A Systematic Review of Intervention Studies That Address HIV-Related Stigmas Among US Healthcare Workers and Health Systems: Applying a Theory-Based Ontology to Link Intervention Types, Techniques, and Mechanisms of Action to Potential Effectiveness.

BACKGROUND: To end the HIV epidemic, we need to better understand how to address HIV-related stigmas in healthcare settings, specifically the common theoretical bases across interventions so that we can generalize about their potential effectiveness. PURPOSE: We describe theory-based components of stigma interventions by identifying their functions/types, techniques, and purported mechanisms of change. METHODS: This systematic review examined studies published by April 2021. We applied a transtheoretical ontology developed by the Human Behaviour Change Project, consisting of 9 intervention types (ITs), 93 behavior change techniques (BCTs), and 26 mechanisms of action (MOAs). We coded the frequency and calculated the potential effectiveness of each IT, BCT, and MOA. We evaluated study quality with a 10-item adapted tool. RESULTS: Among the nine highest quality studies, indicated by the use of an experimental design, the highest potentially effective IT was "Persuasion" (i.e. using communication to induce emotions and/or stimulate action; 66.7%, 4/6 studies). The highest potentially effective BCTs were "Behavioral practice/rehearsal" (i.e. to increase habit and skill) and "Salience of consequences" (i.e. to make consequences of behavior more memorable; each 100%, 3/3 studies). The highest potentially effective MOAs were "Knowledge" (i.e. awareness) and "Beliefs about capabilities" (i.e. self-efficacy; each 67%, 2/3 studies). CONCLUSIONS: By applying a behavior change ontology across studies, we synthesized theory-based findings on stigma interventions. Interventions typically combined more than one IT, BCT, and MOA. Practitioners and researchers can use our findings to better understand and select theory-based components of interventions, including areas for further evaluation, to expedite ending the HIV epidemic.

HIV and Intersectional Stigma Reduction Among Organizations Providing HIV Services in New York City: A Mixed-Methods Implementation Science Project.

Stigma remains a pervasive barrier to Ending the HIV Epidemic (EHE) in New York City (NYC). As part of an EHE implementation science planning process, we mapped multi-level HIV-related stigma-reduction activities, assessed their evidence base, and characterized barriers and facilitators. We interviewed and surveyed a convenience sample of 27 HIV prevention and/or treatment services organizations in NYC, March-August, 2020, using an embedded mixed-methods design. The greatest facilitators of stigma reduction included integration of health services, hiring staff who represent the community, and trainings. Intersecting stigmas were primarily addressed through the integration of HIV with mental health and substance use services. Barriers were multilevel, with organizational structure and capacity most challenging. A strong base of stigma-reduction activities was utilized by organizations, but intersectional frameworks and formal evaluation of activities' impact on stigma were lacking. Effectiveness-implementation hybrid research designs are needed to evaluate and increase the uptake of effective stigma-reduction approaches in NYC.

Sexual Stigma Patterns Among Nigerian Men Who Have Sex with Men and Their Link to HIV and Sexually Transmitted Infection Prevalence.

Sexual stigma facilitates the spread of HIV and sexually transmitted infections (STIs) but little is known about stigma affecting Nigerian men who have sex with men (MSM). We assessed patterns of sexual stigma across Nigerian MSM and their relationship to HIV and STIs. Data were collected from the TRUST/RV368 Study, a prospective cohort of 1480 Nigerian MSM enrolled from March 2013 to February 2016 using respondent driven sampling. Structural equation modeling was utilized to assess the association between stigma classes and HIV and STI prevalence, adjusting for participants' characteristics. A dose-response association was found between stigma class and HIV prevalence (27, 40, 55%, overall χ2 p < 0.001) and STI prevalence (15, 21, 24%, overall χ2 p = 0.011). These data suggest that stigma mitigation strategies, combined with increased engagement of MSM and retention in the HIV care continuum, need to be a component of interventions focused on reducing HIV transmission risks among MSM in Nigeria.

The Synergistic Impact of Sexual Stigma and Psychosocial Well-Being on HIV Testing: A Mixed-Methods Study Among Nigerian Men who have Sex with Men.

Although sexual stigma has been linked to decreased HIV testing among men who have sex with men (MSM), mechanisms for this association are unclear. We evaluated the role of psychosocial well-being in connecting sexual stigma and HIV testing using an explanatory sequential mixed methods analysis of 25 qualitative and 1480 quantitative interviews with MSM enrolled in a prospective cohort study in Nigeria from March/2013-February/2016. Utilizing structural equation modeling, we found a synergistic negative association between sexual stigma and suicidal ideation on HIV testing. Qualitatively, prior stigma experiences often generated psychological distress and perceptions of feeling unsafe, which decreased willingness to seek services at general health facilities. MSM reported feeling safe at the MSM-friendly study clinic but still described a need for psychosocial support services. Addressing stigma and unmet mental health needs among Nigerian MSM has the potential to improve HIV testing uptake.

Serosorting and Sexual Risk for HIV Infection at the Ego-Alter Dyadic Level: An Egocentric Sexual Network Study Among MSM in Nigeria.

The objective of this egocentric network study was to investigate engagement in serosorting by HIV status and risk for HIV between seroconcordant and serodiscordant ego-alter dyads. Respondent-driving sampling was used to recruit 433 Nigerian men who have sex with men (MSM) from 2013 to 2014. Participant (ego) characteristics and that of five sex partners (alters) were collected. Seroconcordancy was assessed at the ego level and for each dyad. Among 433 egos, 18 % were seroconcordant with all partners. Among 880 dyads where participants knew their HIV status, 226 (25.7 %) were seroconcordant, with 11.7 % of HIV positive dyads seroconcordant and 37.0 % of HIV negative dyads seroconcordant. Seroconcordant dyads reported fewer casual sex partners, less partner concurrency, and partners who had ever injected drugs, but condom use did not differ significantly. Serosorting may be a viable risk reduction strategy among Nigerian MSM, but awareness of and communication about HIV status should be increased. Future studies should assess serosorting on a partner-by-partner basis.

Just text me! Texting sexually transmitted disease clients their test results in Florida, February 2012-January 2013.

BACKGROUND: In response to increasing sexually transmitted diseases (STDs), diminishing resources, and delays in prompt treatment, the Florida STD Program began providing test results through text message in 2011. The aims of the evaluation of the first year of the project were to assess (1) client uptake and completion of texting and (2) whether texting was associated with a shorter treatment time frame. METHODS: Clients screened for STDs at clinics in 3 Florida counties were offered the option to receive test results through coded texts. A positive code prompted clients to call back for treatment information. Texting was conducted through the state's surveillance application, Patient Reporting Investigation Surveillance Manager (PRISM). Evaluation data on clients who opted in (texters) and clients who did not opt in (nontexters) were retrieved from Patient Reporting Investigation Surveillance Manager and descriptively analyzed. RESULTS: From February 2012 to January 2013, 10,272 clients were offered texting in Clay, Duval, and Seminole counties. Of those offered, 52% opted in. Among texters who were positive and had not been treated (n = 345), 57% called back. Texters received treatment in 5.1 days and nontexters received treatment in 6.7 days (P = 0.036). Texters who called back received treatment 3 days sooner than texters who did not call back (P < 0.001). CONCLUSIONS: Texting offers STD programs an alternative to traditional notification procedures and may be a viable option for STD programs to reduce the use of staff resources and increase timely treatment for clients. In addition, it can be integrated within an existing surveillance database to minimize the burden of the new process.

Social determinants of health analysis makes causal inference and requires analytic epidemiology methods.

The growing emphasis on reducing health disparities and addressing social determinants of health (SDH) has prompted many national and local health agencies to report population health data by SDH measures. However, many agencies rely on descriptive epidemiology methods for such reports and are susceptible to biased findings due to inadequate confounding control. In this brief analytic essay, using the data presented in an HIV Surveillance Report by the Centers for Disease Control and Prevention (CDC), we demonstrated an example of how reporting health outcomes by SDH with descriptive methods could bias the results and conclusions. SDH are causes of health disparities and SDH analysis requires analytic epidemiology methods to ensure valid research results and effective interventions.

Two rotavirus outbreaks caused by genotype G2P[4] at large retirement communities: cohort studies.

BACKGROUND: Outbreaks of rotavirus gastroenteritis in elderly adults are reported infrequently but are often caused by G2P[4] strains. In 2011, outbreaks were reported in 2 Illinois retirement facilities. OBJECTIVE: To implement control measures, determine the extent and severity of illness, and assess risk factors for disease among residents and employees. DESIGN: Cohort studies using surveys and medical chart abstraction. SETTING: Two large retirement facilities in Cook County, Illinois. PATIENTS: Residents and employees at both facilities and community residents with rotavirus disease. MEASUREMENTS: Attack rates, hospitalization rates, and rotavirus genotype. RESULTS: At facility A, 84 of 324 residents (26%) were identified with clinical or laboratory-confirmed rotavirus gastroenteritis (median age, 84 years) and 11 (13%) were hospitalized. The outbreak lasted 7 weeks. At facility B, 90 case patients among 855 residents (11%) were identified (median age, 88 years) and 19 (21%) were hospitalized. The facility B outbreak lasted 9.3 weeks. Ill employees were identified at both locations. In each facility, attack rates seemed to differ by residential setting, with the lowest rates among those in more separated settings or with high baseline level of infection control measures. The causative genotype for both outbreaks was G2P[4]. Some individuals shed virus detected by enzyme immunoassay or genotyping reverse transcription polymerase chain reaction for at least 35 days. G2P[4] was also identified in 17 of 19 (89%) samples from the older adult community but only 15 of 40 (38%) pediatric samples. LIMITATION: Medical or cognitive impairment among residents limited the success of some interviews. CONCLUSION: Rotavirus outbreaks can occur among elderly adults in residential facilities and can result in considerable morbidity. Among older adults, G2P[4] may be of unique importance. Health professionals should consider rotavirus as a cause of acute gastroenteritis in adults. PRIMARY FUNDING SOURCE: None.

An Exploratory Study to Describe Transgender People with HIV Who Accessed Medicaid and Their Viral Suppression Over Time in New York City, 2013-2017.

Purpose: Although HIV surveillance contains information on HIV outcomes among transgender persons with HIV (TPWH), it does not include other important data, for example, gender-affirming health care, which may influence viral suppression (VS). We describe TPWH accessing Medicaid and the association of gender-affirming surgery with VS. Methods: Through matching Medicaid claims with HIV registry data, a cohort of previously identified TPWH in Medicaid was compared to cisgender women and men in terms of VS in 2013-2017 in New York City. Medicaid claims were used to identify TPWH who obtained gender-affirming surgery (e.g., chest, genital surgeries). We described the VS of those who had surgery and examined temporal trends in VS pre- and postsurgery and by surgery type. Results: 1730 TPWH were enrolled in Medicaid and in HIV care in 2013-2017. Overall for VS at last laboratory, TPWH in Medicaid had lower VS (76.0%) than cisgender women (80.4%) and men (83.3%). The exception was the 185 TPWH who obtained gender-affirming surgery (86.5%). Among 160 TPWH in Medicaid who obtained gender-affirming surgery and achieved VS, VS increased presurgery (66.3% 2 years prior, 76.9% 1 year prior) and remained high 1 year after (86.3%) and 2 years after (87.7%) (the last percentage is only among those who had surgery before 2017, N=81). Conclusion: Gender-affirming surgery may be an important motivator to becoming virally suppressed and was associated with sustained high VS, which can lead to improved survival and quality of life. Medicaid and other insurers should consider improving access to gender-affirming surgery among TPWH.

"Building that strong energy": An exploration of stigma coping strategies among sexual and gender minorities in Nigeria.

Sexual and gender minority stigma (SGM stigma) affecting Nigerian sexual and gender minorities (SGM) is associated with suboptimal HIV outcomes, and one mechanism found to explain the relationship is suicidal ideation. A better understanding of coping strategies may help mitigate the harmful impacts of SGM stigma. Interviews of 25 SGM from Abuja, Nigeria participating in the [Blinded for Review] study were thematically analyzed in regards to how they coped with SGM stigma. Four coping themes emerged: avoidant behaviors, self-monitoring so as to not attract stigma, seeking support and safe spaces to be themselves, and empowerment and self-acceptance through a process of cognitive change. They utilized multiple coping strategies, often believing that stigma could be avoided through the right actions and a masculine appearance. Multi-level and person-centered interventions that increase safety and support, facilitate resiliency, and improve mental health and engagement in HIV programming could mitigate the effects of SGM stigma and coping responses of isolation, blame, and mental health stressors among Nigerian SGM.

Sexually transmitted infection testing of adult film performers: is disease being missed?

BACKGROUND: Undiagnosed sexually transmitted infections (STIs) may be common in the adult film industry because performers frequently engage in unprotected oral and anal intercourse, STIs are often asymptomatic, and the industry relies on urine-based testing. METHODS: Between mid-May and mid-September 2010, a consecutive sample of adult film industry performers recruited from a clinic in Los Angeles, California, that provides medical care to performers was offered oropharyngeal, rectal, and urogenital testing for Gonorrhea, and rectal and urogenital testing for Chlamydia. RESULTS: During the 4-month study period, 168 participants were enrolled: 112 (67%) were female and 56 (33%) were male. Of the 47 (28%) who tested positive for Gonorrhea and/or Chlamydia, 11 (23%) cases would not have been detected through urogenital testing alone. Gonorrhea was the most common STI (42/168; 25%) and the oropharynx the most common site of infection (37/47; 79%). Thirty-five (95%) oropharyngeal and 21 (91%) rectal infections were asymptomatic. Few participants reported using condoms consistently while performing or with their personal sex partners. CONCLUSIONS: Adult film industry performers had a high burden of STIs. Undiagnosed asymptomatic rectal and oropharyngeal STIs were common and are likely reservoirs for transmission to sexual partners inside and outside the workplace. Performers should be tested at all anatomical sites irrespective of symptoms, and condom use should be enforced to protect workers in this industry.

Improving Data on the HIV Epidemic in New York City by Identifying Transgender Persons in Medicaid in 2013-2017.

Purpose: Undercounting of transgender people with HIV (PWH) in New York City (NYC) remains prevalent. We sought to improve our ability to accurately enumerate transgender PWH and address their needs for gender-affirming health care. Methods: We enhance previous algorithms used to identify transgender beneficiaries, using diagnoses, prescriptions, and sex at birth from Medicaid claims in 2013-2017. We then matched beneficiaries to individuals diagnosed with HIV in the HIV surveillance registry to identify transgender PWH. Results: Our algorithm identified 6043 transgender persons who accessed Medicaid in 2013-2017, with 1472 (24%) reported to the HIV registry, 1168 (79%) of whom were accurately identified as transgender in the registry. We found 292 transgender persons in the registry that had accessed Medicaid but were not identified by our algorithm, for a total of 6335 transgender persons accessing Medicaid (0.1% of the NYC Medicaid population), including 1764 transgender PWH (28% of transgender persons accessing Medicaid). From 2013 to 2017, there was a 35% increase in transgender persons identified in Medicaid claims using our algorithm. Conclusion: We identified a large number of transgender persons in Medicaid, many of whom were PWH. We saw a sizeable increase over the 5-year period, likely due, in part, to expansion of Medicaid policy to cover gender-affirming health care. Given the high proportion of transgender PWH accessing Medicaid, Medicaid claims data are a valuable source of health information for the transgender population, a group that is often difficult to identify due to issues of underreporting, stigma, reduced access to appropriate care, and misgendering by health care personnel.

Reducing Intersecting Stigmas in HIV Service Organizations: An Implementation Science Model.

BACKGROUND: HIV-related and intersectional stigmas are key barriers for service delivery, but best practices are nascent for addressing them in high-resource and high-burden contexts such as New York City (NYC). The Stigma Reduction and Resilience (STAR) implementation science (IS) Mapping Project in 2020 identified untested stigma reduction efforts in HIV organizations, highlighting the need for an IS framework. SETTING: Organizations providing HIV prevention and/or care in NYC. METHODS: An interagency team determined that IS provides a structured approach for addressing identified gaps in stigma reduction efforts, but defining existing IS concepts and adapting IS frameworks were necessary to facilitate its use. The Implementation Research Logic Model was adapted to empower HIV organizations to use IS to implement stigma reduction. RESULTS: Questions, definitions, and tips were developed to guide, strengthen, and simplify the application of IS within HIV organizations to improve the reduction of HIV and intersecting stigmas. The resulting Stigma Reduction Logic Model incorporates tools for implementers who synthesize each component of the logic model (intervention, determinants, implementation strategies, mechanisms, and outcomes), including a menu of options for selecting stigma reduction interventions and implementation determinants, a checklist to assess organizational readiness for stigma reduction, and an IS terminology guide applied for stigma reduction. CONCLUSIONS: Stigma reduction initiatives and research can use this model to enable implementers, researchers, and HIV organization stakeholders to use the methodology of IS to build consensus for, systematically plan, implement, and evaluate stigma reduction activities relevant to the HIV epidemic. The next step is testing the model's utility.

Pathways from sexual stigma to incident HIV and sexually transmitted infections among Nigerian MSM.

OBJECTIVES: Sexual stigma affecting MSM in Nigeria may be an important driver of HIV and other sexually transmitted infections (STIs), but potential mechanisms through which this occurs are not well understood. This study assessed the contributions of suicidal ideation and sexual risk behaviors to causal pathways between stigma and HIV/STIs. DESIGN: Data were collected from the TRUST/RV368 Study, a prospective cohort of 1480 MSM from Abuja and Lagos, Nigeria. METHODS: Participants enrolled from March 2013 to February 2016 were classified into three stigma subgroups based on a latent class analysis of nine stigma indicators. Path analysis was used to test a model where disclosure led to stigma, then suicidal ideation, then condomless sex with casual sex partners, and finally incident HIV infection and/or newly diagnosed STIs, adjusting the model for age, education, having had female sex partners in the past 12 months, and sex position. Both direct and indirect (mediational) paths were tested for significance and analyses were clustered by city. RESULTS: As stigma increased in severity, the proportion of incident HIV/STI infections increased in a dose-response relationship (low: 10.6%, medium: 14.2%, high 19.0%, P = 0.008). All direct relationships in the model were significant and suicidal ideation and condomless sex partially mediated the association between stigma and incident HIV/STI infection. CONCLUSION: These findings highlight the importance of the meaningful integration of stigma-mitigation strategies in conjunction with mental health services as part of a broader strategy to reduce STI and HIV acquisitions among Nigerian MSM.

High prevalence of HIV, chlamydia and gonorrhoea among men who have sex with men and transgender women attending trusted community centres in Abuja and Lagos, Nigeria.

INTRODUCTION: Sexually transmitted infection (STI) and HIV prevalence have been reported to be higher amongst men who have sex with men (MSM) in Nigeria than in the general population. The objective of this study was to characterize the prevalence of HIV, chlamydia and gonorrhoea in this population using laboratory-based universal testing. METHODS: TRUST/RV368 represents a cohort of MSM and transgender women (TGW) recruited at trusted community centres in Abuja and Lagos, Nigeria, using respondent-driven sampling (RDS). Participants undergo a structured comprehensive assessment of HIV-related risks and screening for anorectal and urogenital Chlamydia trachomatis and Neisseria gonorrhoeae, and HIV. Crude and RDS-weighted prevalence estimates with 95% confidence intervals (CIs) were calculated. Log-binomial regression was used to explore factors associated with prevalent HIV infection and STIs. RESULTS: From March 2013 to January 2016, 862 MSM and TGW (316 in Lagos and 546 in Abuja) underwent screening for HIV, chlamydia and gonorrhoea at study enrolment. Participants' median age was 24 years [interquartile range (IQR) 21-27]. One-third (34.2%) were identified as gay/homosexual and 65.2% as bisexual. The overall prevalence of HIV was 54.9%. After adjusting for the RDS recruitment method, HIV prevalence in Abuja was 43.5% (95% CI 37.3-49.6%) and in Lagos was 65.6% (95% CI 54.7-76.5%). The RDS-weighted prevalence of chlamydia was 17.0% (95% CI 11.8-22.3%) in Abuja and 18.3% (95% CI 11.1-25.4%) in Lagos. Chlamydia infection was detected only at the anorectal site in 70.2% of cases. The RDS-weighted prevalence of gonorrhoea was 19.1% (95% CI 14.6-23.5%) in Abuja and 25.8% (95% CI 17.1-34.6%) in Lagos. Overall, 84.2% of gonorrhoea cases presented with anorectal infection only. Over 95% of STI cases were asymptomatic. In a multivariable model, increased risk for chlamydia/gonorrhoea was associated with younger age, gay/homosexual sexual orientation and higher number of partners for receptive anal sex. HIV infection was associated with older age, female gender identity and number of partners for receptive anal sex. CONCLUSIONS: There is a high burden of infection with HIV and asymptomatic chlamydia and gonorrhoea among MSM and TGW in Nigeria. Most cases would have been missed without anorectal screening. Interventions are needed to target this population for appropriate STI screening and management beginning at a young age.