of social and public health problems. However, even with the success of syringe service programs and opioid substitution programs in European countries (and others) the US remains historically low in terms of coverage and access with regard to these programs. This manuscript investigates predictors of historical change in drug treatment coverage for PWID in 90 US metropolitan statistical areas (MSAs) during 1993–2007, a period in which, overall coverage did not change. Methods Drug treatment coverage was measured as the number of PWID in drug treatment, as calculated by treatment entry and census data, divided by numbers of PWID in each MSA. Variables suggested by the Theory of Community Action (i.e., need, resource availability, institutional opposition, organized support, and service symbiosis) were analyzed using mixed-effects multivariate models within dependent variables lagged in time to study predictors of later change in coverage. Results Mean coverage was low in 1993 (6.7%; SD 3.7), and did not increase by 2007 (6.4%; SD 4.5). Multivariate results indicate that increases in baseline unemployment rate (β = 0.312; pseudo-p < 0.0002) predict significantly higher treatment coverage; baseline poverty rate (β = − 0.486; pseudo-p < 0.0001), and baseline size of public health and social work workforce (β = 0.425; pseudo-p < 0.0001) were predictors of later mean coverage levels, and baseline HIV prevalence among PWID predicted variation in treatment coverage trajectories over time (baseline HIV * Time: β = 0.039; pseudo-p < 0.001). Finally, increases in black/white poverty disparity from baseline predicted significantly higher treatment coverage in MSAs (β = 1.269; pseudo-p < 0.0001). Conclusions While harm reduction programs have historically been contested and difficult to implement in many US communities, and despite efforts to increase treatment coverage for PWID, coverage has not increased. Contrary to our hypothesis, epidemiologic need, seems not to be associated with change in treatment coverage over time. Resource availability and institutional opposition are important predictors of change over time in coverage. These findings suggest that new ways have to be found to increase drug treatment coverage in spite of economic changes and belt-tightening policy changes that will make this difficult

Police killings of Black people and rates of sexually transmitted infections: A cross-sectional analysis of 75 large US metropolitan areas, 2016

Objectives Emerging literature shows that racialised police brutality, a form of structural racism, significantly affects health and well-being of racial/ethnic minorities in the USA. While public health research suggests that structural racism is a distal determinant of sexually transmitted infections (STIs) among Black people, no studies have empirically linked police violence to STIs. To address this gap, our study measures associations between police killings and rates of STIs among Black residents of US metropolitan statistical areas (MSAs). Methods This cross-sectional ecological analysis assessed associations between the number of Black people killed by police in 2015 and rates of primary and secondary syphilis, gonorrhoea and chlamydia per 100 000 Black residents of all ages in 2016 in 75 large MSAs. Multivariable models controlled for MSA-level demographic and socioeconomic characteristics, police expenditures, violent crime, arrest and incarceration rates, insurance rates and healthcare funding. Results In 2015, the median number of Black people killed by police per MSA was 1.0. In multivariable models, police killings were positively and significantly associated with syphilis and gonorrhoea rates among Black residents. Each additional police killing in 2015 was associated with syphilis rates that were 7.5% higher and gonorrhoea rates that were 4.0% higher in 2016. Conclusions Police killings of Black people may increase MSA-level risk of STI infections among Black residents. If future longitudinal analyses support these findings, efforts to reduce STIs among Black people should include reducing police brutality and addressing mechanisms linking this violence to STIs

Relationship of Racial Residential Segregation to Newly Diagnosed Cases of HIV among Black Heterosexuals in US Metropolitan Areas, 2008–2015

Social science and public health literature has framed residential segregation as a potent structural determinant of the higher HIV burden among black heterosexuals, but empirical evidence has been limited. The purpose of this study is to test, for the first time, the association between racial segregation and newly diagnosed heterosexually acquired HIV cases among black adults and adolescents in 95 large US metropolitan statistical areas (MSAs) in 2008–2015. We operationalized racial segregation (the main exposure) using Massey and Denton’s isolation index for black residents; the outcome was the rate of newly diagnosed HIV cases per 10,000 black adult heterosexuals. We tested the relationship of segregation to this outcome using multilevel multivariate models of longitudinal (2008–2015) MSA-level data, controlling for potential confounders and time. All covariates were lagged by 1 year and centered on baseline values. We preliminarily explored mediation of the focal relationship by inequalities in education, employment, and poverty rates. Segregation was positively associated with the outcome: a one standard deviation decrease in baseline isolation was associated with a 16.2% reduction in the rate of new HIV diagnoses; one standard deviation reduction in isolation over time was associated with 4.6% decrease in the outcome. Exploratory mediation analyses suggest that black/white socioeconomic inequality may mediate the relationship between segregation and HIV. Our study suggests that residential segregation may be a distal determinant of HIV among black heterosexuals. The findings further emphasize the need to address segregation as part of a comprehensive strategy to reduce racial inequities in HIV

Attitudes toward Methadone among Out-of-Treatment Minority Injection Drug Users: Implications for Health Disparities

Injection drug use (IDU) continues to be a significant public health issue in the U.S. and internationally, and there is evidence to suggest that the burden of injection drug use and associated morbidity and mortality falls disproportionately on minority communities. IDU is responsible for a significant portion of new and existing HIV/AIDS cases in many parts of the world. In the U.S., the prevalence of HIV and hepatitis C virus is higher among populations of African-American and Latino injection drug users (IDUs) than among white IDUs. Methadone maintenance therapy (MMT) has been demonstrated to effectively reduce opiate use, HIV risk behaviors and transmission, general mortality and criminal behavior, but opiate-dependent minorities are less likely to access MMT than whites. A better understanding of the obstacles minority IDUs face accessing treatment is needed to engage racial and ethnic disparities in IDU as well as drug-related morbidity and mortality. In this study, we explore knowledge, attitudes and beliefs about methadone among 53 out-of-treatment Latino and African-American IDUs in Providence, RI. Our findings suggest that negative perceptions of methadone persist among racial and ethnic minority IDUs in Providence, including beliefs that methadone is detrimental to health and that people should attempt to discontinue methadone treatment. Additional potential obstacles to entering methadone therapy include cost and the difficulty of regularly attending a methadone clinic as well as the belief that an individual on MMT is not abstinent from drugs. Substance use researchers and treatment professionals should engage minority communities, particularly Latino communities, in order to better understand the treatment needs of a diverse population, develop culturally appropriate MMT programs, and raise awareness of the benefits of MMT

Evidence for HIV transmission across key populations: a longitudinal analysis of HIV and AIDS rates among Black people who inject drugs and Black heterosexuals in 84 large U.S. metropolitan areas, 2008–2016

Purpose: To assess cross-population linkages in HIV/AIDS epidemics, we tested the hypothesis that the number of newly diagnosed AIDS cases among Black people who inject drugs (PWID) was positively related to the natural log of the rate of newly diagnosed HIV infections among Black non-PWID heterosexuals in 84 large U.S. metropolitan statistical areas (MSAs) in 2008–2016. Methods: We estimated a multilevel model centering the time-varying continuous exposures at baseline between the independent (Black PWID AIDS rates) and dependent (HIV diagnoses rate among Black heterosexuals) variables. Results: At MSA level, baseline (standardized β = 0.12) Black PWID AIDS rates and change in these rates over time (standardized β = 0.11) were positively associated with the log of new HIV diagnoses rates among Black heterosexuals. Thus, MSAs with Black PWID AIDS rates that were 1 standard deviation= higher at baseline also had rates of newly diagnosed HIV infections among Black non-PWID heterosexuals that were 10.3% higher. A 1 standard deviation increase in independent variable over time corresponded to a 7.8% increase in dependent variable. Conclusions: Black PWID AIDS rates may predict HIV rates among non-PWID Black heterosexuals. Effective HIV programming may be predicated, in part, on addressing intertwining of HIV epidemics across populations