Ending AIDS as a public health threat by 2030: Time to reset targets for 2025.

Paul De Lay and co-authors introduce a Collection on the design of targets for ending the AIDS epidemic.

Breaking Down Barriers to HIV Care for Gay and Bisexual Men and Transgender Women: The Advocacy and Other Community Tactics (ACT) Project.

Despite the prevailing consensus on the role that stigma and discrimination play in limiting access to HIV prevention technology, discouraging HIV testing, and impeding access to HIV care, studies that focus on structural interventions to address stigma and discrimination for gay, bisexual, and other men who have sex with men and transgender women are surprisingly uncommon. We aimed to identify the outcomes from a coordinated set of community-led advocacy initiatives targeting structural changes that might eliminate barriers to HIV care for gay and bisexual men and transgender women in five African and two Caribbean countries. We conducted a prospective evaluation that included repeated site visits and in-depth semi-structured interviews with 112 people with direct knowledge of project activities, accomplishments, failures, and challenges. Using outcome harvesting and qualitative analysis methods, we observed that over the 18-month implementation period, local advocacy efforts contributed to enhanced political will on the part of duty bearers for ensuring equitable access to HIV care, increases in the availability of affirming resources, improved access to existing resources, and changes in normative institutional practices to enable access to HIV care. Evidence on Project ACT points to the vital role community-led advocacy plays in addressing stigma and discrimination as structural barriers to HIV care.

RESUMEN: Estudios cual centran en intervenciones estructurales para abordar el estigma y la discriminación de los hombres gay, bisexuales y otros hombres que tienen sexo con hombres y mujeres transgénero son sorprendentemente poco comunes, a pesar del consenso prevaleciente sobre el rol que desempeñan el estigma y la discriminación al limitar el acceso a la tecnología de prevención del VIH, desalentar las pruebas del VIH e impedir el acceso a la atención del VIH. Nuestro objetivo era identificar los resultados de un conjunto coordinado de iniciativas de incidencia política dirigidas por la comunidad que apuntan a cambios estructurales que podrían eliminar las barreras a la atención del VIH para hombres gay y bisexuales y mujeres transgénero en cinco países de África y dos del Caribe. Realizamos una evaluación prospectiva que incluyó visitas repetidas al sitio y entrevistas profundas semiestructuradas con 112 personas con conocimiento directo de las actividades, logros, fracasos y desafíos del proyecto. Utilizando métodos de recolección de resultados y análisis cualitativo, observamos que durante el período de implementación de 18 meses, los esfuerzos de promoción local contribuyeron a una mayor voluntad política por parte de los titulares de deberes para garantizar el acceso equitativo a la atención del VIH, aumentos en la disponibilidad de recursos afirmativos, mejoras al acceso a los recursos existentes y cambios en las prácticas institucionales normativas para permitir el acceso a la atención del VIH. La evidencia sobre el Proyecto ACT apunta al papel vital que desempeñan las iniciativas de incidencia política liderada por la comunidad para abordar el estigma y la discriminación como barreras estructurales para la atención del VIH.

Economic, Mental Health, HIV Prevention and HIV Treatment Impacts of COVID-19 and the COVID-19 Response on a Global Sample of Cisgender Gay Men and Other Men Who Have Sex with Men.

There is an urgent need to measure the impacts of COVID-19 among gay men and other men who have sex with men (MSM). We conducted a cross-sectional survey with a global sample of gay men and other MSM (n = 2732) from April 16, 2020 to May 4, 2020, through a social networking app. We characterized the economic, mental health, HIV prevention and HIV treatment impacts of COVID-19 and the COVID-19 response, and examined whether sub-groups of our study population are disproportionately impacted by COVID-19. Many gay men and other MSM not only reported economic and mental health consequences, but also interruptions to HIV prevention and testing, and HIV care and treatment services. These consequences were significantly greater among people living with HIV, racial/ethnic minorities, immigrants, sex workers, and socio-economically disadvantaged groups. These findings highlight the urgent need to mitigate the negative impacts of COVID-19 among gay men and other MSM.

RESUMEN: Existe una necesidad urgente para medir los impactos de COVID-19 entre hombres gay y otros hombres que tienen sexo con hombres (HSH). Hemos conducido una encuesta multifuncional con una prueba mundial de hombres gay y otros HSH (n = 2732) desde el 16 de Abril hasta el 4 de Mayo del 2020, a través de una aplicación de red social. Nosotros caracterizamos los impactos económicos, de salud mental, prevención del VIH y tratamiento del VIH e impactos a COVID-19 y la respuesta de COVID-19, y examinamos si subgrupos de nuestra población de estudio fueron impactados desproporcionadamente por COVID-19. Muchos hombres no tan solo reportaron consecuencias económicas y de salud mental, sino también interrupciones de prevención y de pruebas de VIH, y cuidado del VIH y servicios de tratamiento. Encontramos consecuencias más significantes entre personas viviendo con VIH, grupos raciales/etnicos, migrantes, sexo servidores, y groupos socioeconomicamente disfavorecidos. Los resultados subrayan la necesidad crucial de mitigar los impactos multifacéticos de COVID-19 entre los hombres homosexuales y otros HSH, especialmente para aquellos con vulnerabilidades entrelazadas.

Participatory praxis as an imperative for health-related stigma research.

BACKGROUND: Participatory praxis is increasingly valued for the reliability, validity, and relevance of research results that it fosters. Participatory methods become an imperative in health-related stigma research, where the constitutive elements of stigma, healthcare settings, and research each operate on hierarchies that push those with less social power to the margins. DISCUSSION: Particularly for people who are stigmatized, participatory methods balance the scales of equity by restructuring power relationships. As such, participatory praxis facilitates a research process that is responsive to community-identified priorities and creates community ownership of the research, catalyzing policy change at multiple levels and foregrounds, and addresses risks to communities from participating in research. Additionally, through upholding the agency and leadership of communities facing stigma, it can help to mitigate stigma's harmful effects. Health-related stigma research can reduce the health inequities faced by stigmatized groups if funders and institutions require and reward community participation and if researchers commit to reflexive, participatory practices. A research agenda focused on participatory praxis in health-related stigma research could stimulate increased use of such methods. CONCLUSION: For community-engaged practice to become more than an ethical aspiration, structural changes in the funding, training, publishing, and tenure processes will be necessary.

Reductions in access to HIV prevention and care services are associated with arrest and convictions in a global survey of men who have sex with men.

OBJECTIVES: Men who have sex with men (MSM) are disproportionately impacted by HIV. Criminalisation of homosexuality may impede access to HIV services. We evaluated the effect of the enforcement of laws criminalising homosexuality on access to services. METHODS: Using data from a 2012 global online survey that was published in a prior paper, we conducted a secondary analysis evaluating differences in perceived accessibility to health services (ie, 'how accessible are ____' services) between MSM who responded 'yes'/'no' to: 'have you ever been arrested or convicted for being gay/MSM?' RESULTS: Of the 4020 participants who completed the study and were included in the analysis, 8% reported ever being arrested or convicted under laws relevant to being MSM. Arrests and convictions were most common in sub-Saharan Africa (23.6% (58/246)), Eastern Europe/Central Asia (18.1% (123/680)), the Caribbean (15% (15/100)), Middle East/North Africa (13.2% (10/76)) and Latin America (9.7% (58/599)). Those arrested or convicted had significantly lower access to sexually transmitted infection treatment (adjusted OR (aOR)=0.81; 95% CI 0.67 to 0.97), condoms (aOR=0.77; 95% CI 0.61 to 0.99) and medical care (aOR=0.70; 95% CI 0.54 to 0.90), compared with other MSM, while accounting for clustering by country and adjusting for age, HIV status, education and country-level income. CONCLUSIONS: Arrests and convictions under laws relevant to being MSM have a strong negative association with access to HIV prevention and care services. Creating an enabling legal and policy environment, and increasing efforts to mitigate antihomosexuality stigma to ensure equitable access to HIV services are needed, along with decriminalisation of homosexuality, to effectively address the public health needs of this population.

Availability and Use of Substance Abuse Treatment Programs Among Substance-Using Men Who Have Sex With Men Worldwide.

BACKGROUND: Substance use is common among men who have sex with men (MSM) worldwide, and epidemiologic data suggest that alcohol/substance-using MSM are at greater risk for HIV. However, there are scarce data on substance abuse treatment programs (SATPs) for substance-using MSM. OBJECTIVES: We examined proportions of substance use as well as SATP availability and use. We used multivariable regression models, controlling for potential confounders, to examine behavioral and demographic correlates of SATP availability and use. METHODS: This is a cross-sectional study of a multi-region, online sample of substance-using MSM. RESULTS: In this sample, 75% were substance-using MSM of whom 36% reported at-least-weekly use. Substance use was most prevalent among respondents from Eastern Europe/Central Asia (86%) and Latin America (79%). Among substance-using MSM, 96% and 33% reported alcohol intoxication and other substance use, respectively; 11% reported having high SATP availability; and 5% reported using SATPs. Controlling for global region of origin and age, high SATP availability was associated with high access to HIV risk-reduction education (aOR = 3.19; CI = 1.48-6.89), mental health services (aOR = 2.53; CI = 1.32-4.83), and medical care (aOR = 2.32; CI = 1.12-4.80); less than college-level education (aOR = 0.32; CI = 0.18-0.54); and higher comfort levels with providers (aOR = 1.75; CI = 1.30-2.37). Controlling for substance use frequency and personal income additionally, using SATPs was associated with higher levels of connection to the gay community (aOR = 2.76; CI = 1.22-6.22). CONCLUSION: In this global sample of MSM, we found high alcohol intoxication and other substance use proportions. Few substance-using MSM report SATP availability, highlighting the need to develop novel substance use programs outside traditional treatment settings.

West Hollywood is Not That Big on Anything But White People: Constructing "Gay Men of Color".

Rather than a defined endpoint that is waiting to be discovered or developed, racial and sexual identities can be considered social identities which are fluid, malleable, and socially created through a social process that defines what it means to be a member of a social group. This paper expands the work on how social identities are constructed by examining personal anecdotes used by gay men of color to discuss how they come to see themselves as "gay men of color." In doing so, we find that gay men of color use a number of cultural tropes that provide them the framework necessary to structure their experiences within a larger social context of a largely white, heterosexual society. Drawing on these cultural tropes, gay men of color create a social identity that is simultaneously raced and sexed through the use of shared cultural tropes that define what it means to be a member of this group.

Sexual stigma, criminalization, investment, and access to HIV services among men who have sex with men worldwide.

Globally, HIV disproportionately affects men who have sex with men (MSM). This study explored associations between access to HIV services and (1) individual-level perceived sexual stigma; (2) country-level criminalization of homosexuality; and (3) country-level investment in HIV services for MSM. 3,340 MSM completed an online survey assessing access to HIV services. MSM from over 115 countries were categorized according to criminalization of homosexuality policy and investment in HIV services targeting MSM. Lower access to condoms, lubricants, and HIV testing were each associated with greater perceived sexual stigma, existence of homosexuality criminalization policies, and less investment in HIV services. Lower access to HIV treatment was associated with greater perceived sexual stigma and criminalization. Criminalization of homosexuality and low investment in HIV services were both associated with greater perceived sexual stigma. Efforts to prevent and treat HIV among MSM should be coupled with structural interventions to reduce stigma, overturn homosexuality criminalization policies, and increase investment in MSM-specific HIV services.

Stress and coping with racism and their role in sexual risk for HIV among African American, Asian/Pacific Islander, and Latino men who have sex with men.

The deleterious effects of racism on a wide range of health outcomes, including HIV risk, are well documented among racial/ethnic minority groups in the United States. However, little is known about how men of color who have sex with men (MSM) cope with stress from racism and whether the coping strategies they employ buffer against the impact of racism on sexual risk for HIV transmission. We examined associations of stress and coping with racism with unprotected anal intercourse (UAI) in a sample of African American (N = 403), Asian/Pacific Islander (N = 393), and Latino (N = 400) MSM recruited in Los Angeles County, CA during 2008-2009. Almost two-thirds (65 %) of the sample reported being stressed as a consequence of racism experienced within the gay community. Overall, 51 % of the sample reported having UAI in the prior 6 months. After controlling for race/ethnicity, age, nativity, marital status, sexual orientation, education, HIV serostatus, and lifetime history of incarceration, the multivariate analysis found statistically significant main effects of stress from racism and avoidance coping on UAI; no statistically significant main effects of dismissal, education/confrontation, and social-support seeking were observed. None of the interactions of stress with the four coping measures were statistically significant. Although stress from racism within the gay community increased the likelihood of engaging in UAI among MSM of color, we found little evidence that coping responses to racism buffered stress from racism. Instead, avoidance coping appears to suggest an increase in UAI.

Syndemic conditions associated with increased HIV risk in a global sample of men who have sex with men.

OBJECTIVE: We evaluated the relationship among syndemic conditions (defined as a cluster of interconnected psychosocial health conditions), sexual behaviours and self-reported HIV infection in a global sample of men who have sex with men (MSM). METHODS: We used generalised estimating equations logistic regression models with robust SEs to assess the relationships among cumulative number of syndemic conditions--including depression, substance use, violence, sexual stigma and homelessness--and unprotected anal intercourse (UAI) and HIV infection, while accounting for clustering within-country in a global cross-sectional survey of 3934 MSM across 151 countries. RESULTS: We observed parallel, significant dose-response associations between the number of syndemic conditions and UAI, as well as number of syndemic conditions and HIV infection. Compared with participants without syndemics, the adjusted OR (aOR) for UAI among those with 1, 2 and 3 or more syndemic conditions were 1.44 (Bonferroni-adjusted 95% CI 1.23 to 1.68), 1.89 (1.51 to 2.36) and 2.03 (1.43 to 2.89), respectively. Compared with participants without syndemics, the aOR for HIV infection among those with 1, 2 and 3 or more syndemic conditions were 1.67 (1.24 to 2.26), 2.02 (1.44 to 2.85) and 2.35 (1.31 to 4.21), respectively. CONCLUSIONS: This analysis provides evidence of intertwining syndemics that may operate synergistically to increase HIV risk among MSM globally. To curb HIV effectively and advance the health of MSM, multiple conditions must be addressed concurrently using multi-level approaches that target both individual and structural risk factors.

Substance use and experienced stigmatization among ethnic minority men who have sex with men in the United States.

Research has documented deleterious effects of racism among ethnic minorities and of homophobia among men who have sex with men (MSM). Less is known about the impact of multiple forms of stigmatization on ethnic minority MSM. This study examined substance use by African American, Asian/Pacific Islander and Latino MSM, and the associations of experienced racism and homophobia from various sources with polydrug use and stimulant drug use. Experienced racism within the general community was associated with higher levels of use; other forms of discrimination were either not associated with polydrug or stimulant use or had more complex relationships with use. Implications for further research and interventions are discussed.

From personal survival to public health: community leadership by men who have sex with men in the response to HIV.

Community leadership and participation by gay men and men who have sex with men (MSM) have been central to the response to HIV since the beginning of the epidemic. Through a wide array of actions, engagement of MSM has been important in the protection of communities. The connection between personal and community health as drivers of health advocacy continue to be a powerful element. The passion and urgency brought by MSM communities have led to the targeting and expansion of HIV and AIDS research and programming, and have improved the synergy of health and human rights, sustainability, accountability, and health outcomes for all people affected by HIV. MSM are, however, frequently excluded from the evidence-based services that they helped to develop, despite them generally being the most effective actors in challenging environments. Without MSM community involvement, government-run health programmes might have little chance of effectively reaching communities or scaling up interventions to lessen, and ultimately end, the HIV pandemic.

Experiences of discrimination and their impact on the mental health among African American, Asian and Pacific Islander, and Latino men who have sex with men.

OBJECTIVES: We examined the associations between specific types and sources of discrimination and mental health outcomes among US racial/ethnic minority men who have sex with men (MSM) and how these associations varied by race/ethnicity. METHODS: A chain-referral sample of 403 African American, 393 Asian and Pacific Islander (API), and 400 Latino MSM recruited in Los Angeles County, California completed a standardized questionnaire. Data were obtained from the Ethnic Minority Men's Health Study from May 2008 to October 2009. RESULTS: Past-year experiences of racism within the general community and perceived homophobia among heterosexual friends were positively associated with depression and anxiety. Past-year homophobia experienced within the general community was also positively associated with anxiety. These statistically significant associations did not vary across racial/ethnic groups. The positive association of perceived racism within the gay community with anxiety differed by race/ethnicity, and was statistically significant only for APIs. Perceived homophobia within the family was not associated with either depression or anxiety. CONCLUSIONS: Higher levels of experiences of discrimination were associated with psychological distress among MSM of color. However, specific types and sources of discrimination were differentially linked to negative mental health outcomes among African American, API, and Latino MSM.

Dimensions of racism and their impact on partner selection among men of colour who have sex with men: understanding pathways to sexual risk.

While many studies have established the relationship between experiences of racism and sexual risk among men of colour who have sex with men, the pathways by which this occurs are underdeveloped. To address this gap, we must better investigate the lived realities of racism in the gay community. In this study, we had the unique opportunity to examine experiences of racism among African American, Asian/Pacific Islander and Latino men who have sex with men living in Los Angeles through focus groups and individual in-depth interviews. We found three themes of racism: exclusion from West Hollywood and the mainstream gay community, sexual rejection based on race/ethnicity and sexual stereotypes. There were differences across the three racial groups in the experiences of each theme, however. We then considered how racism impacted partner selection and found that race played a salient role in determining power differentials within mixed-race partnerships. Finally, we discussed several future areas for research that can better establish pathways between racism and sexual risk.

Barriers to and enablers of the HIV services continuum among gay and bisexual men worldwide: Findings from the Global Men's Health and Rights Study.

OBJECTIVES: To assess ecological, structural, community and individual level correlates of health services utilization along a continuum of HIV care, and sexual health and support services among gay and bisexual men worldwide. METHODS: Using a nonprobability internet sample of 6,135 gay and bisexual men, we assessed correlates of utilization of health services. Chi-Square Tests of Independence were performed to assess drop off along a continuum of HIV care. Multivariable logistic regression analyses using generalized estimating equation models were conducted adjusting for geographic region and clustering by country. In multivariable analyses, we determined the association between utilization outcomes, and ecologic, structural, community and individual correlates by fitting separate generalized estimating equation (GEE) logistic regression models for each of the outcomes, fitted with robust SEs, and accounting for clustering by country. Stratified by sexual identity, analyses adjusted for variables that could influence HIV-related health outcomes including racial/ethnic minority status, participant age, insurance, ability to make ends meet, as well as country-level income (income of country of residence defined by the World Bank). RESULTS: Among men living with HIV (n = 1001), being in HIV care (n = 867) was associated with being on ART (X2 = 191.17, p < .001), and viral load suppression (X2 = 14.03, p < .001); and using ART (n = 840) was associated viral load suppression (X2 = 21.66, p < .001). Overall, the pattern of utilization outcomes were similar for both gay and bisexual men. For example, utilization of PrEP, being in HIV care and utilization of most of the sexual health and support services were negatively associated with sexual stigma. Whereas, utilization of most HIV prevention, and sexual health and support services were positively associated with provider discrimination. Utilization of all HIV prevention and all sexual health services were positively associated with greater community engagement, and receiving services from LGBT-led organizations. Bisexual men had higher odds of reporting provider discrimination when utilizing condom services (gay: AOR = 1.14, [0.95-1.36]; bisexual: 1.58, [1.10-2.28]), PrEP (gay: AOR = 1.06, [0.77-1.45]; bisexual: AOR = 2.14, [1.18-3.89], mental health services (gay: AOR = 1.03, [0.86-1.23]; bisexual: AOR = 1.32, [1.07-1.64]), and community-based support (gay: AOR = 1.23, [1.05-1.45]; bisexual: AOR = 1.49, [1.14-1.93]) than gay men. Bisexual men also reported higher odds of accessing services from LGBT-led organizations when utilizing PrEP (gay: AOR = 5.26, [2.50-11.05]; bisexual: AOR = 7.12, [3.16-16.04]), and community-based support/self-help groups/individual counseling (gay: AOR = 2.63, [1.72-4.01]; bisexual: AOR = 3.35, [2.30-4.88]. CONCLUSIONS: It is essential that barriers to health services utilization be addressed at structural and community levels. Structural interventions should be designed to reduce sexual stigma, as well as train and sensitize healthcare providers; and strengthen community level interventions that bring gay and bisexual men together to lead comprehensive health services.

Would the Siblings of Latinx Men Who Have Sex With Men Encourage Their Brothers to Use PrEP? Findings From a Feasibility and Acceptability Study.

We explored whether siblings can be engaged in PrEP promotion. We used the Information-Motivation-Behavior model to develop and conduct surveys and dyadic interviews with Latino men who have sex with men (LMSM) and their siblings (n = 31) and three sibling-only focus groups (n = 20). For LMSM, only n = 14 (45%) agreed they would benefit from taking PrEP, yet n = 22 (71%) would take PrEP to make their sibling worry less about them, and n = 23 (74%) requested a PrEP referral. For siblings, n = 20 (65%) believed PrEP would benefit their brother, and n = 19 (95%) in the focus groups said they would take PrEP to help their brother get started. Qualitative results include (1) siblings' support for PrEP use, (2) explicit conversations about sex were not necessary for discussing sexual health, and (3) siblings wanted to understand what they could do to encourage their brother to consider PrEP. We conclude siblings can be engaged in PrEP promotion.