Validity and reliability of the Neilands sexual stigma scale among Kenyan gay, bisexual, and other men who have sex with men.

BACKGROUND: We evaluated the validity and reliability of the Neilands sexual stigma scale administered to 871 gay, bisexual, and other men who have sex with men (GBMSM) at two research locations in Kenya. METHODS: Using cross-validation, exploratory factor analysis (EFA) was performed on a randomly selected subset of participants and validated using confirmatory factor analysis (CFA) on the remaining participants. Associations of the initial and final stigma scale factors with depressive symptoms, alcohol use, and other substance use were examined for the entire dataset. RESULTS: EFA produced a two-factor scale of perceived and enacted stigma. The CFA model fit to the two-factor scale was improved after removing three cross-loaded items and adding correlated errors (chi-squared = 26.5, df 17, p = 0.07). Perceived stigma was associated with depressive symptoms (beta = 0.34, 95% CI 0.24, 0.45), alcohol use (beta = 0.14, 95% CI 0.03, 0.25) and other substance use (beta = 0.19, 95% CI 0.07, 0.31), while enacted stigma was associated with alcohol use (beta = 0.17, 95% CI 0.06, 0.27). CONCLUSIONS: Our findings suggest enacted and perceived sexual stigma are distinct yet closely related constructs among GBMSM in Kenya and are associated with poor mental health and substance use.

Integration of voluntary male medical circumcision for HIV prevention into norms of masculinity: findings from Kisumu, Kenya.

While it is clear that in many communities ideas about masculinity and circumcision are connected, it is still unclear how young Kenyan men in the former Nyanza province from the traditionally non-circumcising Luo people perceive voluntary medical male circumcision as connected to masculinity and the role of voluntary medical male circumcision in the transition from boyhood to manhood. The objective of this study was to explore norms of masculinity and the decision-making process among Luo young men to provide a better understanding of how circumcision and masculinity relate to cultural norms within this community. The methodology consisted of eight FGDs with male peer groups and 24 in-depth interviews to elicit young men's perceptions of masculinity and voluntary medical male circumcision. Findings from thematic analysis reveal that young men described several key characteristics of masculinity including responsibility, bravery and sexual attractiveness. For some young men, voluntary medical male circumcision has embedded itself into cultural norms of masculinity by being a step in the transition from boyhood to manhood and by being a marker of some of these masculine characteristics. In the case of voluntary medical male circumcision, there may be opportunities to integrate other programming that helps men transition into healthy adulthood.

A qualitative study on the impact of the 2016 US election on the health of immigrant families in Southeast Michigan.

BACKGROUND: Given the anti-immigrant rhetoric and policy proposals by President Donald Trump during the 2016 presidential campaign and afterwards, his election to president in November 2016 and subsequent policy changes has affected immigrant families. In this study, we aim to better understand how post-election policy change may have impacted the health and well-being, including health and social service utilization, of Latino immigrants in Southeastern Michigan. METHODS: We conducted 28 in-depth interviews with frontline staff at two Federally Qualified Health Centers and a non-profit agency. These staff had intimate knowledge of and insights into the lived experiences of the mixed-status immigrant families they serve. The interviews were audio recorded, transcribed, and analyzed thematically. RESULTS: Our findings show three major themes: (1) An increased and pervasive fear of deportation and family separation among mixed-status immigrant clients, (2) The fear of deportation and family separation has resulted in fractures in community cohesion, and (3) Fear of deportation and family separation has had an impact on the healthcare utilization and health-related behaviors of mixed-status families. Staff members report that these three factors have had an impact on physical and mental health of these immigrant clients. CONCLUSIONS: These results add to previous literature on the effect of immigration policies on the health and provide key insights for interventions to improve the health of immigrants within this socio-political environment.

Contextualizing willingness to participate: recommendations for engagement, recruitment & enrolment of Kenyan MSM in future HIV prevention trials.

BACKGROUND: The HIV epidemic among men who have sex with men (MSM) continues to expand globally. The addition of an efficacious, prophylactic vaccine to combination prevention offers immense hope, particularly in low- and middle- income countries which bear the greatest global impact. However, in these settings, there is a paucity of vaccine preparedness studies that specifically pertain to MSM. Our study is the first vaccine preparedness study among MSM and female sex workers (FSWs) in Kenya. In this paper, we explore willingness of Kenyan MSM to participate in HIV vaccine efficacy trials. In addition to individual and socio-cultural motivators and barriers that influence willingness to participate (WTP), we explore the associations or linkages that participants draw between their experiences with or knowledge of medical research both generally and within the context of HIV/AIDS, their perceptions of a future HIV vaccine and their willingness to participate in HIV vaccine trials. METHODS: Using a social network-based approach, we employed snowball sampling to recruit MSM into the study from Kisumu, Mombasa, and Nairobi. A field team consisting of seven community researchers conducted in-depth interviews with a total of 70 study participants. A coding scheme for transcribed and translated data was developed and the data was then analysed thematically. RESULTS: Most participants felt that an HIV vaccine would bring a number of benefits to self, as well as to MSM communities, including quelling personal fears related to HIV acquisition and reducing/eliminating stigma and discrimination shouldered by their community. Willingness to participate in HIV vaccine efficacy trials was highly motivated by various forms of altruism. Specific researcher responsibilities centred on safe-guarding the rights and well-being of participants were also found to govern WTP, as were reflections on the acceptability of a future preventive HIV vaccine. CONCLUSION: Strategies for engagement of communities and recruitment of trial volunteers for HIV vaccine efficacy trials should not only be grounded in and informed by investigations into individual and socio-cultural factors that impact WTP, but also by explorations of participants' existing experiences with or knowledge of medical research as well as attitudes and acceptance towards a future HIV vaccine.

Information, motivation, and behavioral skills for early pre-ART engagement in HIV care among patients entering clinical care in KwaZulu-Natal, South Africa.

Little is known regarding factors implicated in early engagement and retention in HIV care among individuals not yet eligible for antiretroviral therapy (pre-ART) in sub-Saharan Africa. Identifying such factors is critical for supporting retention in pre-ART clinical care to ensure timely ART initiation and optimize long-term health outcomes. We assessed patients' pre-ART HIV care-related information, motivation, and behavioral skills among newly diagnosed ART-ineligible patients, initiating care in KwaZulu-Natal, South Africa. The survey was interviewer-administered to eligible patients, who were aged 18 years or older, newly entering care (diagnosed within the last six-months), and ineligible for ART (CD4 count > 200 cells/mm(3)) in one of four primary care clinical sites. Self-reported information, motivation, and behavioral skills specific to retention in pre-ART HIV-care were characterized by categorizing responses into those reflecting potential strengths and those reflective of potential deficits. Information, motivation, and behavioral skills deficits sufficiently prevalent in the overall sample (i.e.,≥30% prevalent) were identified as areas in need of specific attention through intervention efforts adapted to the clinic level. Gender-based differences were also evaluated. A total of 288 patients (75% female) completed structured interviews. Across the sample, eight information, eight motivation, and eight behavioral skills deficit areas were identified as sufficiently prevalent to warrant specific targeted attention. Gender differences did not emerge. The deficits in pre-ART HIV care-related information, motivation, and behavioral skills that were identified suggest that efforts to improve accurate information on immune function and HIV disease are needed, as is accurate information regarding HIV treatment and transmission risk prior to ART initiation. Additional efforts to facilitate the development of social support, including positive interactions with clinic staff and decreasing community-level stigma and to decrease structural and resource-depleting demands of HIV care may be particularly valuable to facilitate retention in pre-ART HIV care.

Immigration law enforcement, social support, and health for Latino immigrant families in Southeastern Michigan.

RATIONALE: Social support is a key determinant of physical and mental health outcomes. Implementation of restrictive immigration policies in the U.S. under the Trump administration impacted the way mixed-status Latino families (i.e., those with varying legal statuses, including undocumented) maintained social relationships and provided social support. OBJECTIVE: This paper examines how federal immigration policies introduced after the 2016 U.S. presidential election impacted social networks and support related to health for undocumented and mixed-status Latino families. METHODS: We interviewed 23 clients and 28 service providers at two Federally Qualified Health Centers and one non-profit organization in Southeast Michigan. The interviews were audio-recorded, transcribed, and analyzed thematically. RESULTS: Policies introduced during the Trump administration increased opportunities for deportation and contributed to the isolation of mixed-status Latino families by transforming safe spaces of social interaction into prime locations for immigration enforcement activity. Despite the limitations created by these restrictive policies, mixed-status families employed alternative mechanisms to maintain access to vital informal and formal support systems while simultaneously navigating emerging immigration-related threats. CONCLUSIONS: Elections have health consequences and immigration policies are needed that promote the health and well-being of Latino immigrant communities.

Barriers & facilitators to healthcare and social services among undocumented Latino(a)/Latinx immigrant clients: Perspectives from frontline service providers in Southeast Michigan.

Immigration- and enforcement-related policies and laws have significantly and negatively impacted the health and well-being of undocumented immigrants. We examine barriers and facilitators to healthcare and social services among undocumented Latino(a)/Latinx immigrants specifically in the post 2016 US presidential election socio-political climate. By grounding our study on the perspectives of frontline providers, we explore their challenges in meeting the needs of their undocumented clients. These include client access to healthcare and social services, the barriers providers face in providing timely and effective services, and avenues to reduce or overcome factors that impede service provision to improve quality of care for this population. Data are from 28 in-depth interviews with frontline healthcare and social service providers. Based on data analysis, we found that the domains of the Three Delays Model used in obstetric care provided a good framework for organizing and framing the responses. Our findings suggest that these undocumented clients encounter three phases of delay: delay in the decision to seek care, delay in identifying and traveling to healthcare facilities, and delay in receiving adequate and appropriate care at healthcare facilities. Given the current socio-political climate for immigrants, healthcare and social services organizations that serve undocumented clients should adapt existing services or introduce new services, including those that are not site-based.

Impact of anti-immigrant rhetoric and policies on frontline health and social service providers in Southeast Michigan, U.S.A.

Rising hostility towards immigrants characterised the 2016 Presidential election in the United States (US) and subsequent policy priorities by the new presidential administration. The political shift towards aggressive policies targeting undocumented immigrants is far-reaching and extends into other communities that convive con-or coexist with-immigrant communities. Our study aims to examine the rippling effects of these anti-immigrant policies and rhetoric on health and social service providers in Southeast Michigan who predominantly serve Latino immigrants. Between April and August 2018, we conducted in-depth individual interviews in two Federally Qualified Health Centers and a non-profit social service agency at a county health department. We interviewed 28 frontline health and social service providers. After coding and thematic analyses, we found that staff members' experiences in supporting immigrant clients was congruent with definitions of secondary trauma stress and compassion fatigue, whereby exposure to clients' trauma combined with job burden subsequently impacted the mental health of providers. Major themes included: (a) frontline staff experienced a mental and emotional burden in providing services to immigrant clients given the restrictive anti-immigrant context; and (b) this burden was exacerbated by the increased difficulties in providing these services to their clients. Staff described psychological and emotional distress stemming from exposure to clients' immigration-related trauma and increased mental health needs. This distress was exacerbated by an increased demand to meet clients' needs, which involved explaining or translating documents into English, assisting with legal paperwork, referring clients to mental health resources, addressing increased transportation barriers, and reestablishing trust with the community. Our findings add qualitative data on the mental health implications for frontline providers who support Latino immigrant clients impacted by immigration and highlights the need for further research and resources that address the workplace-related stress generated by heightened immigration enforcement.

Beyond biomedical and comorbidity approaches: Exploring associations between affinity group membership, health and health seeking behaviour among MSM/MSW in Nairobi, Kenya.

We explored general health and psychosocial characteristics among male sex workers and other men who have sex with men in Nairobi, Kenya. A total of 595 MSM/MSW were recruited into the study. We assessed group differences among those who self-reported HIV positive (SR-HIVP) and those who self-reported HIV negative (SR-HIVN) and by affinity group membership. Quality of life among SR-HIVP participants was significantly worse compared to SR-HIVN participants. Independent of HIV status and affinity group membership, participants reported high levels of hazardous alcohol use, harmful substance use, recent trauma and childhood abuse. The overall sample exhibited higher prevalence of moderate to severe depressive symptoms compared to the general population. Quality of life among participants who did not report affinity group membership (AGN) was significantly worse compared to participants who reported affinity group membership (AGP). AGN participants also reported significantly lower levels of social support. Membership in affinity groups was found to influence health seeking behaviour. Our findings suggest that we need to expand the mainstay biomedical and comorbidity focused research currently associated with MSM/MSW. Moreover, there are benefits to being part of MSM/MSW organisations and these organisations can potentially play a vital role in the health and well-being of MSM/MSW.

Depressive symptoms and problematic alcohol and other substance use in 1476 gay, bisexual, and other MSM at three research sites in Kenya.

OBJECTIVE: Information on mental health and substance use challenges among gay, bisexual, and other MSM (GBMSM) is needed to focus resources on these issues and optimize services for HIV prevention and care. We determined factors associated with depressive symptoms and problematic alcohol and other substance use among GBMSM in Kenya. METHODS: Self-identified GBMSM in three HIV research studies in Kenya provided information on depressive symptoms [Patient Health Questionnaire 9 (PHQ-9)], alcohol use [Alcohol Use Disorder Identification Test (AUDIT)], and other substance use [Drug Abuse Screening Test 6 (DAST-6)]. Associations were evaluated using mixed effects Poisson regression. RESULTS: Of 1476 participants, 452 (31%) reported moderate-to-severe depressive symptoms (PHQ-9 ≥ 10), 637 (44%) hazardous alcohol use (AUDIT ≥ 8), and 749 (51%) problematic substance use (DAST-6 ≥ 1). Known HIV-positive status was not associated with these outcomes. Transactional sex was associated with hazardous alcohol use [adjusted prevalence ratio (aPR) 1.34, 95% confidence interval (CI) 1.12-1.60]. Childhood abuse and recent trauma were associated with moderate-to-severe depressive symptoms (aPR 1.43, 95% CI 1.10-1.86 and aPR 2.43, 95% CI 1.91-3.09, respectively), hazardous alcohol use (aPR 1.36, 95% CI 1.10-1.68 and aPR 1.60, 95% CI 1.33-1.93, respectively), and problematic substance use (aPR 1.32, 95% CI 1.09-1.60 and aPR 1.35, 95% CI 1.14-1.59, respectively). CONCLUSION: GBMSM in rights-constrained settings need culturally appropriate services for treatment and prevention of mental health and substance use disorders, in addition to human rights advocacy to prevent abuse. Mental health and substance use screening and treatment or referral should be an integral part of programs, including HIV prevention and treatment programs, providing services to GBMSM.

Prioritizing Risk in Preparation for a Demonstration Project: A Mixed Methods Feasibility Study of Oral Pre-Exposure Prophylaxis (PREP) among Female Sex Workers in South India.

BACKGROUND: HIV prevalence among female sex workers (FSWs) in India remains well above the national average. Pre-exposure prophylaxis (PrEP), a new HIV prevention technology, may help to reduce HIV incidence, but there is a dearth of research that can inform the potential scale-up of PrEP in India. In partnership with Ashodaya Samithi, a local sex worker collective, we conducted a feasibility study to assess acceptance of a planned PrEP demonstration project, willingness to use PrEP, and recommendations for project roll-out among FSWs in southern Karnataka. METHODS: From January-April 2015, 6 focus group discussions, 47 in-depth interviews, and 427 interviewer-administered questionnaires were completed by female sex workers. All participants were 18 years of age or older and practiced sex work. Qualitative data were coded for key themes and emergent categories. Univariate descriptive analysis was employed to summarise the quantitative data. RESULTS: Qualitative. PrEP was described as an exciting new prevention technology that places control in the hands of FSWs and provides a "double safety" in combination with condom use. Participants expressed agreement that women who may experience more HIV risk in their occupational environments should be prioritized for enrollment into a demonstration project. Quantitative. 406 participants (95%) expressed interest in PrEP. Participants prioritized the inclusion of FSWs under the age of 25 (79%), those who do not use condoms when clients offer more money (58%), who do not consistently use condoms with regular partners (57%), who drink alcohol regularly (49%), and who do not use condoms consistently with clients (48%). DISCUSSION: This feasibility study indicated strong interest in PrEP and a desire to move forward with the demonstration project. Participants expressed their responses in terms of public health discourses surrounding risk, pointing to the importance of situating PrEP scale up within the trusted spaces of community-based organizations as a means of supporting PrEP uptake and adherence.

Frontline Health Service Providers' Perspectives on HIV Vaccine Trials among Female Sex Workers and Men Who Have Sex with Men in Karnataka, South India.

BACKGROUND: Little qualitative research is available on the role of frontline health service providers (FHSPs) in the implementation of clinical trials, particularly in developing countries. This paper presents findings from a qualitative study about the perspectives of FHSPs on future HIV vaccine trials involving female sex workers (FSWs) and men who have sex with men (MSM) in three districts of Karnataka, India. In particular, we explore FHSPs' knowledge of and views on clinical trials in general, and examine their potential willingness to play a role if such trials were introduced or implemented in the region. METHODS: A field team of four researchers from Karnataka-two of whom self-identified with FSW or MSM communities ("community researchers") and two with backgrounds in social work-conducted in-depth interviews with FHSPs. Including community researchers in the study helped to build rapport with FSW and MSM participants and facilitate in-depth discussions. A coding scheme for transcribed and translated data was developed using a framework analysis approach. Data was then analysed thematically using a combination of a priori and emergent codes. RESULTS: Over half of FHSPs demonstrated limited knowledge or understanding of clinical trials. Despite reported skepticism around the testing of HIV vaccines in developing countries and concerns around potential side effects, most FHSPs strongly advocated for the implementation of HIV vaccine clinical trials in Karnataka. Further, most FHSPs expressed their willingness to be involved in future HIV vaccine clinical trials in varying capacities. CONCLUSION: Given that FHSPs are often directly involved in the promotion of health and well-being of FSWs and MSM, they are well-positioned to play leadership, ethical, and communicative roles in future HIV vaccine trials. However, our findings reveal a lack of awareness of clinical trials among FHSP participants, suggesting an important area for capacity building and staff development before viable and ethical clinical trials can be set up in the region.