Contrary to our hypothesis, staying in shelters or meeting criteria for depressive symptomatology or significant distress on the CES-D scale was not associated with current smoking. Given that the more than half the participants reported a shelter stay or depressive symptomatology, these characteristics may not have differentiated smokers and nonsmokers in our study sample. Persons who reported a jail or prison stay in the past 6 months at enrollment had a non-significantly higher likelihood of being a smoker than those without a history of incarceration. Consistent with our hypothesis and previous studies,use of illicit substances and alcohol use were associated with current smoking among participants in our study. Comorbid substance use disorders pose significant challenges to smoking cessation because the use of illicit substances may provide social cues to smoking and augment the pleasurable effects of nicotine.Given these findings, there is mounting evidence for the integration of treatment for nicotine dependence with that of substance use treatment.A meta-analysis showed that treating nicotine addiction during substance use treatment may enhance short-term smoking cessation and lead to prolonged abstinence from alcohol and other illicit substances.Lower cigarette consumption and prior quit attempts were associated with increased likelihood of a subsequent quit attempt at follow-up. Time to first cigarette after waking, a nicotine dependence measure predictive of smoking cessation,was not associated with making a quit attempt in adjusted analysis. Concurrent use of other tobacco products, which is common among homeless adults,may reduce reliance on cigarettes and may reduce the predictive validity of time to first cigarette after waking as a predictor of cigarette quit attempts.Contrary to our hypothesis and previous studies that have shown an association with depression and decreased quit attempts,ebb flow table our results showed a higher likelihood of quit attempts among those who with depressive symptomatology .

In post hoc analysis we found that persons with depressive symptomatology showed a non-statistically significant higher likelihood of having received advice from a healthcare provider to quit smoking, suggesting that these individuals may have been both more engaged in health care and more likely to receive advice to quit and/ or other resources for smoking cessation. Staying in a shelter was associated with an increased likelihood of a quit attempt. Shelters may provide a more stable environment than unsheltered environments to engage in smoking cessation. Shelters have smoke-free policies that may motivate individuals to make quit attempts.Few shelters offer on-site resources, but most provide referrals to community-based resources for smoking cessation.These factors may also encourage quit attempts among homeless clients. Previous research has shown that the majority of smokers who attempt to quit smoking relapse back to smoking,but the longer the duration of smoking abstinence, the higher the likelihood of successful quitting.In a study of former smokers in the general population, only 12% of those who had abstained from smoking for less than 1 month at baseline were continuously abstinent from smoking at follow-up 1 year later; almost 50% had resumed smoking at follow-up.Only three participants reported sustained abstinence at 6 months follow-up. The results of this study highlight the difficulty of quitting smoking successfully, a task that is much more challenging when faced with the stress of material resource constraints and social disorganization common in homelessness.Given that a significant proportion of the sample was engaged in quitting behaviors during the study interval, our findings highlight the need for more effective therapies that increase the rate of successful quitting among older homeless smokers.Previous studies have identified limited access or poor adherence to smoking cessation aids, depression, lack of access to smoke-free homes, illicit substance use, and stress from social stressors as factors associated with relapse.Despite being socioeconomically disadvantaged, about one-fourth of the participants in the current study reported that they had used NRT or FDA-approved medications during the last quit attempt, a proportion that is similar to the general population.Although a minority of our study population reported achieving 30-day or 90-day abstinence, use of cessation medications was not associated with abstinence.

We may have been under powered to detect a meaningful difference in abstinence rates between those who did and did not use NRT, highlighting a need for studies that explore the efficacy of NRT for smoking cessation in this population. Other factors may influence the efficacy of NRT for smoking cessation in the homeless population including intensity of smoking,use of concurrent tobacco products, frequency of use of NRT, and access to other treatments for cessation; these factors merit further exploration. Examining access to smoke-free living environments, identifying messages to convey smoking-related health effects, and identifying perceptions of current tobacco control strategies may provide additional insights into developing effective interventions for smoking cessation among this population. Our study had several limitations. As in our previous work,we relied on self-reports of tobacco cessation behaviors, potentially leading to recall bias and over- or under-estimation of cessation rates. The lack of biomarker-verified measures of abstinence could result in potential inaccuracies in the estimates of prolonged abstinence. The slightly lower 6-month follow-up rate among smokers than nonsmokers may have led to a potential differential misclassification bias in estimates of tobacco cessation at follow-up. While we were able to assess whether participants switched to other tobacco products for cigarette smoking cessation, we were unable to assess concurrent use of other tobacco products with cigarette smoking. We were unable to determine whether receipt of tobacco cessation services in homeless shelters could have influenced sheltered participants’ decision to make a quit attempt. Our study sample that included predominantly African American participants may not be generalizable to other populations of older homeless adults across the United States. However, given the increased tobacco-related disease burden among African American smokers,our study provides insight into smoking cessation behaviors that might guide intervention development for this population. Despite these limitations, this is among the first studies on tobacco use and cessation to focus specifically on older homeless adults.

The high prevalence of smoking and the low rates of successful quitting highlight numerous opportunities to intervene to increase quitting rates among this population. Among these, increasing access to smoke-free living environments and identifying effective cessation therapies will be critical to reducing tobacco-related disease burden among older homeless adults.There were over 2 million incident cases of bacterial sexually transmitted infections in the United States in 2017.Surveillance data suggest dramatic increases in the incidence of syphilis, chlamydia, and gonorrhoea despite overall declining rates of new HIV infections.Preliminary estimates comparing new STI diagnoses between 2013 and 2017 indicate a 76% increase in syphilis, a 67% increase in gonorrhoea, and a 21% increase in chlamydia.These substantial increases have raised concerns about the spread of treatment-resistant gonorrhoea, increased morbidity from untreated infections, and other serious public health consequences . There is also uncertainty regarding whether the high incidence of STIs will compromise the long-term success of antiretroviral therapy -based prevention strategies such as pre-exposure prophylaxis and treatment as prevention .4 Although ART-based prevention will likely remain effective even in the presence of STIs,available data are not sufficient to rule out the possibility that STI-induced genital inflammation can facilitate local shedding of HIV despite systemic control.People with HIV , particularly men who have sex with men , are among the most severely impacted by the STI epidemic. For example, county surveillance data from San Francisco, California, indicate that between 2011 and 2014, the number of new STI cases among PWH increased by over 38% from 992 to 1372.Unhealthy alcohol use and drug use are prevalent among PWH,hydroponic grow table and place individuals at even greater risk for STIs as these have been associated with risk-taking behaviours and worse health outcomes.Unhealthy alcohol use refers to a range of drinking behaviors that increase the risk of negative health consequences.Previous studies have found that unhealthy alcohol use and drug use are associated with condomless sex and poor medication adherence and retention in care.Given the burden of STIs in this medically vulnerable population, it is critical to identify subgroups of PWH at greatest STI risk to target resources and optimize screening and early treatment. In this study, we examined the prevalence of bacterial STIs and associated correlates, including alcohol and drug use and partner PrEP use, among a primary care-based cohort of PWH with unhealthy alcohol use in an integrated healthcare system.

During the 24-month follow-up interview, participants were asked whether any of their partners in the last year used PrEP . Participants could respond with either “Yes,” “No,” “All my partners have been HIV-positive,” or “Don’t know/refuse.” Those who had no partners in the previous year were automatically marked as “Don’t know/refuse.” Participant responses were categorized by partner HIV status and PrEP use into mutually exclusive categories: HIV-positive partners only ; HIV-negative partners with at least one on PrEP; and HIV-negative none on PrEP . Participants with responses coded as “Don’t know/refuse” were excluded from our analyses to avoid misclassification as this group potentially included individuals who were not sexually active in the previous year. Participants were also asked about condom use during anal and/or vaginal sex and total number of partners in the last six months. Additional data collected included stimulant use , opiate use , cannabis use, and use of other drugs in the last year, as well as any alcohol and/or drug use before sex in the last six months. Drug and alcohol use were assessed using an interviewer-administered questionnaire . Severity of alcohol use was measured using the Alcohol Use Disorder Identification Test .AUDIT scores were interpreted based on standard cut-offs: <7 indicated low risk for alcohol use disorder; indicated hazardous use; suggested high risk for alcohol use disorder; and scores 20 or greater suggested a likelihood for alcohol use disorder.Interview responses were combined with laboratory data regarding most recent HIV viral load and positive STI tests in the prior year from the KPNC electronic health record. HIV viral suppression was defined as most recent viral load <75 copies/mL. Our outcome of interest was prevalence of any laboratory-confirmed bacterial STI in the year prior to the 24-month follow-up interview. STI testing was completed as part of routine clinical care. Extragenital testing was based on patient and provider discretion, and results were included in our analysis if tests returned positive. Syphilis was tested using a rapid plasma reagin and a treponemal IgG and IgM antibody test. Syphilis infections that occurred within the study period were identified based on a 4-fold increase in RPR titers.Those who had no positive results were assumed not to have an STI because PWH are screened for those STIs frequently in our healthcare delivery system, with quarterly testing recommended for most of those who are sexually active. Participant characteristics, including viral load, were summarized using descriptive statistics. The Kruskal-Wallis test was used to evaluate differences in median number of sex partners between PWH who had HIV-positive partners only, those who had at least one partner on PrEP, and those who did not report any partner PrEP use. Differences in condom use across partner groups were evaluated using chi-square tests. We estimated prevalence ratios to evaluate the association between alcohol and drug use and partner PrEP use with STIs using Poisson regression models fitted with robust variance estimators. Covariates were selected a priori using clinical judgment and all variables in the unadjusted models were used in the final adjusted model. Variance inflation factor was used to test for collinearity between all of the predictor variables. Analyses were completed using Stata 14 . This study was approved by the Institutional Review Boards at KPNC and at the University of California, San Francisco . Of the 614 PWH in the parent study, 553 participants completed 24-month interviews; of those, 88 did not provide partner information and were excluded from this analysis. Participant characteristics are summarized in Table 1. Of the 465 PWH in this analysis, median age was 52 years . Most were white , college educated , and MSM . Thirty-two percent of participants had HIV-positive partners only, 31% had at least one HIV-negative partner in the previous year who took PrEP, and 37% had HIV-negative partners without reported PrEP use. Approximately 94% of all participants were virologically suppressed. Of the 318 PWH with HIV negative partners, most were either suppressed or reported partner PrEP use in the prior year. The majority of participants had low risk alcohol use. However, self-reported drug use in the past year was common.