Sexual Networking and HIV/STI Prevention Among Men who have Sex with Men and Identify as Persons of Color in the Era of COVID-19 in Boston, MA: Qualitative Findings from the National HIV Behavioral Surveillance Project.

Men who have sex with men and identify as persons of color (MSM of color) are significantly impacted by HIV in the United States. The COVID-19 pandemic may have disproportionately exacerbated HIV-related disparities among MSM of color by affecting sexual networking behaviors and disrupting access to sexual health care. The current study explored the impact of COVID-19 on sexual networking and HIV/sexually transmitted infection (STI) prevention behaviors among MSM of color in Boston, MA. Eighteen semi-structured interviews were conducted via the 2020-2021 Boston sample of the National HIV Behavioral Surveillance (NHBS) project. Eligible participants were at least 18 years old, identified as a man or non-binary person assigned male at birth and as a person of color, and endorsed ever having sex with men. Interviews were coded using inductive and deductive approaches, and themes were extracted using thematic analysis. When participants were asked about the impact of COVID-19 on sexual networking and HIV/STI prevention, the following themes emerged: (1) differing interpretations of COVID-19 public health guidance, (2) behavior change to meet social and sexual needs, (3) limited or changed access to HIV/STI prevention services; and (4) avoidance of healthcare appointments. Overall, the pandemic affected sexual networking and HIV/STI prevention behaviors among MSM of color. Though changes in sexual networking varied, most participants decreased in-person networking, increased dating app use, and prioritized longer-term relationships. Despite loosening of restrictions, these impacts may persist and should inform the adaptation of sexual networking guidance and interventions to mitigate HIV-related disparities in communities of color.

Associations Between Health Insurance Coverage with HIV Detection and Prevention Behaviors Among Individuals with Undiagnosed HIV or at Increased Risk for HIV Infection in the USA.

BACKGROUND: Improving HIV detection and prevention remains a critical public health initiative that requires policy-based solutions. This study sought to compare HIV detection/prevention behaviors before and after healthcare reform in Massachusetts, USA, among heterosexually active persons - the group with the highest reported number of undiagnosed HIV cases. The current study sought to (1) characterize differences in insurance coverage and HIV detection/prevention behaviors between cycles 1 (2006) to 5 (2019); (2) evaluate socio-demographic disparities in insurance coverage accounting for cycle; and (3) evaluate associations between health insurance coverage and HIV detection/prevention behaviors accounting for cycle and socio-demographics. METHODS: This is a secondary analysis of the National HIV Behavioral Surveillance (NHBS) project: Boston HET cycle (i.e., made up of heterosexually active persons living in the Boston area) data. Descriptive, bivariate (e.g., chi-square), and multiple logistic and negative binomial loglink regression analyses were conducted. RESULTS: In chi-square analyses with post hoc Bonferroni tests, the proportion of participants with current health insurance significantly increased from cycle 1 (77%) to cycle 2 (95%), p < .001. In the regression models that controlled for NHBS cycle, 1-year change in age (adjusted odds ratio [aOR] = 1.03, 95% confidence interval [CI] = 1.02, 1.05), female gender (aOR = 3.41, 95% CI = 2.48, 4.69), and change in education category (aOR = 1.19, 95% CI = 1.02, 1.39) were associated with a higher likelihood of having health insurance. In regression models that controlled for cycle, age, gender, and education, participants with health insurance were more likely than those without insurance to report seeing a medical provider in the past year (aOR = 3.49, 95% CI = 2.32, 4.66), ever having an HIV test (aOR = 1.52, 95% CI = 0.35, 2.69) and more frequent HIV testing in the past 2 years (incidence rate ratio [IRR] = 1.44, 95% = 1.14, 1.82). Participants with health insurance did not differ from those without insurance in number of vaginal condomless sex partners (IRR = 1.16, 95% CI = 0.95, 1.41) but did report more condomless anal sex partners in the past year (IRR = 1.97, 95% CI = 1.46, 2.65). CONCLUSIONS: This study demonstrates how health insurance coverage is positively associated with HIV detection and prevention relevant to both US and international efforts to end the HIV epidemic.

Psychology Internship Training Amidst COVID-19: Balancing Training Opportunities, Patient Care, and Risk of Exposure.

The emergence of the 2019 novel coronavirus (COVID-19) has dramatically altered how psychologists deliver its training. At least for the time being, virtual care has become the primary method for delivering mental health services. This has allowed patients and clinicians to continue to access and provide services in a way that would have been impossible years ago. Not only has this shift impacted patients, but it has also impacted supervision and training. The impact has been especially profound on inpatient units where the psychiatric and medical acuity is high of patients and the therapeutic milieu is an important aspect of treatment. The purpose of this paper is to review the impact of COVID-19 on pre-doctoral psychology interns during their rotation on an inpatient psychiatry unit at the start of the pandemic (January to June of 2020) and use these experiences to onboard the next class of interns in the new academic year (July 2020 to June 2021) using a hybrid model of in-person and virtual training experiences. At the end of 2020/2021 rotation, we voluntarily asked interns to complete a questionnaire that was developed based on the qualitative experiences of the previous class to assess the effectiveness of this hybrid model. We also surveyed multi-disciplinary staff members who were essential personnel and required to work in person during this time about their experiences of safety and support. With this information, we explore and offer guidance to other inpatient training sites who are likely to encounter similar challenges during this time. In particular, we discuss the integration of virtual technology into this training experience, as well as the restructuring of clinical and supervisory experiences. We highlighted several short-term strategies that we have flexibly adapted to our inpatient unit. The lessons learned herein seek to guide supervisors and trainees alike in adapting their psychology training programs to meet the evolving demands of COVID-19.

Daily Associations Between Alcohol Consumption and Antiretroviral Therapy (ART) Adherence Among HIV-Positive Men Who Have Sex With Men.

Alcohol consumption is one of the strongest predictors of suboptimal adherence to antiretroviral therapy (ART), however, there is little research that has investigated both within- and between-person associations of alcohol consumption and ART adherence at the event-level. In this secondary data-analysis, (N = 22) HIV-positive MSM prospectively reported daily alcohol consumption and ART adherence for 42-days. Multilevel models demonstrated (1) days in which participants reported consuming any alcohol was associated with 2.48 increased odds of ART non-adherence, compared to days in which participants reported no alcohol consumption, and (2) there was a non-significant trend indicating days in which participants reported consuming greater than their own average levels of alcohol was associated with increased odds of ART non-adherence. Findings highlight the importance of combining intervention efforts that address alcohol consumption and suboptimal ART adherence, and indicate a need for future research to investigate the mechanisms by which alcohol influences ART adherence.

Development of a Telephone-Delivered Acceptance and Commitment Therapy Intervention for People Living with HIV who are Hazardous Drinkers.

Alcohol use among people living with HIV (PWH) has been increasingly recognized as an important component of HIV care. Transdiagnostic treatments, such as Acceptance and Commitment Therapy (ACT), that target core processes common to multiple mental health and substance-related problems, may be ideal in HIV treatment settings where psychological and behavioral health comorbidities are high. In advance of a randomized clinical trial (RCT), the overall objective of this study was to systematically adapt an ACT-based intervention originally developed for smoking cessation, into an ACT intervention for PWH who drink at hazardous levels. Consistent with the ADAPT-ITT model, the adaptation progressed systematically in several phases, which included structured team meetings, three focus group discussions with PWH (N = 13), and in-depth interviews with HIV providers (N = 10), and development of standardized operating procedures for interventionist training, supervision, and eventual RCT implementation. The procedures described here offer a template for transparent reporting on early phase behavioral RCTs.

Discrimination experiences, resilience, and cardiovascular disease risk factors among sexual minority women.

Resilience, or the process of adapting to adversity, may protect against the harmful effects of minority-related stressors on the cardiovascular health of sexual minority women (SMW). An online survey was conducted in a sample of cisgender, non-heterosexual women to evaluate resilience as a moderator of the association between discrimination experiences and key cardiovascular disease (CVD) risk factors: stress, tobacco-smoking, hazardous alcohol consumption, poor diet quality, physical inactivity, and sedentary behaviors. Overall, 191 women (mean age = 29.34, SD = 6.92; 84.5% White) completed the survey and met eligibility to be included in the data analysis. White race (b = - 6.71, SE = 2.49) and education (b = - 3.36, SE = 0.56) were each independently associated with fewer discrimination experiences. Latinx ethnicity was associated with more discrimination experiences (b = 9.34, SE = 2.61). Education was associated with greater resilience (b = 4.57, SE = 0.83). Multivariable regression models were adjusted for race, ethnicity, and education. Discrimination was associated with a higher likelihood of smoking in the past month (b = 0.04, SE = 0.02) and drinking at hazardous levels (b = 0.09, SE = 0.02). Resilience was associated with less stress (b = - 0.15, SE = 0.02), a lower likelihood of hazardous alcohol consumption (b = - 0.02, SE = 0.01) and less time spent engaging in sedentary behaviors (b = - 0.02, SE = 0.01). One moderation emerged, such that discrimination was negatively associated with stress for those low in resilience (b = - 1.75, SE = 0.58), and not associated with stress for those high in resilience. These findings may inform the development of CVD-risk reduction interventions for SMW, which could include both strategies to mitigate the effects of discrimination on substance use and coping skills to promote resilience.

Substance Use Stigma, Avoidance Coping, and Missed HIV Appointments Among MSM Who Use Substances.

Men who have sex with men (MSM) living with HIV who use substances have multiple stigmatized identities. Theory suggests that internalization of stigma may elicit avoidance behaviors associated with these stigmas, potentially resulting in suboptimal engagement in HIV care. We investigated interrelationships between internalized stigmas related to HIV, sexual orientation, and substance use; avoidance coping; and missed HIV appointments among 202 MSM living with HIV who use substances. Neither HIV nor sexual orientation-related internalized stigmas were associated with missed appointments, however, internalized substance use stigma (SUS) was associated (OR 1.47, 95% CI 1.15, 1.87). The relationship between internalized SUS and missed appointments was partially accounted for by avoidance coping (b = 0.12; bootstrap 95% CI 0.02, 0.25). To better understand the role of SUS, we assessed relationships between enacted and anticipated SUS and missed appointments (OR 2.08, 95% CI 1.52, 2.84 and OR 1.44, 95% CI 1.10, 1.88, respectively). Avoidance coping fully accounted for the relationship between anticipated SUS and missed appointments (b = 0.12; 95% CI 0.02, 0.25). Results suggest that avoidance strategies to manage anticipated SUS may result in substance using MSM forgoing HIV care appointments.

Framed Messages to Increase Condom Use Frequency Among Individuals Taking Daily Antiretroviral Medication for Pre-exposure Prophylaxis.

PrEP delivery and routine care provide a unique opportunity to promote sexually transmitted infection (STI) prevention by both increasing STI testing frequency and creating a space for affirmative and effective safer sex counseling. This study was a feasibility and acceptability pilot of an adapted framed message intervention to increase condom use frequency with PrEP. In the formative phase, two focus groups with PrEP users (N = 7) provided feedback on a provisional loss-framed message intervention and identified potential study barriers. In the pilot trial, the adapted loss-framed message intervention was compared to a gain-framed message intervention and enhanced skills condition in a sample of PrEP users (N = 29). In terms of intervention feasibility, 58% of approached PrEP users completed the eligibility screen; 79% of those eligible enrolled in the study and 66% of enrolled participants completed the three-month follow-up. In terms of intervention acceptability, participants found the informational messages, regardless of assignment, to be moderately interesting (M = 6.24, SD = 2.97) and useful (M = 7.07, SD = 3.00), and very easy to understand (M = 9.50, SD = 0.97) on Likert-type scales ranging from 1 to 10. In terms of intervention effects, there was a small effect of the gain-framed intervention (b = .58, SE = .93, CI = -1.33, 2.48, Cohen's d = .26) on HIV/STI risk transmission. There was a small-medium effect of both the loss- (b = 2.00, SE = .90, CI = .15, 3.85, Cohen's d = 1.46) and gain-framed (b = 2.24, SE = .93, CI = .34, 4.15, Cohen's d = 1.65) interventions on condom use motivation. Finally, there was a medium-large effect of both the loss- (b = .97, SE = 1.33, CI = -1.88, 3.82, Cohen's d = .54) and gain-framed intervention (b = 1.97, SE = 1.33, CI = -.88, 4.82, Cohen's d = .87) on condom use frequency. Further refinement and testing, in a larger -scale trial with higher ecological validity than this initial pilot intervention, is warranted.

Medication Beliefs, HIV-Related Stigmatization, and Adherence to Antiretroviral Therapy: An Examination of Alternative Models.

HIV-related stigma and beliefs about medication necessity and concerns have separately demonstrated significant associations with antiretroviral adherence in people with HIV. However, no work has examined both of these associations in the same model. Based on the necessity-concerns framework, this study examined four alternative models of relationships among HIV-related stigma, medication beliefs, and adherence. Cross-sectional analyses were used to test the four alternative models to best depict associations among HIV-related stigma, medication beliefs, and medication adherence. Models tested included two indirect effects models, an interaction model, and a simple predictors model with no interaction or indirect effects. The outcome variable was HIV medication adherence, and model fit was determined by variance accounted for, Akaike information criterion (AIC), and Bayesian information criterion (BIC) values. An interaction model between internalized stigma and medication concerns accounted for the most variance in adherence. There was also a significant indirect effect of internalized stigma on adherence via medication concerns. Medication concerns are a promising target for interventions focusing on increasing adherence among people with HIV.

Assessing the interaction between depressive symptoms and alcohol use prior to antiretroviral therapy on viral suppression among people living with HIV in Rural Uganda.

Although there is evidence of individual associations between depressive symptoms and hazardous alcohol use with suboptimal antiretroviral therapy (ART) adherence among people living with HIV (PLWH), few studies have established how the two risk factors may interact to predict viral suppression. We conducted secondary data analyses with two cohorts of Ugandan PLWH (N = 657) to investigate the hypothesized interaction between depressive symptoms (Center for Epidemiological Studies Depression Scale) and hazardous alcohol use (Alcohol Use Disorder Identification Test -Consumption and/or Phosphatidylethanol biomarker) prior to ART initiation with viral suppression (<550 copies/ml). We were unable to detect an interaction between depressive symptoms and hazardous alcohol use prior to ART initiation with viral suppression in the first two years (M = 19.9 months) after ART initiation (p = 0.75). There was also no evidence of a main effect association for depressive symptoms (Adjusted Odds Ratio [AOR] = 0.88, 95% Confidence Interval [CI]: 0.50, 1.55) or hazardous alcohol use (AOR = 1.37, 95% CI: 0.80, 2.33). PLWH with depressive symptoms and/or hazardous alcohol use appear to exhibit similar levels of viral suppression as others in care; further work is needed to determine effects on HIV testing and treatment engagement.

Examining sexual minority engagement in recovery community centers.

INTRODUCTION: Research indicates that sexual minority (SM) individuals with alcohol and other drug use disorders may underutilize recovery resources generally but be more likely to use recovery community centers (RCCs). To inform recovery supports, this study characterized SM and heterosexual RCC members by demographics and clinical and recovery support service utilization. METHODS: Cross-sectional secondary analyses compared SM and heterosexual RCC members in the northeastern U.S. (n = 337). Qualitative analyses coded the top three recovery facilitators. RESULTS: Of the 337 participants (Meanage[SD] = 40.98[12.38], 51.8 % female), SM RCC members were more likely than heterosexuals to endorse lifetime psychiatric diagnoses and emergency department mental health treatment (p < .01). RCC service utilization and qualitatively derived recovery facilitators were mostly consistent across groups. CONCLUSIONS: RCCs engaged SM individuals in recovery in ways consistent with heterosexuals. Despite otherwise vastly similar demographic characteristics across sexual identity, findings suggest a need for additional mental health resources for SM individuals in recovery.

Facets of Gender Expression and Discrimination in Relation to Alcohol and Other Drug Use Severity Among Sexual Minority Women and Gender Diverse Individuals Assigned Female at Birth.

Purpose: Sexual minority women and gender diverse individuals assigned female at birth (SMW+) consistently report more alcohol and other drug (AOD) use severity than heterosexual women, with greater disparities reported among bisexual plus (bi+) SMW (including bisexual, pansexual, queer, and those with attractions to more than one gender regardless of identity). Furthermore, emerging evidence suggests that SMW with masculine gender expression (e.g., SMW with masculine gender appearance) disproportionately experience problematic AOD use compared to those with feminine gender expression. The minority stress model, which has predominantly been investigated in relation to internalized homonegativity and sexuality-based discrimination, may also account for these AOD use disparities. This study examined gender expression, related discrimination, and AOD use severity among SMW+. Methods: In a 2020 sample of SMW+ (n = 236), we investigated AOD use severity in relation to gender expression (appearance, emotional expression, and gender roles) and gender expression-based discrimination after controlling for internalized homonegativity and sexuality-based discrimination through an online survey. Results: Masculine gender roles were associated with AOD use severity, whereas masculine appearance and emotional expression were not. In multivariable models, gender identity was inconsistently associated with alcohol use severity, sexuality-based discrimination was consistently associated with alcohol use severity and inconsistently associated with other drug use severity, and gender expression-based discrimination was associated with neither. Conclusion: This study emphasizes the importance of examining intersecting aspects of minority identity among SMW+, including facets of gender expression, in relation to AOD use severity.

Shame and stigma in association with the HCV cascade to cure among people who inject drugs.

BACKGROUND: Psycho-social experiences including shame and experienced and internalized stigma have been associated with substance use, HCV infection, and reluctance to disclose HCV status and pursue treatment. These psycho-social barriers have been examined independently for many chronic diseases, including HCV, but to our knowledge have not been quantitatively explored in a large multi-site US-based sample of people who inject drugs (PWID) in HCV treatment. METHODS: We examine baseline relationships with HCV-stigma and engagement across the HCV treatment cascade as well as baseline and longitudinal relationships between shame and engagement across the HCV treatment cascade including treatment initiation, adherence, completion, and sustained virologic response (SVR) among a multi-site sample of PWID with HCV, where N=755 were randomized to the pragmatic trial comparing HCV treatment outcomes in modified directly observed treatment (mDOT) or patient navigation, and N=623 initiated treatment. RESULTS: While cross-sectional assessments of shame and HCV-stigma were not associated with engagement across the HCV treatment cascade, those whose shame scores decreased compared to those who reported consistently high and increasing levels of shame were significantly more likely to complete HCV treatment (aOR=5.29; 95%CI: 1.56,18.00) and achieve SVR (aOR=6.32; 95%CI: 1.61, 24.87). CONCLUSION: Results underscore the relationships between lower levels of shame and health-related behavior and treatment outcomes among PWID and suggest SVR achievement may contribute to reductions in shame or that reductions in shame may contribute to continued treatment and thus SVR.

Evaluating Food Intake Outcomes Among Sexual Minority Women: A Systematic Review.

Purpose: Sexual minority women (SMW) have a higher prevalence of obesity and weight-related health disparities when compared with heterosexual women that may be explained by differences in food intake. This systematic review had two primary aims: (1) synthesize the results for food intake outcomes among SMW, organized primarily according to the dietary risk assessment; and (2) identify possible theoretically informed moderators and mediators of the association between women's sexual identity and differences in food intake. Methods: The literature search was conducted using the PubMed and PsycInfo databases to identify articles published until March 23, 2021. Inclusion criteria were: (1) included a sample of adult SMW, (2) quantitatively assessed a food intake outcome, and (3) published in an English language peer-reviewed journal in the past 10 years. Thirteen articles were eligible and included in the review. Results: Overall, there were inconsistent findings comparing food intake between SMW and heterosexual women. There was some evidence to suggest that identity characteristics beyond sexual orientation (e.g., race and gender presentation) and place of residence (e.g., urban vs. rural settings) were plausible moderators. Only one variable pertaining to SMW's developmental history, mother's diet quality, was identified as a possible mediator. The main critiques of the literature include the predominance of convenience sampling, cross-sectional data, and inconsistencies in the measurement of sexual orientation and diet. Conclusion: This review highlights that further work is needed to consider additional hypotheses to explain disparities in obesity and weight-related health disparities among SMW to inform comprehensive behavioral intervention strategies.

A conceptual model of alcohol use and adherence to antiretroviral therapy: systematic review and theoretical implications for mechanisms of action.

Alcohol consumption is one of the most prevalent correlates of antiretroviral therapy (ART) adherence, yet causal processes underlying this association remain largely unexplored. The goal of this systematic review was to develop a conceptual model that describes the causal effect of alcohol consumption on ART nonadherence. We reviewed 230 studies that examined the association between alcohol consumption and ART adherence with three primary aims: (1) to replicate and extend previous reviews of the literature, (2) to summarize and critique study designs capable of answering questions about temporal overlap and (3) to summarize potential mechanisms of action. A model of alcohol-associated ART nonadherence was proposed to guide future work, integrating general theories of ART adherence and theory on the psychological and behavioral effects of alcohol intoxication. The conceptual model describes two mechanistic processes-prospective memory impairment and interactive toxicity beliefs/avoidance behaviors-involved in alcohol-associated intentional and unintentional nonadherence, respectively. This model can be used to guide future research on the causal processes involved in the frequently observed correlation between alcohol consumption and adherence.

Intersecting internalized stigmas and HIV self-care among men who have sex with men and who use substances.

RATIONALE: Men who have sex with men (MSM) are disproportionately affected by HIV, substance use, and stigma related to co-existing or intersecting identities that are stigmatized or devalued by society (e.g., being a sexual minority male, a person living with HIV, or a person who uses substances). Evidence indicates that when stigma is internalized it may act as a barrier to engagement in self-care behaviors. OBJECTIVE: Gaining a better understanding of how intersecting internalized stigmas affect HIV self-care among MSM who use substances. METHODS: To investigate these relationships, we conducted semi-structured qualitative interviews until we reached thematic saturation (n = 33) with HIV + MSM who use substances and were sub-optimally engaged in HIV care. Interviews inquired about identity, internalized stigmas, substance use, HIV self-care behaviors, and interrelationships between concepts. RESULTS: Our sample was 61% African American and 76% reported annual incomes of ≤$20,000. Approximately half of the participants explicitly described how intersecting internalized stigmas impacted their sense of self and their behavior. The overwhelming majority conveyed that internalized stigma related to substance use was the most burdensome and was considered a barrier to HIV self-care behaviors. Participants also described internalized stigmas related to HIV and sexual orientation, as well as race, effeminateness, poverty, and housing instability, which together impacted their psychological wellbeing and HIV self-care. CONCLUSIONS: Our results indicate a need for clinicians to consider and address intersecting internalized stigmas, particularly internalized stigma related to substance use, to both reduce substance use and improve HIV self-care among MSM who use substances and are sub-optimally engaged in HIV care.

Depressive symptoms as a longitudinal predictor of sexual risk behaviors among African-American adolescents.

OBJECTIVE: Understanding individual level factors associated with sexual risk behaviors among African-American adolescents remains an important public health priority. The current secondary data analysis examined the longitudinal association between a baseline assessment of depressive symptoms and sexual risk behaviors reported 6 months later; the purpose was to determine whether the association of depressive symptoms to risky sex varies as a function of gender. A secondary aim was to examine self-efficacy for sex refusal and condom use assessed at a 3-month follow-up as mediators of the depressive symptoms-sexual risk relationship. METHODS: The sample consisted of 782 sexually active African-American adolescents (Mage = 15.3 years, SD = 1.08; 54% female) recruited to participate in a sexual health intervention trial. Data analyses focused on vaginal sex, and outcomes included: (a) sexual activity with 2 or more partners in the previous 3 months; (b) the relative frequency of condom use in the previous 3 months; (c) noncondom use at last occasion of sex; and (d) positive sexually transmitted infection (STI) screening. RESULTS: Depressive symptoms predicted sex with 2 more partners for female participants, but no other risk markers for the sample as a whole. However, there was a significant indirect effect of depressive symptoms on condomless sex via decreased condom use self-efficacy for both male and female adolescents. CONCLUSIONS: These findings have important implications for HIV/STI prevention, in which behavioral interventions may benefit from modules that include a focus on the influence of mood on self-efficacy for safer sex practices. (PsycINFO Database Record (c) 2019 APA, all rights reserved).