Efficacy of Behavioral Intervention, Text Messaging, and Extended Intervention to Address Alcohol Misuse in Sexual Minority Men with HIV: A Factorial Randomized Clinical Trial.

This clinical trial examined the individual and combined effects of three different approaches to reducing alcohol misuse among a sample of sexual minority men (SMM) with HIV. Specifically, we used a 2 × 2 × 2 randomized factorial design to compare: (a) behavioral intervention based in motivational interviewing (MI) vs. brief intervention (BI), (b) interactive text messaging (ITM) for alcohol use vs. no ITM, and (c) extended intervention (EI) length of nine months vs. a one-month intervention duration. Participants (N = 188) were SMM with HIV and alcohol misuse recruited in Miami, FL, and Boston, MA. Participants were randomized to one of eight intervention combinations and assessed at 6- and 12-month follow-ups. Large reductions of over 50% in drinks per week and heavy drinking days were observed in all conditions at follow-up. Those who received ITM, compared to those who did not, reported significantly lower drinks consumed per week at 6 and 12 months (incidence rate ratios = 0.73 [95% CI = 0.57, 0.90] and 0.72 [95% CI = 0.56, 0.87], respectively), and increased odds of cessation of alcohol misuse at 12 months, odds ratio = 1.46, 95% CI = 1.03, 2.08. Results provided no evidence of better alcohol use outcomes for either MI or EI relative to their comparison conditions, and no specific combination of intervention components demonstrated a notable benefit. This study suggests a two-session BI can effectuate substantial reductions in alcohol use in SMM with HIV and that adding one month of ITM can yield further improvements. Clinical Trials Number: NCT02709759.

PrEP Uptake and Methamphetamine Use Patterns in a 4-Year U.S. National Prospective Cohort Study of Sexual and Gender Minority People, 2017-2022.

Methamphetamine use is on the rise among sexual and gender minority people who have sex with men (SGMSM), escalating their HIV risk. Despite pre-exposure prophylaxis (PrEP) being an effective biomedical HIV prevention tool, its uptake in relation to methamphetamine use patterns in SGMSM has not been studied. In a U.S. cohort study from 2017 to 2022, 6,253 HIV-negative SGMSM indicated for but not using PrEP were followed for four years. Methamphetamine use was categorized (i.e., newly initiated, persistently used, never used, used but quit), and PrEP uptake assessed using generalized estimating equation (GEE), adjusted for attrition. Participants had a median age of 29, with 51.9% White, 11.1% Black, 24.5% Latinx, and 12.5% other races/ethnicities. Over the four years, PrEP use increased from 16.3 to 27.2%. GEE models identified risk factors including housing instability and food insecurity. In contrast, older age, health insurance, clinical indications, and prior PrEP use increased uptake. Notably, Latinx participants were more likely to use PrEP than Whites. Regarding methamphetamine use, those who newly initiated it were more likely to use PrEP compared to non-users. However, those who quit methamphetamine and those who persistently used it had PrEP usage rates comparable to those of non-users. Though PrEP uptake increased, it remained low in SGMSM. Methamphetamine use was associated with PrEP uptake. Healthcare providers should assess methamphetamine use for harm reduction. Prioritizing younger, uninsured SGMSM and addressing basic needs can enhance PrEP uptake and reduce HIV vulnerabilities.

Discrimination and adherence in a cross-sectional study of Latino sexual minority men with HIV: Coping with discrimination as a mediator and coping self-efficacy as a moderator.

Discrimination is associated with antiretroviral therapy non-adherence and reduced well-being among people with HIV. We examined the potential for coping to mediate the associations between intersectional discrimination and non-adherence and coping self-efficacy (confidence in one's ability to cope with discrimination) as a moderator that may buffer the negative effects of discrimination on non-adherence in a cross-sectional convenience sample of 82 Latino sexual minority men with HIV. In bivariate linear regressions, discrimination targeting Latino ethnic origin, undocumented residency status, and sexual orientation were each significantly associated with lower self-reported antiretroviral therapy non-adherence (percentage of prescribed doses taken in the last month) and greater use of disengagement coping (denial, substance use, venting, self-blame, behavioral disengagement). Associations between discrimination targeting Latino ethnicity and non-adherence, and discrimination targeting undocumented residency status and non-adherence, were each mediated by disengagement coping responses. Moderation analyses highlighted significant discrimination by coping self-efficacy interaction effects-both coping self-efficacy for problem solving and stopping unpleasant emotions/thoughts each moderated the associations between Latino discrimination and adherence, between undocumented residency status discrimination and adherence, and between HIV discrimination and adherence. Coping self-efficacy for getting social support moderated the association between undocumented residency status discrimination and adherence. Further, the interaction coefficients across models indicated that the negative effects of discrimination on adherence were attenuated at higher levels of coping self-efficacy. Findings highlight the need for structural interventions that reduce-and ultimately eliminate-discrimination, and interventions that address the harmful effects of discrimination and adherence improvement interventions to enhance coping skills among people faced with intersectional discrimination.

Modeling the Impact of Race, Socioeconomic Status, Discrimination and Cognitive Appraisal on Mental Health Concerns Among Heavy Drinking HIV+ Cisgender MSM.

Prior research has attributed mental health disparities between marginalized and non-marginalized populations to socioeconomic differences (i.e., education, income, employment), stigma (e.g., HIV-related discrimination), and cognitive appraisal (i.e., optimism, hostility, satisfaction with life), but the relations among these variables have not been examined concomitantly. The current study utilized structural equation modeling to examine how race and socioeconomic status impact mental health outcomes through increased exposure to stigma and more negative cognitive appraisals. Data came from a randomized controlled trial of motivational interviewing to address heavy drinking in cisgender men with HIV who have sex with men (n = 180). We found that self-reported discrimination experiences related to race/ethnicity, sexual orientation, and HIV status significantly mediated the relation between socioeconomic status and mental health concerns, whereas cognitive appraisal did not. These findings suggest that, among heavy drinking men with HIV who have sex with men, having low socioeconomic resources may increase exposure to discrimination which, in turn, may worsen mental health. Interventions that address social determinants, like socioeconomic disadvantage, and that enhance coping resources related to stigma, may have positive effects on mental health.ClinicalTrials.gov Identifier NCT01328743. Date of Registration 09/09/2019.

RESUMEN: Investigaciones anteriores han atribuido las disparidades de salud mental entre poblaciones marginadas y no marginadas a diferencias socioeconómicas (es decir, educación, ingresos, empleo), estigma (por ejemplo, discriminación relacionada con el VIH) y evaluación cognitiva (es decir, optimismo, hostilidad, satisfacción con la vida), pero las relaciones entre estas variables no han sido examinadas concomitantemente. El estudio actual utilizó modelos de ecuaciones estructurales para examinar cómo la raza y el estatus socioeconómico afectan los resultados de salud mental a través de una mayor exposición al estigma y evaluaciones cognitivas más negativas. Los datos provienen de un ensayo controlado aleatorio de entrevistas motivacionales para abordar el consumo excesivo de alcohol en hombres cisgénero con VIH que tienen sexo con hombres (n = 180). Encontramos que las experiencias de discriminación autoinformadas relacionadas con la raza/etnicidad, la orientación sexual y el estado serológico respecto al VIH mediaron significativamente en la relación entre el estado socioeconómico y los problemas de salud mental, mientras que la evaluación cognitiva no lo hizo. Estos hallazgos sugieren que, entre los hombres con VIH que beben mucho y tienen sexo con hombres, tener bajos recursos socioeconómicos puede aumentar la exposición a la discriminación que, a su vez, puede empeorar la salud mental. Las intervenciones que abordan los determinantes sociales, como la desventaja socioeconómica, y que mejoran los recursos de afrontamiento relacionados con el estigma, pueden tener efectos positivos en la salud mental.

PrEP uptake as a social movement among gay and bisexual men.

Despite PrEP's effectiveness as an HIV prevention intervention, uptake among gay and bisexual men remains low. Historical involvement in AIDS activism may reveal important ways of mobilising gay and bisexual men to increase PrEP uptake. Data come from a qualitative study to understand New York City gay and bisexual men's experiences with PrEP. Informed by a constructivist grounded theory approach, we assessed ways in which gay and bisexual men's relational experiences concerning PrEP were congruent with features of past AIDS activism. Participants' mean age was 32.5 years, half were men of colour, and over half had been taking PrEP for less than one year. Analysis revealed three primary themes related to AIDS activism strategies: (1) framing, which referenced how participants referred to PrEP as an empowering, liberatory and community-building intervention (2) reactions, which encompassed positive to negative expressions about PrEP and sex; and (3) innovation, which conveyed ways that participants engaged in processes of transferring lay knowledge about PrEP through leadership roles across social and digital encounters. Findings suggest that the ways in which gay and bisexual men communicate about PrEP with peers are consistent with features of AIDS activism. Deploying lay knowledge using framing strategies through peer-based intervention could expand PrEP uptake. However, elements of PrEP stigma must be addressed to engage with the wide-ranging HIV prevention needs of gay and bisexual men.

A heavy burden: Associations between sexual minority status, mental health, and BMI in women.

BACKGROUND: Sexual minority women (SMW) are at increased risk of elevated body mass index (BMI) compared to heterosexual women, increasing their vulnerability to chronic diseases. Nonmonosexual SMW appear to be at additional risk for elevated BMI, likely due to unique sexual minority stressors. METHODS: A total of 437 SMW and heterosexual women completed a cross-sectional, online survey including self-report measures of sexual orientation dimensions, weight, psychological distress, and eating behaviors. We investigated relations among these variables to better understand disparities in self-reported BMI based on sexual orientation and sexual orientation discordance (SOD). RESULTS: SMW self-reported more psychological distress, more binge eating, and higher BMIs than their heterosexual peers, with nonmonosexual groups of SMW often reporting the highest values. SOD was positively associated with psychological distress. CONCLUSIONS: SMW-particularly nonmonosexual SMW-are at increased risk for psychological distress, binge eating, and elevated BMI relative to heterosexual peers. Future research should further elucidate mechanisms for these disparities.

PrEP Uptake and Discontinuation Among a U.S. National Sample of Transgender Men and Women.

Pre-exposure prophylaxis (PrEP) has revolutionized HIV prevention efforts by effectively preventing the sexual transmission of HIV infection. Few studies have examined PrEP uptake and discontinuation among transgender individuals who are underserved in HIV prevention efforts. An online U.S. nationwide survey screened 294 HIV-negative transgender people for participation in a larger cohort study. We analyzed associations between demographic characteristics and PrEP use and discontinuation. We conducted thematic analyses of open-ended responses to identify reasons for PrEP discontinuation. Fifty-one participants (17.4%) reported ever receiving a PrEP prescription. Transgender men reported higher PrEP use than transgender women (χ2 = 18.06; p < 0.0001). PrEP discontinuation was reported by 49.0% of individuals who reported PrEP use. Reasons for PrEP discontinuation were related to side effects, insurance coverage, relationship status, and access to providers. HIV prevention efforts to increase PrEP should include mechanisms for PrEP uptake and re-initiation among transgender individuals.

RESUMEN: La profilaxis pre-exposición (PrEP) ha revolucionado la prevención del VIH al prevenir efectivamente la transmisión del VIH. Pocos estudios han examinado la adopción y descontinuación de PrEP entre las personas transgénero quienes son desatendidas en los esfuerzos de prevención del VIH. Una encuesta nacional en-línea de EEUU calificó a 294 personas transgénero VIH-negativas para participar en un estudio cohorte más grande. Analizamos las asociaciones entre las características demográficas y el uso y descontinuación de PrEP. Realizamos análisis temáticos de las respuestas a preguntas abiertas para identificar razones para la descontinuación de PrEP. Cincuenta y uno participantes (17.4%) reportaron haber tomado PrEP alguna vez. Los hombres transgénero reportaron mayor uso de PrEP que las mujeres transgénero (χ2 = 18.06; p < 0.0001).  La descontinuación de PrEP fue reportada por 49.0% de los individuos que reportaron haber usado PrEP. Las razones por la descontinuación se relacionaron a los efectos secundarios, la cobertura del seguro medico, el estado civil, y el acceso a proveedores de salud. Los esfuerzos de prevención del VIH para aumentar el uso de PrEP deben incluir mecanismos para la adopción y reinicio entre las personas transgénero.

Pilot Randomized Controlled Trial of an Intervention to Improve Coping with Intersectional Stigma and Medication Adherence Among HIV-Positive Latinx Sexual Minority Men.

We developed and pilot-tested an eight-session community-based cognitive behavior therapy group intervention to improve coping with intersectional stigma, address medical mistrust, and improve antiretroviral treatment adherence. Seventy-six HIV-positive Latinx sexual minority men (SMM; 38 intervention, 38 wait-list control) completed surveys at baseline, and 4- and 7-months post-baseline. Adherence was electronically monitored. Intention-to-treat, repeated-measures regressions showed improved adherence in the intervention vs. control group from baseline to follow-up [electronically monitored: b (95% CI) 9.24 (- 0.55, 19.03), p = 0.06; self-reported: b (95% CI) 4.50 (0.70, 8.30), p = .02]. Intervention participants showed marginally decreased negative religious coping beliefs in response to stigma [b (95% CI) = - 0.18 (- 0.37, 0.01), p = .06], and significantly lower medical mistrust [b (95% CI) = - 0.47 (- 0.84, - 0.09), p = .02]. Our intervention holds promise for improving HIV outcomes by empowering Latinx SMM to leverage innate resilience resources when faced with stigma.ClinicalTrials.gov ID (TRN): NCT03432819, 01/31/2018.

RESUMEN: Hemos desarrollado un estudio piloto para poner a prueba un programa de ocho-sesiones de terapia cognitivo-conductual basado en un grupo de comunidad para abordar el estigma interseccional, la desconfianza médica y mejorar la adherencia al tratamiento antirretroviral. Setenta y seis hombres Latinos de minorías sexuales VIH positivos (38 en el grupo de intervención, 38 en el grupo de control de lista de espera) completaron encuestas al inicio, y cuatro y siete meses después de la línea de base. La adherencia fue medida electrónicamente. Los resultados del análisis mostraron una mejor adherencia en el grupo de intervención en comparación al grupo de control desde el inicio hasta el seguimiento [monitoreado electrónicamente: b (95% IC) 9.24 (− 0.55, 19.03), p = .06; y autoreporte: b (95% IC) 4.50 (0.70, 8.30), p = .02]. Los participantes del grupo de intervención mostraron una disminución marginal en las creencias negativas de afrontamiento religioso al estigma [b (95% IC) − 0.18 (− 0.37, 0.01), p = .06], y significativamente menor desconfianza médica [b (95% IC) − 0.47 (− 0.84, − 0.09), p = .02]. Nuestra intervención es prometedora para mejorar los resultados del VIH al empoderar a hombres Latinos de minorías sexuales para tomar ventaja de los recursos de resiliencia innatos cuando se enfrentan al estigma.

Experiences Receiving HIV-Positive Results by Phone: Acceptability and Implications for Clinical and Behavioral Research.

Improving HIV testing rates and increasing early detection among men who have sex with men (MSM) are critical strategies for enhancing overall health and decreasing HIV transmission. Remote testing and phone delivery of HIV test results may reduce barriers such as geographic isolation or HIV-related stigma. In 2018-19, 50 MSM completed qualitative interviews about their experience receiving a positive HIV test result via phone through their participation in a research study that included remote HIV testing. Interview topics included the acceptability of, and concerns about, phone delivery of HIV results, as well as suggestions for improvement. Interviews were transcribed, coded, and analysed using an inductive thematic approach. Overall, participants reported high acceptability of phone delivery of HIV-positive results. Participants praised the support and information provided by study staff. Benefits identified included increased convenience compared to in-person medical visits, allowing participants to emotionally process their test results privately, as well as receiving the results from supportive and responsive staff members. A few participants indicated drawbacks to phone-based HIV test result delivery, such as logistical concerns about receiving a phone call during the day (e.g., while at work), reduced confidentiality, and the lack of in-person emotional support. Overall, participants described phone delivery of positive HIV-results as acceptable. At-home testing with phone delivery has the potential to increase HIV testing access, especially to geographically isolated or medically underserved patients.

Higher and Higher? Drug and Alcohol Use and Misuse among HIV-Vulnerable Men, Trans Men, and Trans Women Who Have Sex with Men in the United States.

BACKGROUND: Substance use (SU) and misuse are disproportionately more common among sexual and gender minority (SGM) individuals compared to their heterosexual peers. Yet, little is known about regional and demographic differences in use and misuse among SGM. In this study, we investigated regional and demographic differences in SU and misuse in a U.S. national, internet-based cohort (n = 6,280) of men and trans persons who have sex with men. Methods: Data collected included the WHO ASSIST (substance) and AUDIT (alcohol) SU scales to estimate recent (≤ 3 months) non-problematic use (≤ 3 ASSIST, ≤ 10 AUDIT) and misuse (≥4 ASSIST, ≥11 AUDIT). We used bivariate and multivariable logistic models to examine demographic and regional factors associated with SU and misuse. Results: Participants reported using alcohol (85.6%), cannabis (53.9%), and inhalants (39.1%) in the past three months. More than one-third self-reported misuse of cannabis, Gamma-Hydroxybutyrate (GHB), inhalants, methamphetamines, and prescription sedatives. We observed regional differences in substance use for cannabis (Southeast aOR = 0.76, 95% CI: 0.63-0.93; West aOR = 1.27, 95% CI: 1.02-1.59, ref. Northeast) and prescription Stimulants (Midwest aOR = 1.39, 95% CI: 1.00-1.93), as well as for cannabis misuse (Southeast aOR = 0.83, 95% CI: 0.69-0.99). We also observed significant associations between socioeconomic factors with use and misuse. Conclusions: Findings suggest geographic differences in misuse of certain substances among men and trans persons who have sex with men in the US, and that socio-economic factors, also play a key role in indicating risk.

Demographic, Behavioral, and Geographic Differences Between Men, Transmen, and Transwomen Currently on PrEP, Former PrEP Users, and Those Having Never Used PrEP.

Many recent studies have compared men currently taking pre-exposure prophylaxis (PrEP) to men not taking PrEP. However, less is known about demographic, behavioral, and geographic characteristics of men formerly, but not currently, taking PrEP. Using a 2017-2018 U.S. national, internet-based sample (n = 10,504) of men, transmen, and transwomen who have sex with men, we compared three groups based on their PrEP experiences. Results highlight individual-level financial and geo-contextual barriers to PrEP use that can inform prevention efforts to improve PrEP initiation and continuation for both PrEP-naïve and PrEP-experienced individuals, respectively.

Social and Medical Gender Affirmation Experiences Are Inversely Associated with Mental Health Problems in a U.S. Non-Probability Sample of Transgender Adults.

A dearth of research has explored concurrently the associations between multiple forms of gender affirmation (or transitioning) and the mental health of transgender adults. In 2015, 288 U.S. transgender adults completed a cross-sectional, online survey assessing demographics, gender affirmation experiences, and mental health. Adjusting for age and discrimination experiences, we used mixed-effect logistic regression analyses to examine changes in self-reported suicidal ideation, suicide attempts, and non-suicidal self-injury (NSSI) before and after initiating the gender affirmation process, and linear regression analyses to examine associations between gender affirmation experiences and self-reported depressive, anxiety, and stress symptoms. Overall, 81.3% of participants identified along the female-to-male, trans masculine gender spectrum (of which 20.9% identified as non-binary) and 18.8% identified along the male-to-female, trans feminine gender spectrum (of which 7.4% identified as non-binary). Nearly all participants (98.6%) reported disclosing their gender identity to family or a coworker; 67.4% endorsed recently using hormones, and 31.3% endorsed a gender-affirming medical procedure. In multivariable models, participants were at greater odds of NSSI, contemplating suicide, and attempting suicide before initiating the gender affirmation process compared to after. In additional models, gender identity disclosure and medical procedure engagement were inversely associated with depressive and anxiety symptoms, whereas gender identity disclosure, hormone use, and medical procedure engagement were inversely associated with stress symptoms. Finally, the number of gender affirmation experiences endorsed was inversely associated with depressive, anxiety, and stress symptoms. Findings support the possibility that social and medical gender affirmation experiences may be protective against mental health problems in transgender adults.

The Impact of Pre-Exposure Prophylaxis on Sexual Communication and Sexual Behavior of Urban Gay and Bisexual Men.

Pre-exposure prophylaxis (PrEP) has altered the public health landscape for gay, bisexual, and other men who have sex with men (GBM) by significantly increasing protection against HIV infection. Early epidemiologic data showed GBM generally used PrEP as prescribed, i.e., as an additional protective tool over and above barrier protection, although subsequent reports have been equivocal. Irrespective of population-level trends, some GBM appear to have reevaluated their HIV risk tolerance and changed their interactions with sex partners. Scant published data have focused on factors that influence PrEP-using GBM's decisions about sexual behavior-including condom use as well as sex with HIV-positive partners-and sexual communication practices. Thus, in this study, we investigated those research concerns qualitatively via content analysis of individual interviews conducted with 103 GBM in New York City (M age 32.5 years, 50% White, 64% on PrEP > 6 months). Emergent themes reflect (1) participants' strong HIV knowledge; (2) changing GBM community norms about condom use on PrEP; (3) increased focus on risk tolerance with individual differences in post-PrEP condom use; (4) appreciation for routine sexually transmitted infection (STI) screening in PrEP care concomitant with some STI knowledge deficits; (5) decreased stigma concerning, and greater comfort with, HIV-positive sex partners; and (6) increased confidence discussing HIV status and condom use preferences with partners. Findings have implications for future research as well as for clinical practice, such as enhanced STI education and provider-initiated discussions about risk compensation, serosorting, and sexual communication skills.

Sexual minority men want provider behavior consistent with attitudes and norms during patient-provider interactions regarding HIV prevention.

HIV is a health problem for sexual minority men in the United States. One factor among many that contributes to this HIV disparity is poor patient-provider interactions. We focused on specific provider behavior preferred by sexual minority men during patient-provider interactions about HIV prevention. We interviewed 20 HIV-negative sexual minority men who endorsed 1+ psychosocial HIV risk factor. We used follow up interviews and conventional content analysis. Among our sample, 55% identified as White; 50% as bisexual, (Mage = 28.45). Findings suggested even some providers knowledgeable about sexual minority health provided unhelpful care to sexual minority men (knowledge-behavior discrepancy). Some knowledgeable providers engaged in affirmative, tailored treatment (knowledge-behavior consistency). Specific behaviors of preferred patient-provider interactions regarding HIV prevention are reported. Our recommendations are based on patient perceptions, which is a limit and strength. We identified an important type of unhelpful patient-provider interaction for HIV-negative sexual minority men beyond discriminatory experiences. Patient-provider interaction efforts need to go beyond education to help providers practice skills. With increased focus on cultural competency for sexual minority patients, more providers may advertise their practice as affirmative, yet interactions will likely vary, may require lifelong practice of cultural humility, and impact HIV prevention.

An initial randomized controlled trial of behavioral activation for treatment of concurrent crystal methamphetamine dependence and sexual risk for HIV acquisition among men who have sex with men.

Men who have sex with men (MSM) continue to be the largest risk group for HIV infections in the U.S., where crystal methamphetamine abuse heightens risk for HIV infection through greater engagement in condomless anal sex (CAS). Existing treatments lack attention to replacement activities or the role of depressed mood. Behavioral activation (BA) is an evidence-based approach for depression that involves identifying and participating in pleasurable, goal-directed activities. We hypothesize, for MSM abusing crystal methamphetamine, re-learning how to engage in non-drug-using aspects of life would facilitate their ability to benefit from sexual risk reduction (SRR) counseling. Project IMPACT was a pilot randomized-controlled-trial. Forty-six MSM at sexual risk of acquiring HIV who met DSM-IV criteria for crystal methamphetamine dependence were enrolled. Of those MSM, 41 were randomized: 21 were assigned to the intervention, two sessions of SRR, ten sessions of BA with SRR, and one session of relapse prevention; 20 participants were assigned to a control condition (two sessions of SRR). At the acute post-intervention visit, intervention participants reported an average of 3.2 CAS acts with men who were HIV-infected or whose status they did not know, compared to 4.5 among control participants (ß = -0.36; 95% CI: -0.69, -0.02; p = 0.035). At the 6-month post-intervention visit, intervention participants reported 1.1 CAS acts with men who were HIV-infected or whose status they did not know compared to 2.8 among control participants (ß = -0.95; 95% CI: -1.44, -0.46; p < 0.0001). Similarly, intervention participants reported 1.0 CAS acts under the influence of crystal methamphetamine with men who were HIV-infected or whose status they did not know compared to 2.5 among control participants (ß = -0.87; 95% CI: -1.38, -0.36; p = 0.0005). Lastly, intervention participants reported more continuous days abstaining from crystal methamphetamine compared to control (50.1 vs. 39.0, respectively) (ß = 0.25; 95% CI: 0.16, 0.34; p < 0.0001). Findings are encouraging, provide evidence of feasibility and acceptability, and demonstrate initial efficacy for reducing sexual risk for HIV and crystal methamphetamine use.

Gay and Bisexual Men's Strategies to Maintain Daily Adherence to Their HIV Pre-exposure Prophylaxis (PrEP) Medication: Results from a Qualitative Study.

Since FDA approval in 2012, HIV pre-exposure prophylaxis (PrEP) has been adopted by key populations, including gay and bisexual men (GBM), to reduce their HIV transmission risk. Given that PrEP is optimally effective when taken as prescribed, it is critical to understand the adherence strategies GBM use. We conducted one-on-one, semi-structured interviews with GBM taking PrEP in 2015-2016 (n = 103). Using thematic analysis, we identified six adherence strategies, with most participants (84.3%) utilizing multiple strategies to maintain adequate adherence: (1) integrating PrEP into part of a daily routine, (2) using a pillbox, (3) cognitive strategies/visual cues, (4) setting recurring smartphone alarms or reminders, (5) keeping medication on oneself at all times, and (6) partner or peer support for reminders and/or pill sharing. Overall, participants reported high PrEP adherence (M = 1.6 missed doses in the prior 30 days), though nearly all described missing at least one dose unintentionally in the past. Participants credited their high levels of adherence in part to the strategies they adopted. Providers working with GBM prescribed PrEP, especially patients reporting difficulties with adherence, might consider recommending any or all of the six strategies described in this study.

Applying behavioral activation to sustain and enhance the effects of contingency management for reducing stimulant use among individuals with HIV infection.

There is a high prevalence of stimulant use among HIV-infected individuals, which is associated with suboptimal antiretroviral therapy (ART) adherence, HIV treatment interruptions, detectable HIV viral load, and transmission of HIV via increased sexual risk behavior. Contingency management (CM) is an initially effective treatment for stimulant use. However, the effects of CM are not sustained after the active intervention has ended. One potential contributor to the intractability of existing treatments may be a lack of attention to replacement activities or the role of depressed mood. Behavioral activation (BA) is an evidence-based approach for depression that involves identifying and participating in pleasurable, goal-directed activities. As a potential approach to address the CM rebound effect - informed by our formative qualitative research with the participant population - we conducted an open pilot trial of an intervention combining CM-BA for HIV-infected individuals with stimulant use disorder. Participants completed weekly BA therapy sessions (10-16 sessions) and thrice-weekly toxicology screenings (12 weeks); contingencies were rewarded for negative toxicology tests to support reengagement into positive life activities. Major assessments were conducted at baseline, 3-, and 6-months. Toxicology screening was repeated prior to the 6-month assessment. Eleven participants with stimulant use disorder enrolled; 7 initiated treatment and completed the full intervention. The mean age was 46 (SD = 5.03) and 14% identified as a racial/ethnic minority. Of the completers, the mean change score in self-reported stimulant use within the past 30 days (within-person change; reduction in self-reported stimulant use) was 4.14 days at 3 months and 5.0 days at 6 months [Cohen's d = 0.89]. The mean change score in weekly toxicology screens (reduction in positive toxicology screens) was .71 at 3 months and 1 at 6 months [Cohen's d = 1.05]. Exit interviews indicated that the integrated intervention was well received and acceptable. This study provides preliminary evidence that a combined CM-BA intervention for this population was feasible (100% retention at 6-months), acceptable (100% of intervention sessions attended; participants rated the intervention 'acceptable' or 'very acceptable'), and may be an option to augment the potency and sustained impact of CM for this population. Future pilot testing using a randomized controlled design is warranted.

Minority Stressors Associated with Sexual Risk Behaviors and HIV Testing in a U.S. Sample of Transgender Individuals.

The majority of published research on transgender health focuses on associations between external minority stressors (e.g., discrimination) and health. Little is known about how internal minority stressors (e.g., identity concealment and expecting rejection) might predict HIV disparities. The current study addresses this gap by examining the association between external and internal minority stressors and sexual risk behaviors and HIV testing history in a sample of 300 transgender adults across the U.S. Transgender-related discrimination and expecting rejection were associated with sexual risk behaviors. When controlling for covariates, none of the minority stressors were associated with HIV testing. Results illustrate how minority stress, both external and internal, may operate uniquely for transgender individuals.

A randomized controlled efficacy trial of behavioral activation for concurrent stimulant use and sexual risk for HIV acquisition among MSM: project IMPACT study protocol.

BACKGROUND: In the United States, problematic stimulant use is a prevalent and difficult to treat problem among men who have sex with men (MSM), as well as a major driver of HIV transmission through the large number of sexual partners and concomitant condomless anal sex (CAS). Evidence-based behavioral studies that address problematic stimulant use in MSM at risk for HIV infection are also lacking. In this paper, we describe the design of a behavioral intervention trial to reduce sexual risk behavior and stimulant use in HIV-uninfected MSM. METHODS: This study, funded by the National Institute on Drug Abuse (NIDA), is a randomized controlled trial (RCT) testing an integrated HIV risk reduction and behavioral activation counseling intervention (IMPACT) for HIV-uninfected, stimulant using MSM in Boston, MA, and Miami, FL. Participants are randomized (2:2:1) to either (1) the IMPACT intervention; (2) a relaxation condition, an active therapy time- and intensity-matched control; or (3) a standard of care risk reduction counseling comparison. At enrollment, all participants receive an HIV test and pre- and post-test counseling. The primary outcome is the difference in the rate of change in the number of self-reported condomless anal sex acts without the protection of consistent Pre-Exposure Prophylaxis (PrEP) use, as well as reductions in stimulant use during the prior 4-months. Major assessments are conducted at baseline, 4-, 8-, and 12-month follow-up visits. DISCUSSION: Effective and sustainable behavioral interventions are sorely needed to reduce HIV acquisition in stimulant using MSM at risk for HIV infection. In this study, we will evaluate the evidence of efficacy of the IMPACT intervention to reduce HIV acquisition in HIV-uninfected, stimulant-using MSM. If found effective, the intervention tested here holds promise for being readily integrated into real-world clinical settings. TRIAL REGISTRATION: ClinicalTrials.gov number NCT03175159 , registered June 5, 2017.