Hiding in plain sight: highlighting the research gap on access to HIV and other sexual health services for underrepresented gay men in developed Western countries - insights from a scoping review with a focus on Arab men.

BACKGROUND: Strategies pertaining to HIV and sexual health for gay, bisexual, and other men who have sex with men (GBMSM) have shifted focus towards underrepresented subgroups within some developed Western countries. Although emerging research exists on some subgroups, limited attention has been given to the needs of Arab GBMSM in these contexts. Considering they are part of a large diaspora, understanding their access to services is crucial. This paper focuses on Arab GBMSM as a case study within a scoping review, highlighting their hidden status within the broader landscape of HIV and sexual health research for GBMSM in the West. METHODS: A multi-method search strategy was employed, including searching four electronic databases using several terms within each of the following search topics: Arab, GBMSM, HIV and other sexual health services, and developed Western countries. RESULTS: Of the 384 articles found, only one addressed the research question and met the inclusion criteria, revealing a stark scarcity of research on access to HIV and sexual health services for this population. CONCLUSIONS: This review highlights a paucity of research on access to HIV and sexual health services for underrepresented GBMSM populations in developed Western countries. The literature indicates that, for Arab men, this may be due to a difficulty in participant recruitment and poor data collection efforts. By focusing on one hidden population, we aim to advocate for inclusive policies and interventions that promote equitable sexual health access for all. Addressing this research gap aligns with broader local and global HIV strategies to reduce disparities among underrepresented GBMSM populations.

Beyond the challenge to research integrity: imposter participation in incentivised qualitative research and its impact on community engagement.

Participant recruitment for qualitative research often offers incentives (honoraria; financial compensation) to increase participation and to recognise lived expertise and time involved in research. While not necessarily a new concern for survey and other quantitative based research, 'spam', 'bot', and other inauthentic forms of research participation has rarely been an apparent issue for qualitative research, given it often involves levels of interaction with potential participants prior to the conduct of in-depth interviews and other methods of data generation. This is no longer the case. A troubling new occurrence has meant that recruitment calls for qualitative research with incentives on public-facing social media have attracted 'imposter' expressions of interest and research participation. In this commentary, we explore this challenge that goes beyond research integrity. In particular, we consider the risks of employing strategies to screen for legitimate participants and the importance of building trust and maintaining community engagement.

'It's like I have this weird superpower': experiences of detectable and undetectable viral load among a cohort of recently diagnosed people living with HIV.

BACKGROUND: By reducing HIV viral load to undetectable levels, HIV treatment slows disease progression and eliminates the possibility of sexual transmission. The promotion of undetectable viral load has also been accompanied by expectations of reducing HIV-related stigma, including self-stigma. Drawing on accounts of people recently diagnosed with HIV, we explored experiences of both detectable and undetectable viral load. METHODS: Between January 2019 and November 2021, semi-structured interviews were conducted with 35 people living with HIV (PLHIV) who had received an HIV diagnosis in Australia from 2016 onward. Of these participants, 24 completed follow-up interviews approximately 12months later. Interviews were transcribed verbatim, entered into NVivo (software v12), and thematically analysed. RESULTS: Reflecting on the period in which their viral load was detectable, some participants described feeling 'dirty,' 'viral,' and 'a risk' to sexual partners. During this period, some participants minimised or ceased having sex, sometimes despite being in ongoing romantic relationships. Reaching undetectable viral load was commonly characterised as an important goal in HIV care and signalled a marker of good health and enabled a return to sexual relationships. However, the psychosocial benefits of undetectable viral load were not universally experienced, with some participants highlighting ongoing challenges of living with HIV long term. CONCLUSIONS: Increasing awareness of the benefits of undetectable viral load is an important and powerful tool for improving the health and wellbeing of PLHIV; however, the period in which one's HIV viral load is detectable can be challenging, particularly as feelings of being 'unclean' and 'a risk' may be internalised. Ensuring PLHIV are appropriately supported during periods of viral detectability is necessary.

Requesting HIV Results Be Conveyed in-Person: Perspectives of Clinicians and People Recently Diagnosed with HIV.

Introduction: Guidelines recommend that, where possible, clinicians convey HIV-positive test results in person in Australia. However, HIV-negative and all other STI results are routinely delivered by phone or text message. Requesting individuals to obtain positive HIV test results in person could be a deviation from the standard delivery of healthcare and be interpreted as indicating a positive HIV diagnosis. Methods: This paper is based on two related, ongoing qualitative studies conducted in Australia with HIV healthcare providers and people recently diagnosed with HIV. In study one, in-depth, semi-structured interviews were conducted with people who had recently received a positive HIV diagnosis. In study two, in-depth, semi-structured interviews were conducted with HIV healthcare and peer support providers. Interviews were analyzed thematically. Results: While clinicians were willing to convey HIV-positive diagnoses by phone, most preferred in-person delivery. In-person delivery enabled clinicians to assess visual cues to better respond to the psychological and emotional needs of patients. For some participants living with HIV, however, the requirement to return to the clinic was interpreted as an unofficial HIV-positive diagnosis. This led to a period in which recently diagnosed participants believed they were HIV-positive without having received an explicit diagnosis. Conclusion: Protocols for delivering HIV diagnoses by phone, followed by a face-to-face appointment, may reduce the period of anxiety for some patients and assist with an early connection to HIV care and support. Policy Implications: In some instances, conveying HIV diagnoses by phone may be more appropriate than recalling individuals to the clinic to deliver a positive HIV diagnosis in person.

U=U, PrEP and the unrealised promise of ending HIV-related stigma.

There is now widespread consensus that by reducing HIV viral load to undetectable levels, HIV treatment also eliminates the risk of HIV sexual transmission. Advocates have hoped that eliminating the risk of HIV will be accompanied by a reduction of HIV-related stigma. These hopes have yet to be realised and people living with HIV continue to report stigma and sexual rejection. The burden of challenging HIV-related stigma has largely fallen on people living with HIV. It is time for those who are HIV-negative to also take on some of the burden in challenging HIV stigma.

Identifying Patterns of Discontinuing and Recommencing Pre-exposure Prophylaxis in the Context of Sexual Behavior Among Gay and Bisexual Men in Australia.

We mapped gay and bisexual men's (GBM) patterns of using pre-exposure prophylaxis (PrEP) over time and explored sexual behavior as PrEP use changed. We conducted semi-structured interviews between June 2020 and February 2021 with 40 GBM living in Australia who had changed their PrEP use since initiating. There was considerable diversity in patterns of discontinuation, suspension, and recommencement of PrEP. Reasons for changing PrEP use mostly centered on accurate perceived changes to HIV risk. Twelve participants reported condomless anal intercourse with casual or fuckbuddy partners after discontinuing PrEP. These sex events were unanticipated, condoms were not a preferred option, and other risk reduction strategies were applied inconsistently. Service delivery and health promotion can support safer sex among GBM when PrEP use fluctuates by promoting event-driven PrEP and/or non-condom-based risk reduction methods during periods off daily PrEP, and guiding GBM to better recognize changing circumstances of risk and when to recommence PrEP.

HIV Diagnosis as Both Biographical Disruption and Biographical Reinforcement: Experiences of HIV Diagnoses Among Recently Diagnosed People Living With HIV.

Despite the potential for HIV treatments to transform the health needs of people living with HIV, receiving a positive HIV diagnosis can be a difficult experience and feelings of shock, distress and concerns for the future are commonly reported. Drawing on Michael Bury's conceptualisation of 'biographical disruption', we utilised semi-structured interviews to explore experiences of HIV diagnoses among 34 people diagnosed with HIV between 2016 and 2020 and living in Australia. Interviews were conducted between January 2018 and August 2021. Despite significant advances in biomedical HIV treatments and prevention, participants commonly experienced HIV diagnosis as emotionally challenging. For those with limited HIV awareness, HIV was commonly understood as a likely fatal condition. For some participants, receiving a positive diagnosis also engendered a degree of uncertainty as to their anticipated life trajectory, particularly its impact on future sexual and romantic relationships, options for starting a family and migration opportunities. For some gay and bisexual male participants, receiving a positive diagnosis almost confirmed a life trajectory that they had worked to avoid and their own sometimes-negative attitudes toward people living with HIV were internalised, making adjusting to diagnosis more complex. While all participants reported challenges in adjusting to an HIV diagnosis, some ultimately came to experience living with HIV as bringing about unexpected and welcome changes to their lives. Our findings highlight the complex and intersecting medical, social and emotional needs of people living with HIV when receiving and adjusting to a positive HIV diagnosis.

Experiences of, and motivations for, disclosing HIV to social and familial networks: considering the social and relational domains of HIV disclosure.

For people living with HIV, decisions about when, how and who to tell about their HIV status can involve navigating complex social, legal and health domains. With a focus on disclosure to broader social and familial networks, we explored the experiences of, and motivations for, HIV (non-)disclosure among recently diagnosed people living with HIV in Australia. Semi-structured interviews were conducted with 35 people diagnosed with HIV from 2016 onwards, of whom 25 completed follow-up interviews. Participants commonly reported anticipating negative responses and rejection from others when considering whether to disclose their HIV status. Some participants also took on the role of ensuring others' wellbeing when disclosing (or not), even as they themselves needed emotional support. Finally, some participants felt it important to be open about their HIV status to raise awareness of HIV and challenge HIV-related stigma. Our findings highlight the complex relational and social contexts that shape HIV disclosure. In addition to supporting individual people living with HIV when disclosing, we argue that educational programmes that target the broader, HIV-negative population are needed to shift the social landscape in which people living with HIV disclose.

COVID-19 Testing in a Weekly Cohort Study of Gay and Bisexual Men: The Impact of Health-Seeking Behaviors and Social Connection.

Gay, bisexual, and other men who have sex with men (GBM) have developed community norms for regular HIV/STI testing. We investigated factors associated with self-reported COVID-19 testing in response to reported COVID-19 cases and public health restrictions. Participants responded to weekly cohort surveys between 10th May 2021 and 27th September 2021. We used the Andersen-Gill extensions to the Cox proportional hazards model for multivariable survival data to predict factors influencing COVID-19 testing. Mean age of the 942 study participants was 45.6 years (SD: 13.9). In multivariable analysis, GBM were more likely to report testing during periods of high COVID-19 caseload in their state of residence; if they were younger; university educated; close contact of someone with COVID-19; or reported coping with COVID-19 poorly. COVID-19 testing was higher among men who: were more socially engaged with other GBM; had a higher proportion of friends willing to vaccinate against COVID-19; and were willing to contact sexual partners for contact tracing. Social connection with other gay men was associated with COVID-19 testing, similar to what has been observed throughout the HIV epidemic, making community networks a potential focus for the promotion of COVID-19 safe practices.

Patient-centred approaches to providing care at HIV diagnosis: perspectives from healthcare and peer-support workers.

BACKGROUND: Early uptake of HIV treatment among those newly diagnosed with HIV can improve individual health and prevent onward transmission. Patient-centred care is considered an important aspect in health care, the management of HIV, and can improve uptake of and adherence to HIV treatments. METHODS: Semi-structured interviews were conducted with sexual health clinicians (n , 10) and HIV support workers (n , 4) to understand how they approached HIV diagnosis delivery and care immediately thereafter. RESULTS: Our thematic analysis identified three themes: (1) centring patient needs at diagnosis; (2) assessing patients' readiness to begin treatment; and (3) referrals to psychosocial support services. Our findings highlight centring patients was an important aspect of how participants delivered HIV diagnoses. By taking this approach, clinicians were best able to consider patient readiness to initiate treatment and referrals to social support services. CONCLUSIONS: Given HIV diagnoses are increasingly occurring in generalist health services, our findings offer an important opportunity to learn from the experiences of specialist sexual health clinicians and HIV support workers.

Belonging, social connection and non-clinical care: Experiences of HIV peer support among recently diagnosed people living with HIV in Australia.

Effective HIV treatments have transformed the medical needs of people living with HIV (PLHIV) to a chronic condition. However, stigma, poorer mental health outcomes and social isolation remain significant challenges for many PLHIV. HIV peer support programs have assisted PLHIV in navigating the clinical, emotional and social aspects of living with HIV. We draw on semi-structured interviews with 26 recently diagnosed PLHIV in Australia to explore experiences of HIV peer support services. Our thematic analysis identified three overarching themes. First, participants commonly reported that peer support programs offered a sense of belonging and connection to a broader HIV community. This established a network, sometimes separate to their existing social networks, of other PLHIV with whom to share experiences of HIV. Second, peer-based programs provided an opportunity for participants to hear firsthand, non-clinical perspectives on living with HIV. While participants valued the clinical care they received, the perspectives of peers gave participants insights into how others had managed aspects of living with HIV such as disclosure, sex and relationships. Finally, participants highlighted important considerations around ensuring referrals were made to socially and culturally appropriate support programs. Peer support programs fill an important gap in HIV care, working alongside and extending the work of the clinical management of HIV. Incorporating formal referrals to peer support services as part of the HIV diagnosis process could assist recently diagnosed PLHIV in adjusting to a positive diagnosis.

Using social media as a platform to publicly disclose HIV status among people living with HIV: Control, identity, informing public dialogue.

Disclosure of HIV status is usually considered a private encounter involving only a limited number of people at a time. Many people living with HIV are strategic about deciding in what contexts, using which approach, to whom, and to what extent they disclose HIV status. However, social media platforms provide opportunities for people to publicly disclose information about themselves to their networks. Utilising semi-structured interviews with people recently diagnosed with HIV in Australia, we explore how, why, and using what strategies people living with HIV use social media as a means of publicly disclosing positive HIV status. Participants placed importance on having control of how they framed their life with HIV and adopted strategies to control the audience to whom they disclosed. Public disclosure on social media helped participants come out of the 'sero-closet', empowered identity affirmation, and enabled them to be voices for other people living with HIV to shift public dialogue. We conclude that public disclosure of a positive HIV status can strip HIV disclosure of being associated with delivering private and unpleasant information, and instead reframe living with HIV from a responsibility to disclose to a right to share.

'It became quite a complex dynamic': The experiences of occupational therapy practice educators' move to digital platforms during the COVID-19 pandemic.

INTRODUCTION: The rapid shift to digital platforms during the COVID-19 pandemic enabled occupational therapy practice education to continue while creating unique learning opportunities for students in an environment of high demand for practice education providers. How occupational therapy practice educators experienced fieldwork supervision during this rapid redesign of service delivery is not widely understood. This study aimed to explore the experiences of practice educators who supervised occupational therapy students during the COVID-19 pandemic in Australia. METHODS: Fifteen occupational therapy practice educators participated in focus groups and individual semi-structured interviews. Reflexive thematic analysis was used to understand the experiences of the participants and explore the barriers and facilitators to providing practice education in this context. FINDINGS: The experiences of the occupational therapy practice educators were interpreted into three themes: (1) Opportunities lost and then created (as two subthemes); (2) The relationship between the student and practice educator (comprising subthemes of practicing self-care and connection and support); and (3) Signing-off of students' competencies. While digital platforms were initially viewed as limiting, they also were used to create new opportunities for student learning. Participants spoke of being mindful of their and students' wellbeing and finding ways to provide connection and support. Participants were challenged by the need to adapt how they evaluated students in the context of a pandemic. CONCLUSION: The findings of this study highlight the complexities of occupational therapy practice education in the rapidly shifting context of the COVID-19 pandemic in Australia. The outcomes highlight the importance of creating new ways of using digital platforms during practice education while focussing on the relationships with students.