A Longitudinal Examination of HIV Risk Perception Accuracy among Sexual Minority Men with History of Childhood Sexual Abuse.

Men who have sex with men (MSM) with history of childhood sexual abuse (CSA) are at high risk for HIV acquisition. One reason is posttraumatic responses compromise ability to accurately appraise risk for danger/vulnerability. Health behavior change models and related interventions assume risk perception can be changed in an enduring manner. Given paucity of studies examining how risk perception changes or sustains over time post-intervention, this underlying assumption is not confirmed. Among this particularly high-risk group who struggle with perceiving risk due to trauma-related cognitions, it may be accuracy of risk perception is fluid. The study primarily aimed to examine accuracy of HIV risk perception over time post-HIV prevention behavioral intervention. Leveraging data from a larger RCT, N = 190 MSM in Boston, MA and Miami, FL USA completed a psychosocial baseline assessment, an intervention aimed to increase awareness of personal HIV risk level, then four follow-up assessments three months apart for a year. Linear mixed effect models were used to examine the degree to which accuracy of HIV risk perception (vs. traditional construct of risk perception with no information about accuracy) predicts sex risk behavior over time delineated by between-person (trait level) and within-person (state level) effects. Majority (92%) of participants fluctuated in HIV risk accuracy over time post-intervention. Within-person risk accuracy (one's accuracy at any given timepoint) predicted sex risk behavior (condomless sex not protected by adherent PrEP) over time, but not between-person (one's average of accuracy). Findings have implications for intervention and counseling related to specific HIV prevention strategies.

Sexual Networking and HIV/STI Prevention Among Men who have Sex with Men and Identify as Persons of Color in the Era of COVID-19 in Boston, MA: Qualitative Findings from the National HIV Behavioral Surveillance Project.

Men who have sex with men and identify as persons of color (MSM of color) are significantly impacted by HIV in the United States. The COVID-19 pandemic may have disproportionately exacerbated HIV-related disparities among MSM of color by affecting sexual networking behaviors and disrupting access to sexual health care. The current study explored the impact of COVID-19 on sexual networking and HIV/sexually transmitted infection (STI) prevention behaviors among MSM of color in Boston, MA. Eighteen semi-structured interviews were conducted via the 2020-2021 Boston sample of the National HIV Behavioral Surveillance (NHBS) project. Eligible participants were at least 18 years old, identified as a man or non-binary person assigned male at birth and as a person of color, and endorsed ever having sex with men. Interviews were coded using inductive and deductive approaches, and themes were extracted using thematic analysis. When participants were asked about the impact of COVID-19 on sexual networking and HIV/STI prevention, the following themes emerged: (1) differing interpretations of COVID-19 public health guidance, (2) behavior change to meet social and sexual needs, (3) limited or changed access to HIV/STI prevention services; and (4) avoidance of healthcare appointments. Overall, the pandemic affected sexual networking and HIV/STI prevention behaviors among MSM of color. Though changes in sexual networking varied, most participants decreased in-person networking, increased dating app use, and prioritized longer-term relationships. Despite loosening of restrictions, these impacts may persist and should inform the adaptation of sexual networking guidance and interventions to mitigate HIV-related disparities in communities of color.

Leveraging A Digital Pill System to Understand Prevention-Effective Adherence to Oral Hiv Pre-Exposure Prophylaxis Among Men Who Have Sex with Men with Substance Use.

Daily oral pre-exposure prophylaxis (PrEP) is highly effective for HIV prevention, though efficacy depends on adherence. Digital pill systems (DPS) can enable direct, real-time adherence measurement. HIV-negative men who have sex with men (MSM) with substance use (excluding alcohol) utilized a DPS over 90 days and completed weekly surveys reporting sexual activity, condom use, and substance use. Responses indicating (1) any sexual activity and substance use or (2) condomless anal intercourse (CAI) in the prior week were categorized as high risk for HIV acquisition. PrEP adherence data for the 7-day period preceding each response was dichotomized as ≤ 3 and ≥ 4 doses/week, indicating prevention-effective adherence, and compared by HIV risk level. Thirteen MSM were analyzed (median age: 32). Of 113 surveys, 48.7% indicated high HIV risk, with 12.4% reporting CAI alone, 16.8% any sexual activity and substance use, and 19.5% both CAI and substance use. Weekly mean PrEP adherence was 90.3% (6.3 of 7 doses/week), with ≥ 4 doses/week recorded during 92.0% of weeks. The proportion of participants with ≥ 4 recorded doses/week was 88.9% during weeks with CAI alone, 89.5% during weeks with any sexual activity and substance use, 92.0% during weeks with both CAI and substance use, and 92.8% during lower risk weeks. Participants ingested ≥ 4 doses/week during 89.1% of all high-risk weeks and 94.8% of low-risk weeks. Overall, participants maintained high levels of PrEP adherence while engaging in HIV risk behaviors. DPS can be deployed concurrently with data collection tools to assess ingestion patterns during periods of elevated risk.

"What if I got rejected by the girl? I would rather stop the pills": barriers and facilitators of adherence to antiretroviral therapy for emerging adults aged 18-29 living with HIV in Zimbabwe.

Emerging adults aged 18-29 have high rates of viral non-suppression, and poorer adherence to ART when compared to older adults. Semi-structured interviews were conducted with 24 emerging adults in Zimbabwe who had a recent history of viral non-suppression, to explore barriers and facilitators of adherence to ART. Interviews were coded using inductive thematic analysis. The mean age of participants was 23, 65% were male, and 79% reported acquiring HIV at birth. Twelve barriers to adherence were identified. Hiding HIV status due to the possible negative consequences of disclosure had a significant impact on adherence to ART. This was particularly important for emerging adults navigating starting intimate relationships. Being away from home, poverty, poor mental health, isolation, significant life events, alcohol, health systems barriers, and stigma were reported as barriers to adherence. Support from peers and family after disclosure of HIV status, phone-based reminders, problem-solving strategies to adhere, knowing others living with HIV, acted as facilitators to adherence to ART. Beliefs about medicines and relationships with health care providers acted as both barriers and facilitators to adherence. Interventions to reduce stigma, foster peer support, and therapy for common mental disorders could facilitate emerging adults aged 18-29 to adhere to ART.

The salience of structural barriers and behavioral health problems to ART adherence in people receiving HIV primary care in South Africa.

Multilevel factors (individual and structural) influence adherence to antiretroviral therapy, particularly in high HIV prevalence areas such as South Africa. The present study examined the relative importance of structural barriers to HIV care and behavioral health factors, depression and alcohol use, in Khayelitsha, Cape Town, South Africa. People receiving HIV care in six primary care clinics in Khayelitsha (N = 194) completed the Center for Epidemiologic Studies Depression Scale, the Alcohol Use Disorders Identification Test, the Structural Barriers to Medication Taking questionnaire, and a qualitative rating of past-two-week adherence. Correlations were employed to examine associations among these variables, and hierarchical regression analysis was used to examine the unique effects of structural barriers over and above depression and alcohol use as predictors of adherence. Participants were primarily Black South African (99%) women (83%), and 41 years old on average. All four variables were significantly correlated. The hierarchical regression analysis showed that among behavioral health predictors, alcohol use alone significantly predicted ART adherence (b = -.032, p = .002). When structural barriers was added to the model, it was the only significant unique predictor of ART adherence (b = -1.58, p < .001). Findings highlight the need to consider structural vulnerabilities in HIV care in South Africa when developing behavioral health interventions.

Associations between alcohol and cigarette use and type 1 and 2 myocardial infarction among people with HIV.

OBJECTIVES: People with HIV have a higher risk of myocardial infarction (MI) than the general population, with a greater proportion of type 2 MI (T2MI) due to oxygen demand-supply mismatch compared with type 1 (T1MI) resulting from atherothrombotic plaque disruption. People living with HIV report a greater prevalence of cigarette and alcohol use than do the general population. Alcohol use and smoking as risk factors for MI by type are not well studied among people living with HIV. We examined longitudinal associations between smoking and alcohol use patterns and MI by type among people living with HIV. DESIGN AND METHODS: Using longitudinal data from the Centers for AIDS Research Network of Integrated Clinical Systems cohort, we conducted time-updated Cox proportional hazards models to determine the impact of smoking and alcohol consumption on adjudicated T1MI and T2MI. RESULTS: Among 13 506 people living with HIV, with a median 4 years of follow-up, we observed 177 T1MI and 141 T2MI. Current smoking was associated with a 60% increase in risk of both T1MI and T2MI. In addition, every cigarette smoked per day was associated with a 4% increase in risk of T1MI, with a suggestive, but not significant, 2% increase for T2MI. Cigarette use had a greater impact on T1MI for men than for women and on T2MI for women than for men. Increasing alcohol use was associated with a lower risk of T1MI but not T2MI. Frequency of heavy episodic alcohol use was not associated with MI. CONCLUSIONS: Our findings reinforce the prioritization of smoking reduction, even without cessation, and cessation among people living with HIV for MI prevention and highlight the different impacts on MI type by gender.

Suicidal Ideation Disparities Among Transgender and Gender Diverse Compared to Cisgender Community Health Patients.

BACKGROUND: Transgender and gender diverse (TGD) individuals experience more severe psychological distress and may be at higher risk for suicide compared to cisgender individuals. The existing literature largely consists of small-sample studies that do not assess subgroup differences. OBJECTIVE: To examine rates of self-reported suicidal ideation among four TGD groups compared to cisgender individuals. DESIGN: Data were extracted from the electronic health records of patients receiving primary care at a community health center specializing in sexual and gender minority health. A logistic regression was used to examine the relationship between sociodemographic variables and the presence of current suicidal ideation. PARTICIPANTS: 29,988 patients receiving care at a community health center in Northeastern US between 2015 and 2018. MAIN MEASURES: Demographic questionnaire, 9-item Patient Health Questionnaire KEY RESULTS: Younger age, sexual and gender minority identity, and public/grants-based insurance were associated with significantly higher odds of suicidal ideation. Relative to cisgender men, transgender men (OR=2.08; 95% CI=1.29-3.36; p=.003), transgender women (OR=3.08; 95% CI=2.05-4.63; p<.001), nonbinary (NB) individuals assigned male at birth (AMAB; OR=3.55; 95% CI=1.86-6.77; p<001), and NB individuals assigned female at birth (AFAB; OR=2.49; 95% CI=1.52-4.07; p<001) all endorsed significantly higher odds of current suicidal ideation, controlling for age, race, ethnicity, sexual orientation, and insurance status. Larger proportions of transgender women (23.6%) and NB AMAB individuals (26.7%) reported suicidal ideation not only compared to cisgender men (6.1%) and women (6.6%), but also compared to transgender men (17.4%; χ2[5, n=25,959]=906.454, p<0.001). CONCLUSIONS: TGD patients were at significantly increased risk of suicidal ideation, even after accounting for age, race, ethnicity, sexual orientation, and insurance status. Findings suggest distinct risk profiles by assigned sex at birth. Consistent assessment of and intervention for suicidal ideation should be prioritized in settings that serve TGD patients.

Posttraumatic Cognitions and Condomless Sex Among Men Who Have Sex with Men (MSM) with a History of Childhood Sexual Abuse: The Role of Avoidance Coping.

This study explicated associations between trauma-related cognitions and condomless sex, examining avoidance coping style and behavior (i.e., substance use) as intermediate variables, among a group disproportionately affected by both trauma and HIV. Two hundred and ninety HIV-negative MSM with a history of childhood sexual abuse (CSA) completed a cross-sectional psychosocial battery. Trauma-related cognitions were positively associated with more acts of condomless sex. Indirect associations on condomless sex were driven by avoidance coping, but not substance use. Findings indicate a need to address trauma-related cognitions and avoidance coping within interventions for reducing HIV risk among MSM with a history of CSA.

Intersecting Relationships of Psychosocial and Structural Syndemic Problems Among People with HIV in South Africa: Using Network Analysis to Identify Influential Problems.

In South Africa, little is known about interrelationships between syndemic problems among people with HIV (PWH). A better understanding of syndemic problems may yield important information regarding factors amenable to mitigation. We surveyed 194 PWH in Khayelitsha, outside of Cape Town, South Africa. We used network analysis to examine the frequency of 10 syndemic problems and their interrelationships. Syndemic problems among PWH in South Africa were common; 159 (82.8%) participants reported at least 2 co-occurring syndemic problems and 90 (46.9%) endorsed 4 or more. Network analysis revealed seven statistically significant associations. The most central problems were depression, substance use, and food insecurity. Three clusters of syndemics were identified: mood and violence; structural factors; and behavioral factors. Depression, substance use, and food insecurity commonly co-occur among PWH in sub-Saharan Africa and interfere with HIV outcomes. Network analysis can identify intervention targets to potentially improve HIV treatment outcomes.

RESUMEN: En Sudáfrica, poco se sabe sobre interrelaciones entre problemas sindémicos entre personas con VIH (PCV). Un major entendimiento de los problemas sindémicos puede arrojar información importante sobre los factores susceptibles de mitigación. Utilizamos el análisis de redes para examinar la frecuencia de 10 problemas sindémicos y sus interrelaciones. Problemas sindémicos entre PCV en Sudáfrica eran communes; 159 (82.8%) participantes presentaron al menos 2 problemas sindémicos concurrentes y 90 (46.9%) presentaron 4 o más. El análisis de red reveló siete asociaciones estadísticamente significativas. Los problemas más centrales fueron la depresión, el uso de sustancias y la inseguridad alimentaria. Se indetificaron tres grupos de sindemias: estado de ánimo y violencia; factores estructurales; y factores de comportamiento. La depresión, el uso de sustancias y la inseguridad alimentaria comúnmente ocurren simultáneamente entre las PCV en el África subsahariana e interfieren con los resultados del VIH. El análisis de redes puede identificar objetivos de intervención para potencialmente mejorar los resultados del tratamiento del VIH.

Cognitive Performance, as well as Depression, Alcohol Use, and Gender, predict Anti-Retroviral Therapy Adherence in a South African Cohort of People with HIV and Comorbid Major Depressive Disorder.

Depression and cognitive impairment, which commonly coexist in people with HIV (PWH), have been identified as potential barriers to optimal antiretroviral therapy (ART) adherence. We investigated associations between cognitive performance, depression (as well as other sociodemographic, psychosocial and psychiatric variables) and ART adherence in a South African cohort of PWH with comorbid major depressive disorder (MDD). Cognitive performance and ART adherence were assessed at two time points 8 months apart (Nbaseline = 105, Nfollow-up = 81). Adherence was indicated by self-report, objective measures (Wisepill usage and plasma tenofovir-diphosphate levels), and HIV viral suppression. Mixed-effects regression models examined associations across both time points. Univariate models detected no significant associations between cognitive performance (globally and within-domain) and ART adherence. Multivariate modelling showed increased depression severity (ß = - 0.54, p < 0.001) and problematic alcohol use (ß = 0.73, p = 0.015) were associated with worse adherence as measured subjectively. Being female (OR 0.27, p = 0.048) and having better global cognitive performance (OR 1.83, p = 0.043) were associated with better adherence as indicated by viral suppression. This study identifies poor global cognitive performance, as well as depression and problematic alcohol use, as potential barriers to optimal ART adherence in PWH and comorbid MDD. Hence, clinicians could consider assessing for cognitive deficits, depression, and problematic alcohol use, and should endeavour to provide the appropriate support so as to improve adherence.

Chronic pain and substance use disorders among older sexual minority men living with HIV: Implications for HIV disease management across the HIV care continuum.

HIV continues to be a critical health issue for sexual minority men (SMM) in the USA. Chronic pain is common in individuals with HIV, including older SMM, and is associated with substance use behaviors. This cross-sectional study sought to address a gap in the literature by characterizing interrelationships among chronic pain, substance use disorders (SUDs), medication adherence, and engagement in HIV care among older (≥50) SMM living with HIV and chronic pain (N = 63). The unadjusted relationship between an opioid use disorder and pain indicated that participants with an opioid use disorder reported higher pain ratings than those without. Presence of alcohol use disorder was significantly associated with missed HIV-care appointments due to chronic pain or substance use, showing that individuals with an alcohol use disorder reported more missed appointments in the past year. Higher pain was significantly associated with the same missed appointments variable, such that those reporting higher pain ratings also reported more missed appointments in the past year. These findings provide preliminary evidence of the interrelationships among chronic pain, SUDs, and engagement in HIV care among older SMM living with HIV and suggest that pain management in this population might support fuller engagement in HIV care.

Perspectives of Young Men Who Have Sex with Men on PrEP Adherence and Peer Navigation: A Qualitative Study.

HIV incidence is disproportionately high among young cisgender men who have sex with men (YMSM), but YMSM are less likely than adults to use HIV pre-exposure prophylaxis (PrEP). Among YMSM living with HIV, peer navigation programs have been effective in linkage to care and increasing medication adherence; such programs may aid HIV-uninfected YMSM in overcoming barriers to engagement in PrEP care. We conducted 32 semi-structured qualitative interviews at a community health center in Massachusetts, USA, specializing in sexual and gender minority health with four sub-groups of YMSM who: (1) had never discussed PrEP with a medical provider, (2) had discussed PrEP with a medical provider but declined a prescription, (3) were prescribed PrEP and have sub-optimal adherence (taking fewer than 4 pills per week), and (4) were prescribed PrEP and were optimally adherent. Domains addressed in the interviews included knowledge of PrEP and HIV prevention, barriers and facilitators to PrEP adherence, and attitudes toward peer navigation for PrEP. Interviews were transcribed and coded using thematic analysis methodology. Multiple themes emerged from the interviews, including finding that perceived costs, anticipated stigma, sexual activity, and relationship status influence PrEP uptake and adherence; establishing pill-taking routines is an important adherence facilitator; and peer navigators could offer benefits for PrEP adherence.

Associations Between Health Insurance Coverage with HIV Detection and Prevention Behaviors Among Individuals with Undiagnosed HIV or at Increased Risk for HIV Infection in the USA.

BACKGROUND: Improving HIV detection and prevention remains a critical public health initiative that requires policy-based solutions. This study sought to compare HIV detection/prevention behaviors before and after healthcare reform in Massachusetts, USA, among heterosexually active persons - the group with the highest reported number of undiagnosed HIV cases. The current study sought to (1) characterize differences in insurance coverage and HIV detection/prevention behaviors between cycles 1 (2006) to 5 (2019); (2) evaluate socio-demographic disparities in insurance coverage accounting for cycle; and (3) evaluate associations between health insurance coverage and HIV detection/prevention behaviors accounting for cycle and socio-demographics. METHODS: This is a secondary analysis of the National HIV Behavioral Surveillance (NHBS) project: Boston HET cycle (i.e., made up of heterosexually active persons living in the Boston area) data. Descriptive, bivariate (e.g., chi-square), and multiple logistic and negative binomial loglink regression analyses were conducted. RESULTS: In chi-square analyses with post hoc Bonferroni tests, the proportion of participants with current health insurance significantly increased from cycle 1 (77%) to cycle 2 (95%), p < .001. In the regression models that controlled for NHBS cycle, 1-year change in age (adjusted odds ratio [aOR] = 1.03, 95% confidence interval [CI] = 1.02, 1.05), female gender (aOR = 3.41, 95% CI = 2.48, 4.69), and change in education category (aOR = 1.19, 95% CI = 1.02, 1.39) were associated with a higher likelihood of having health insurance. In regression models that controlled for cycle, age, gender, and education, participants with health insurance were more likely than those without insurance to report seeing a medical provider in the past year (aOR = 3.49, 95% CI = 2.32, 4.66), ever having an HIV test (aOR = 1.52, 95% CI = 0.35, 2.69) and more frequent HIV testing in the past 2 years (incidence rate ratio [IRR] = 1.44, 95% = 1.14, 1.82). Participants with health insurance did not differ from those without insurance in number of vaginal condomless sex partners (IRR = 1.16, 95% CI = 0.95, 1.41) but did report more condomless anal sex partners in the past year (IRR = 1.97, 95% CI = 1.46, 2.65). CONCLUSIONS: This study demonstrates how health insurance coverage is positively associated with HIV detection and prevention relevant to both US and international efforts to end the HIV epidemic.

Tobacco smoking and binge alcohol use are associated with incident venous thromboembolism in an HIV cohort.

BACKGROUND: People with HIV (PWH) are at increased risk of cardiovascular comorbidities and substance use is a potential predisposing factor. We evaluated associations of tobacco smoking and alcohol use with venous thromboembolism (VTE) in PWH. METHODS: We assessed incident, centrally adjudicated VTE among 12 957 PWH within the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) cohort between January 2009 and December 2018. Using separate Cox proportional hazards models, we evaluated associations of time-updated alcohol and cigarette use with VTE, adjusting for demographic and clinical characteristics. Smoking was evaluated as pack-years and never, former, or current use with current cigarettes per day. Alcohol use was parameterized using categorical and continuous alcohol use score, frequency of use, and binge frequency. RESULTS: During a median of 3.6 years of follow-up, 213 PWH developed a VTE. One-third of PWH reported binge drinking and 40% reported currently smoking. In adjusted analyses, risk of VTE was increased among both current (HR: 1.44, 95% CI: 1.02-2.03) and former (HR: 1.44, 95% CI: 0.99-2.07) smokers compared to PWH who never smoked. Additionally, total pack-years among ever-smokers (HR: 1.10 per 5 pack-years; 95% CI: 1.03-1.18) was associated with incident VTE in a dose-dependent manner. Frequency of binge drinking was associated with incident VTE (HR: 1.30 per 7 days/month, 95% CI: 1.11-1.52); however, alcohol use frequency was not. Severity of alcohol use was not significantly associated with VTE. CONCLUSIONS: Current smoking and pack-year smoking history were dose-dependently associated with incident VTE among PWH in CNICS. Binge drinking was also associated with VTE. Interventions for smoking and binge drinking may decrease VTE risk among PWH.

Cognitive performance in a South African cohort of people with HIV and comorbid major depressive disorder.

Cognitive performance in people with HIV (PWH) may be affected by brain injury attributable to the infection itself, by other medical and psychiatric comorbidities (including major depressive disorder; MDD), and by psychosocial factors (e.g., education, food insecurity). We investigated effects of these variables on cognitive performance in a South African cohort of PWH with comorbid MDD and incomplete adherence to antiretroviral therapy (ART). We also examined (a) associations of depression severity with cognitive performance, and (b) whether improvement in depression led to improved cognitive performance. Participants (N = 105) completed baseline neuropsychological, psychiatric, and sociodemographic assessments. Subsequently, 33 were assigned to a cognitive-behavioural therapy for ART adherence and depression (CBT-AD) and 72 to standard-of-care treatment. Eight months post-baseline, 81 (nCBT-AD = 29) repeated the assessments. We investigated (a) baseline associations between sociodemographic, medical, and psychiatric variables and cognitive performance, (b) whether, from baseline to follow-up, depression and cognitive performance improved significantly more in CBT-AD participants, and (c) associations between post-intervention improvements in depression and cognitive performance. At baseline, less education (ß = 0.62) and greater food insecurity (ß = -0.20) predicted poorer overall cognitive performance; more severe depression predicted impairment in the attention/working memory domain only (ß = -0.25). From baseline to follow-up, depression decreased significantly more in CBT-AD participants (p = .017). Improvement over time in depression and cognitive performance was not significantly associated except in the attention/working memory domain (p = .026). Overall, factors associated with cognitive performance were unrelated to brain injury. We conclude that clinicians examining PWH presenting with cognitive difficulties must assess depression, and that researchers investigating cognitive impairment in PWH must collect information on psychosocial factors.

Ingestible Electronic Sensors for Monitoring Real-time Adherence to HIV Pre-exposure Prophylaxis and Antiretroviral Therapy.

PURPOSE OF REVIEW: This review summarizes the recent advancements and future directions of digital pill systems (DPS) - which utilize ingestible sensors to directly measure medication ingestion events in real-time - in the context of HIV prevention and treatment. RECENT FINDINGS: Two DPS are cleared by the US Food and Drug Administration. The bioequivalence and stability of digitized pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) have been established, and pilot studies have demonstrated the feasibility and acceptability of using DPS for PrEP and ART adherence measurement. Important bioethical and implementation considerations have been identified for future clinical trials. Continued technological advancement may reduce barriers to use, and integration of DPS into behavioral interventions may facilitate adherence improvement efforts. DPS represent an innovative tool for PrEP and ART adherence measurement. Future work will optimize the technology to reduce operational barriers. DPS have significant potential for expansion across a diverse array of diseases, though key bioethical considerations must be examined prior to large-scale implementation.

Age and Year of HIV Diagnosis are Associated with Perceptions of Discrimination and Internalized Stigma Among Sexual Minority Men Who Use Substances.

Discrimination and internalized stigma are barriers to engagement in HIV self-care among men who have sex with men (MSM) living with HIV. However, differences in perceptions of discrimination and internalized stigmas by age, year of HIV-diagnosis, and race are poorly understood. We assessed differences in reported discrimination related to HIV, race, sexual orientation, and substance use and internalized stigmas among 202 MSM living with HIV who use substances. Younger participants reported higher levels of all types of discrimination and internalized stigmas (p-values < 0.001-0.030). Those diagnosed after the advent of antiretrovirals reported higher levels of discrimination related to HIV, sexual orientation, and substance use, as well as internalized stigma related to HIV and substance use (p-values 0.001-0.049). We explored perceived community HIV stigma, which accounted for associations involving age and year of diagnosis. Age, year of diagnosis, and race should be considered when assessing and intervening with stigma.

RESUMEN: La discriminación y el estigma internalizado son barreras para el autocuidado del VIH en hombres que tienen sexo con hombres (HSH) que viven con VIH. Sin embargo, se conoce poco acerca de las diferencia que existe en la percepción de discriminación y estigma internalizado por edad, año de diagnóstico del VIH y raza. Evaluamos diferencias en torno a discriminación relacionada con el VIH reportada, raza, orientación sexual y uso de sustancias además del estigmas internalizado en 202 HSH que viven con VIH y usan sustancias. Los participantes más jóvenes reportaron los niveles más altos de cualquier forma de discriminación y estigma internalizado (valores de p <.001 - .030). Los diagnosticados después de 1996 reportaron niveles más altos de discriminación relacionada con el VIH, la orientación sexual y el uso de sustancias, así como el estigma internalizado relacionado con el VIH y uso de sustancias (valores de p .001 - 049). Para comprender mejor estas diferencias, exploramos el impacto del estigma de VIH comunitario percibido que representó la mayoría de las asociaciones relacionadas con la edad y el año del diagnóstico. Cuando se evalúan las perceptiones de discriminación y estigma internalizado, la edad, el año del diagnóstico y la raza deben ser tomados en cuenta.

"I'd feel like someone was watchin' me watching for a good reason": perceptions of data privacy, access, and sharing in the context of real-time PrEP adherence monitoring among HIV-negative MSM with substance use.

Once-daily oral tenofovir/emtricitabine is highly effective as pre-exposure prophylaxis (PrEP) against HIV but is dependent on adherence, which may be challenging for men who have sex with men (MSM) and use substances. Digital pill systems (DPS) permit the direct, real-time measurement of adherence, though user perceptions of data privacy in this context are unknown. Thirty prospective DPS users - HIV-negative MSM with non-alcohol substance use - completed in-depth qualitative interviews exploring preferences around privacy, access, and sharing of DPS adherence data. Participants discussed some concerns about the impact of DPS use on personal privacy, and emphasized the need for robust data protections in the technology. Participants were interested in having on-demand access to their adherence data, and were most willing to share data with primary care providers and long-term relationship partners. Future investigations exploring bioethical frameworks around DPS use are warranted, and user preferences should inform best practices for protecting DPS data.

Real-World User Experiences with a Digital Pill System to Measure PrEP Adherence: Perspectives from MSM with Substance Use.

Once-daily oral pre-exposure prophylaxis (PrEP) is highly effective for preventing HIV transmission, but adherence can be challenging for men who have sex with men (MSM) who use substances. A novel method for directly measuring ingestion events is a digital pill system (DPS), which comprises an ingestible radiofrequency emitter that signals a wearable Reader device upon PrEP ingestion, relaying ingestion data to a wearable Reader device and then to a smartphone application. Qualitative interviews were conducted with 15 MSM with non-alcohol substance use following an open-label pilot demonstration trial involving use of the DPS to measure PrEP adherence for 90 days. The purpose of this qualitative investigation was to understand overall user experiences and potential barriers and facilitators to using the DPS to measure PrEP adherence among MSM. The DPS was largely perceived as acceptable, novel, and valuable, with most participants reporting that the system was easily integrated into their daily routines. Technological and design factors, especially related to the wearable Reader, impacted participants' interest in using the technology long-term; several suggested improvements were discussed.Trial Registration ClinicalTrials.gov: NCT03842436.

The impact of depression and post-traumatic stress symptoms on physical health perceptions and functional impairment among sexual minority men living with HIV with histories of trauma.

Mental health symptoms may compromise health-related quality of life (HRQOL), including among men who have sex with men (MSM) living with HIV, who experience high rates of trauma and other stressors. This study sought to examine the relative contributions of post-traumatic stress disorder (PTSD) symptoms, depression symptoms, and biological indices of HIV disease status on HRQOL in this population. Participants were 79 MSM with HIV (49% White; 35% Black; 8% Hispanic/Latinx) with trauma histories (52% met current PTSD diagnostic criteria). HRQOL outcomes were general perceptions of health (0-100 visual analog scale) and functional disability (WHODAS 2.0). Dominance analysis was applied to examine the relative share of variance in these outcomes accounted for by PTSD symptom severity, depression symptom severity, viral suppression status, and CD4 count. Depression symptom severity accounted for 70% and 92% of variance in perceived health, respectively, across models (p's < 0.05). Both PTSD symptom severity (45%) and depression symptom severity (43%) scores also accounted for significant variance in functional disability (p's < 0.05). Medical indices of HIV disease progression did not explain significant variance in HRQOL in any model. A trauma-informed approach may aid clinicians in interpreting reports of health and physical functioning in MSM with HIV.