A loss of moral experience: understanding HIV-related stigma in the New York City House and Ball Community.

OBJECTIVES: I incorporated qualitative methods to explore how HIV-related stigma functions in New York City's House and Ball Community (HBC). METHODS: From January through March 2009, I conducted 20 in-depth 1-on-1 interviews with a diverse sample of New York City HBC members. Interviews addressed perceptions of HIV-related stigma, the treatment of HIV-positive members in the community, and the potential impact of HIV-related stigma on risk behaviors. RESULTS: HIV-related stigma contributes to a loss of moral experience for HBC members. Moral experience (i.e., threats to what really matters in a community) disrupts established social connections and hinders the attainment of "ball status" (i.e., amassing social recognition) in the local world of these individuals. CONCLUSIONS: My recommendations address HIV-related stigma in the New York City HBC from the vantage of moral experience and highlight the need for longitudinal studies of individual house members and for the implementation of stigma-focused interventions in the community that utilize the unique ball status hierarchy and HBC network to influence social norms surrounding the treatment of HIV-positive community members.

Community associated methicillin resistant Staphylococcus aureus among New York City men who have sex with men: qualitative research findings and implications for public health practice.

Academic literature has recorded increased microbial resistance in the United States and recent news media has adversely portrayed men who have sex with men (MSM) at increased risk for community associated methicillin resistant Staphylococcus aureus (CA-MRSA) transmission. CA-MRSA is a specific type of bacteria resistant to certain antibiotics, which limits treatment options for those needing clinical care. Infection can manifest as painful abscesses and can cause severe illness. With increased CA-MRSA infections overall, and attention given to MSM populations regarding CA-MRSA, as well as the fact that limited data on sociocultural factors that may facilitate transmission, we undertook a qualitative study to explore contextual influences that may fuel infection among MSM in New York City so that public health professionals can better recognize, and respond appropriately to, potential future outbreaks. In-depth interviews were used to qualitatively investigate perceptions and beliefs regarding transmission, as well as community understandings of treatment options. Participants included thirteen MSM who reported a previous CA-MRSA infection and nine community practitioners. A thematic content analysis of these interviews was conducted and data suggests that behaviors and exposures associated with transmission of CA-MRSA are common in certain MSM networks. Specifically, sociocultural influences and methamphetamine use activities were found to contribute to CA-MRSA transmission. We underscore the role of public health and health services practitioners in providing appropriate CA-MRSA awareness and education to MSM populations.

Promoting sun safety among US Postal Service letter carriers: impact of a 2-year intervention.

OBJECTIVES: We examined whether US Postal Service letter carriers who received a sun safety intervention would wear wide-brim hats and sunscreen significantly more often than those who did not receive the intervention. METHODS: We used a 2-group randomized design with 2662 evaluation cohort participants from 70 US postal stations. Evaluations were conducted at baseline, 3 months, 1 year, and 2 years. Questionnaire items assessed occupational use of sun-screen and wide-brim hats. The 2-year sun safety intervention included the provision of wide-brim hats, accessible sunscreen, reminders, and 6 educational sessions. RESULTS: At the 3-month follow-up evaluations, the odds ratio (OR) for regular sun-screen use was 2.8 times higher among the intervention group than among the control group (95% confidence interval [CI]=2.2, 3.5); at the 2-year follow-up evaluations, the rate was still significantly higher (OR=2.0; 95% CI=1.6, 2.6). Intervention group participants also had significantly higher rates of hat use, with the differences remaining consistent across all follow-ups (OR=2.9; 95% CI=2.3, 3.6). CONCLUSIONS: The intervention should be disseminated to postal stations nationwide and possibly to other occupational groups that work outdoors.

Sun sensitivity in 5 US ethnoracial groups.

Some sun safety activities have included only non-Hispanic white individuals, even though individuals in other ethnoracial groups may be at risk for skin cancer. The objectives of this study were to investigate distributions of self-reported Fitzpatrick skin type within 5 ethnoracial groups and substantiate each group's self-report with an objective measure. The study used a cross-sectional design. The research was conducted at 70 postal stations in Southern California. Participants were US Postal Service letter carriers and included 115 Pacific Islanders, 222 black individuals, 329 Asians, 513 Hispanics, and 1364 non-Hispanic white individuals. Participants self-reported skin type and had skin color measurements taken with colorimeters. Some individuals in each ethnoracial group reported having sun-sensitive skin. Correlation tests assessing the relationship between skin type and colorimeter data showed substantial associations for each group except Asians. Future sun safety research and educational messages should include all potentially high-risk individuals, irrespective of ethnoracial identity.

Ethnoracial differences among outdoor workers in key sun-safety behaviors.

BACKGROUND: Few sun-safety studies have included ethnoracially diverse groups. Comparison across such groups of sun-safety behaviors was the main objective of this analysis. METHODS: Postal workers (n =2543) self-reported frequency of sunscreen, wide-brim hat, and sunglasses use during the last 5 workdays on 5-point Likert-type scales ranging from "never" to "always." Responses were dichotomized by "always" versus all other responses. Generalized estimating equations were used to assess the association between ethnicity/race and frequency of each sun safety behavior. The baseline data reported in this paper were collected in the summer of 2001, and the randomized trial was completed in the summer of 2004. RESULTS: Ethnicity/race was significantly related to sunscreen and sunglasses use. For both sunscreen and sunglasses, the white group had significantly higher "always" rates than the other four groups (30% vs 14% to 23% and 63% vs 44% to 52%, respectively). CONCLUSIONS: The results of this study indicated that although non-Latino white employees tended to have higher rates of sun-safety behaviors, the rates of adequate protection of all groups were low.

Sexual healthcare preferences among gay and bisexual men: a qualitative study in San Francisco, California.

BACKGROUND: Research on gay and other men who have sex with men's (G/MSM) preferences for sexual healthcare services focuses largely on HIV testing and to some extent on sexually transmitted infections (STI). This research illustrates the frequency and location of where G/MSM interface with the healthcare system, but it does not speak to why men seek care in those locations. As HIV and STI prevention strategies evolve, evidence about G/MSM's motivations and decision-making can inform future plans to optimize models of HIV/STI prevention and primary care. METHODS: We conducted a phenomenological study of gay men's sexual health seeking experiences, which included 32 in-depth interviews with gay and bisexual men. Interviews were transcribed verbatim and entered into Atlas.ti. We conducted a Framework Analysis. FINDINGS: We identified a continuum of sexual healthcare seeking practices and their associated drivers. Men differed in their preferences for separating sexual healthcare from other forms of healthcare ("fragmentation") versus combining all care into one location ("consolidation"). Fragmentation drivers included: fear of being monitored by insurance companies, a desire to seek non-judgmental providers with expertise in sexual health, a desire for rapid HIV testing, perceiving sexual health services as more convenient than primary care services, and a lack of healthcare coverage. Consolidation drivers included: a comfortable and trusting relationship with a provider, a desire for one provider to oversee overall health and those with access to public or private health insurance. CONCLUSIONS: Men in this study were likely to separate sexual healthcare from primary care. Based on this finding, we recommend placing new combination HIV/STI prevention interventions within sexual health clinics. Furthermore, given the evolution of the financing and delivery of healthcare services and in HIV prevention, policymakers and clinicians should consider including more primary care services within sexual healthcare settings.

Community member perspectives from transgender women and men who have sex with men on pre-exposure prophylaxis as an HIV prevention strategy: implications for implementation.

BACKGROUND: An international randomized clinical trial (RCT) on pre-exposure prophylaxis (PrEP) as an human immunodeficiency virus (HIV)-prevention intervention found that taken on a daily basis, PrEP was safe and effective among men who have sex with men (MSM) and male-to-female transgender women. Within the context of the HIV epidemic in the United States (US), MSM and transgender women are the most appropriate groups to target for PrEP implementation at the population level; however, their perspectives on evidenced-based biomedical research and the results of this large trial remain virtually unknown. In this study, we examined the acceptability of individual daily use of PrEP and assessed potential barriers to community uptake. METHODS: We conducted semi-structured interviews with an ethnoracially diverse sample of thirty HIV-negative and unknown status MSM (n = 24) and transgender women (n = 6) in three California metropolitan areas. Given the burden of disease among ethnoracial minorities in the US, we purposefully oversampled for these groups. Thematic coding and analysis of data was conducted utilizing an approach rooted in grounded theory. RESULTS: While participants expressed general interest in PrEP availability, results demonstrate: a lack of community awareness and confusion about PrEP; reservations about PrEP utilization, even when informed of efficacious RCT results; and concerns regarding equity and the manner in which a PrEP intervention could be packaged and marketed in their communities. CONCLUSIONS: In order to effectively reduce HIV health disparities at the population level, PrEP implementation must take into account the uptake concerns of those groups who would actually access and use this biomedical intervention as a prevention strategy. Recommendations addressing these concerns are provided.

A qualitative study of provider thoughts on implementing pre-exposure prophylaxis (PrEP) in clinical settings to prevent HIV infection.

BACKGROUND: A recent clinical trial demonstrated that a daily dose tenofovir disoproxil fumarate and emtricitabrine (TDF-FTC) can reduce HIV acquisition among men who have sex with men (MSM) and transgender (TG) women by 44%, and up to 90% if taken daily. We explored how medical and service providers understand research results and plan to develop clinical protocols to prescribe, support and monitor adherence for patients on PrEP in the United States. METHODS: Using referrals from our community collaborators and snowball sampling, we recruited 22 healthcare providers in San Francisco, Oakland, and Los Angeles for in-depth interviews from May-December 2011. The providers included primary care physicians seeing high numbers of MSM and TG women, HIV specialists, community health clinic providers, and public health officials. We analyzed interviews thematically to produce recommendations for setting policy around implementing PrEP. Interview topics included: assessing clinician impressions of PrEP and CDC guidance, considerations of cost, office capacity, dosing schedules, and following patients over time. RESULTS: Little or no demand for PrEP from patients was reported at the time of the interviews. Providers did not agree on the most appropriate patients for PrEP and believed that current models of care, which do not involve routine frequent office visits, were not well suited for prescribing PrEP. Providers detailed the need to build capacity and were concerned about monitoring side effects and adherence. PrEP was seen as potentially having impact on the epidemic but providers also noted that community education campaigns needed to be tailored to effectively reach specific vulnerable populations. CONCLUSIONS: While PrEP may be a novel and clinically compelling prevention intervention for MSM and TG women, it raises a number of important implementation challenges that would need to be addressed. Nonetheless, most providers expressed optimism that they eventually could prescribe and monitor PrEP in their practice.

Validating outdoor workers' self-report of sun protection.

BACKGROUND: Few studies assessing sun safety behaviors have used validated survey instruments. Using an observational strategy, this study measured the validity of self-report of occupational sun protection behaviors. METHODS: Postal workers (N = 1,036) self-reported their frequency of protective clothing and sunglasses use during the past 5 workdays on Likert scales ranging from "Never" to "Always". Responses were dichotomized by Always vs. all other responses. Data collectors observed these same behaviors during mail delivery several days before survey administration. Agreement between the two measures was computed. RESULTS: Self-report for all items was significantly related to observed behaviors, with Kappa values in the good to excellent range (Kappas = 0.51-0.83). CONCLUSIONS: For outdoor postal workers, survey items assessing recent occupational use of sun-protective items had high levels of validity.