"Why Would I Talk To Them About Sex?": Exploring Patient-Provider Communication Among Black Women Experiencing Sexual Pain.

Ineffective patient-provider communication poses a potential health risk to Black women if medical providers are not addressing their needs or concerns. Additionally, less than half of OBGYNs report asking their patients about sexual difficulties, which limits women's opportunities to disclose their experiences of sexual pain. The purpose of this qualitative study is to explore Black women's experiences of patient-provider communication about sexual pain (reoccurring unwanted genital pain). Specifically, we aimed to describe the pathway from sexual pain disclosure to treatment among N = 25 premenopausal Black women living in the southern United States who were experiencing sexual pain. Using constructivist grounded theory, open-ended responses to six interview questions related to healthcare experiences, treatment, and patient-provider communication were qualitatively analyzed and categorized to form a conceptual framework of patient-provider communication about sexual pain. Five key categories emerged related to Black women's experiences with their medical providers regarding sexual pain: (1) provider preferences, (2) healthcare experiences, (3) reasons for non-disclosure, (4) provider responses to sexual pain, and (5) treatment for sexual pain. Useful strategies to improve patient-provider communication are presented for both patients and providers.

A Hybrid Evaluation-Optimization Trial to Evaluate an Intervention Targeting the Intersection of Alcohol and Sex in College Students and Simultaneously Test an Additional Component Aimed at Preventing Sexual Violence.

BACKGROUND: Using the multiphase optimization strategy (MOST), we previously developed and optimized an online behavioral intervention, itMatters, aimed at reducing the risk of sexually transmitted infections (STI) among first-year college students by targeting the intersection of alcohol use and sexual behaviors. PURPOSE: We had two goals: (a) to evaluate the optimized itMatters intervention and (b) to determine whether the candidate sexual violence prevention (SVP) component (included at the request of participating universities) had a detectable effect and therefore should be added to create a new version of itMatters. We also describe the hybrid evaluation-optimization trial we conducted to accomplish these two goals in a single experiment. METHODS: First year college students (N = 3,098) at four universities in the USA were individually randomized in a hybrid evaluation-optimization 2 × 2 factorial trial. Data were analyzed using regression models, with pre-test outcome variables included as covariates in the models. Analyses were conducted separately with (a) immediate post-test scores and (b) 60-day follow-up scores as outcome variables. RESULTS: Experimental results indicated a significant effect of itMatters on targeted proximal outcomes (norms) and on one distal behavioral outcome (binge drinking). There were no significant effects on other behavioral outcomes, including the intersection of alcohol and sexual behaviors. In addition, there were mixed results (positive short-term effect; no effect at 60-day follow-up) of the SVP component on targeted proximal outcomes (students' self-efficacy to reduce/prevent sexual violence and perceived effectiveness of protective behavioral strategies). CONCLUSIONS: The hybrid evaluation-optimization trial enabled us to evaluate the individual and combined effectiveness of the optimized itMatters intervention and the SVP component in a single experiment, conserving resources and providing greatly improved efficiency. TRIAL REGISTRATION: NCT04095065.

First-year college students' alcohol and hookup behaviours: sexual scripting and implications for sexual health promotion.

This study used a sexual scripting framework to analyse data from the Online College Social Life Survey to examine the role of individual, (e.g. gender, race and alcohol use), relational (partner type, condom use behaviours), and contextual factors (sex ratios and fraternity/sorority affiliation) influencing 4,292 first-year college students' hookup experiences. Results suggest that hookups are relatively "safe", with the the majority involving non-penetrative sexual behaviour, condom use, and familiar partners. However, alcohol use affected hookup behaviours and lower levels of condom use were associated with heavy alcohol use, even with less well known partners. Findings point to the importance of interventions that reinforce first-year students' positive behaviours and present them with protective behavioural strategies to use in the context of alcohol, and with repeat or well-known partners to reduce risk and have enjoyable, consensual sexual experiences.

Supporting Health Among Young Men Who Have Sex With Men and Transgender Women With HIV: Lessons Learned From Implementing the weCare Intervention.

Young gay, bisexual, and other men who have sex with men and transgender women with HIV, particularly those who are racial or ethnic minorities, often have poor health outcomes. They also utilize a wide array of social media. Accordingly, we developed and implemented weCare, an mHealth (mobile health) intervention where cyberhealth educators utilize established social media platforms (e.g., Facebook, texting, and GPS-based mobile applications ["apps"]) designed for social and sexual networking) to improve HIV-related care engagement and health outcomes. As part of the process evaluation of weCare, we conducted 32 interviews with intervention participants (n = 18) and HIV clinic providers and staff (n = 14). This article highlights three key intervention characteristics that promoted care engagement, including that weCare is (1) targeted (e.g., using existing social media platforms, similarity between intervention participants and cyberhealth educator, and implementation within a supportive clinical environment), (2) tailored (e.g., bidirectional messaging and trusting relationship between participants and cyberhealth educators to direct interactions), and (3) personalized (e.g., addressing unique care needs through messaging content and flexibility in engagement with intervention). In addition, interviewees' recommendations for improving weCare focused on logistics, content, and the ways in which the intervention could be adapted to reach a larger audience. Quality improvement efforts to ensure that mHealth interventions are relevant for young gay, bisexual, and other men who have sex with men and transgender women are critical to ensure care engagement and support health outcomes.

The Association between Incarceration and Transactional Sex among HIV-infected Young Men Who Have Sex with Men in the United States.

Criminal justice practices in the USA disproportionately affect sexual and racial/ethnic minority men, who are at higher risk of incarceration. Previous research demonstrates associations between incarceration and sexual risk behaviors for men who have sex with men (MSM). However, little of this work focuses on young MSM (YMSM), particularly HIV-infected YMSM, despite nearly one-third reporting engagement in sexual risk behaviors, such as transactional sex. We therefore explored the association between incarceration and transactional sex among HIV-infected YMSM. We recruited 97 HIV-infected YMSM across 14 clinical sites in urban centers from August 2015 to February 2016. We used multivariate logistic regression to examine the relationship between incarceration and transactional sex among YMSM. The majority was 24 years old (78%) and racial/ethnic minority (95%); over half were not in school and reported an annual income of < $12,000. In the multivariate model, having ever been incarcerated (aOR = 3.20; 95% CI 1.07-9.63) was independently associated with a history of transactional sex. Being 24 years vs. younger (aOR = 9.68; 95% CI 1.42-65.78) and having ever been homeless (aOR = 3.71, 95% CI 1.18-11.65) also remained independently associated with a history of transactional sex. This analysis fills a gap in the literature by examining the relationship between incarceration and transactional sex among HIV-infected YMSM. Facilitating youths' engagement with social services available in their HIV clinic may serve as a key strategy in promoting health. Public health efforts need to address social-structural factors driving disproportionate rates of arrest and incarceration and related harms among this population.

The Intersection Between Women's Reproductive Desires and HIV Care Providers' Reproductive Health Practices: A Mixed Methods Analysis.

Background HIV-positive women in the United States can have healthy pregnancies and avoid transmitting HIV to their children. Yet, little is known about the extent to which HIV care providers' reproductive health practices match women's pregnancy desires. Accordingly, we explored young HIV-positive women's pregnancy desires and reproductive health behaviors and examined reproductive health information offered by HIV care clinics. Methods A mixed-method analysis was conducted using data from a 14-site Adolescent Medicine Trials Network (ATN) study. We conducted descriptive statistics on data from 25 HIV-positive women (e.g., demographics, pregnancy desires, and sexual- and health-related behaviors). Qualitative interviews with 58 adolescent and adult clinic providers were analyzed using the constant comparative method. Results About half of the women reported using reproductive health care services (i.e., contraception and pregnancy tests) (n = 12) and wanted a future pregnancy (n = 13). Among women who did not desire a future pregnancy (n = 5), three used dual methods and two used condoms at last sexual encounter. Qualitative themes related to clinics' approaches to reproductive health (e.g., "the emphasis…is to encourage use of contraceptives") and the complexity of merging HIV and reproductive care (e.g., "We [adolescent clinic] transition pregnant moms from our care back and forth to adult care"). Discussion Despite regular HIV-related medical appointments, HIV-positive women may have unaddressed reproductive health needs (e.g., pregnancy desire with providers focused on contraceptive use). Findings from this study suggest that increased support for young HIV-positive women's reproductive health is needed, including supporting pregnancy desires (to choose when, how, and if, to have children).

Transitioning HIV-infected adolescents to adult care at 14 clinics across the United States: using adolescent and adult providers' insights to create multi-level solutions to address transition barriers.

HIV-infected adolescents have disproportionately low rates of care retention and viral suppression. Approximately half disengage from care while transitioning to adult clinics, in part due to fragmented care systems and lack of streamlined protocols. We conducted 58 qualitative interviews with social service and health care providers across 14 Adolescent Trials Network clinics (n = 28) and 20 adult clinics that receive transitioning adolescents (n = 30) from August 2015-June 2016. We used the constant comparative approach to examine processes, barriers, and facilitators of adult care transition. Transition barriers coalesced around three levels. Structural: insurance eligibility, transportation, and HIV-related stigma; Clinical: inter-clinic communication, differences in care cultures, and resource/personnel limitations; and Individual: adolescents' transition readiness and developmental capacity. Staff-initiated solutions (e.g., grant-funded transportation) were often unsustainable and applied individual-level solutions to structural-level barriers. Comprehensive initiatives, which develop collaborative policies and protocols that support providers' ability to match the solution and barrier level (i.e., structural-to-structural), are sorely needed. These initiatives should also support local systematic planning to facilitate inter-clinic structures and communication. Such approaches will help HIV-infected adolescents transition to adult care and improve long-term health outcomes.

Exploring the Social Exchange of Manhood and Masculine Norms Among Black Heterosexual College Men.

Traditional masculine norms state men are tough, protective, and sexually assertive. Young Black men must weigh the rewards and costs of adhering to or deviating from these norms within the college environment, as their choices can be detrimental to their health. Using the ecological-exchange framework, we examined adherence to or deviation from traditional masculine norms from focus groups with 13 Black heterosexual men at two Historically Black Colleges and Universities (HBCUs) and one Minority-Serving Institution. Participants formed their masculinity through experiences with male role models and mothers but felt conflicted in their need to adhere to or deviate from norms. This reflects the processes men go through to develop their masculinity and highlights needed interventions focused on cultivating healthy masculinity.

Black heterosexual college men's masculinity dimensions, protective behavioral intentions, and sexual risk behaviors.

OBJECTIVE: To examine the associations of dimensions of masculinity-respect/toughness and anti-femininity/hypersexuality-with sexual risk behaviors and protective behavioral intentions and the effects of awareness of anti-Blackness. PARTICIPANTS: 127 Black heterosexual men were recruited from four Historically Black Colleges and Universities and one Minority Serving Institution in the South. METHODS: Students completed an online survey as part of a pilot study to assess the sexual health needs of Black college students. RESULTS: Our results indicated that respect/toughness and anti-femininity/hypersexuality were significant correlates of protective behavioral intentions. After accounting for awareness of anti-Blackness and age, anti-femininity/hypersexuality was a significant correlate of sexual risk behaviors. CONCLUSIONS: Our study highlights the complex multi-dimensional construct of masculinity and how forms of anti-Blackness continue to influence HIV vulnerability. Therefore, there is a need to include structural factors within research to better understand behaviors among Black college men and incorporate dimensions of masculinity that promote healthy sexual behaviors in interventions and programming.

itMatters: Optimization of an online intervention to prevent sexually transmitted infections in college students.

ObjectiveTo describe an iterative approach to developing an online intervention targeting the intersection of alcohol use and sexual behaviors among first year college students. Methods and Participants: Using the multiphase optimization strategy (MOST), we conducted two iterative optimization trials to: (1) identify candidate intervention components (i.e., descriptive norms, injunctive norms, outcome expectancies, perceived benefits of protective behavioral strategies, and self-efficacy to use strategies); (2) revise components; and (3) identify the optimized intervention. Participants were first year college students at six geographically diverse universities (optimization trial 1 N = 5,880; optimization trial 2 N = 3,551) Results: For both optimization trials, the results indicated that only descriptive and injunctive norms produced a significant effect (p<.05). Conclusions: The iterative process of MOST allowed us to develop an optimized intervention which is an essential tool to maximize intervention effectiveness and efficiency to improve uptake, sustainability, and public health impact.

Sexual sensation seeking, hookups, and alcohol consumption among first-year college students.

OBJECTIVE: To explore sexual sensation seeking (SSS) among an ethnically-diverse sample of first-year college students and their hookup behaviors. PARTICIPANTS: 1,480 first-year college students who hooked up in the last 30 days were recruited from four universities in 2016. METHODS: Students completed an online survey before completing an online STI and alcohol prevention intervention. RESULTS: Male and sexual minority students had significantly higher SSS scores compared to female and heterosexual students respectively. Students with higher SSS scores were less likely to report condom use at last vaginal and anal hookup, more likely to hookup under the influence of alcohol and participate in a wide range of sexual behaviors. There were no significant mean differences in SSS scores by level of intoxication during their last hookup. CONCLUSION: These findings highlight the role of SSS in predicting sexual risk behaviors of first-year college students and the overall low SSS scores among this sample.

Black First-Year College Students' Alcohol Outcome Expectancies.

BACKGROUND: Alcohol outcome expectancies (AOEs) are associated with college students' varied alcohol consumption. Existing research on AOEs focuses primarily on heterosexual White students. Thus, it is important to explore how the intersection of multiple identities such as race, gender, and sexual orientation influence the endorsement of specific AOEs. PURPOSE: This paper examines AOEs among Black first-year college students, with specific attention to the influence of gender and sexual orientation. METHODS: Participants were 307 Black students from four universities in the United States. We conducted bivariate analyses using the 2-factor and 4-factor B-CEOA scale. RESULTS: Most students did not hold positive AOEs such as tension reduction and sexual enhancement. They were more likely to endorse negative AOEs such as behavioral and cognitive impairment and social risk. DISCUSSION: Black first-year college students reported more negative expectations associated with alcohol use, including those related to negative social risks and consequences. Thus, AOEs may serve as a protective factor against alcohol use among Black college students. TRANSLATION TO HEALTH EDUCATION PRACTICE: Alcohol interventions should be tailored to focus on the intersection of race, gender, and sexual orientation. Culturally relevant alcohol interventions have the potential to reduce the immediate and long-term consequences of alcohol use.

Healthcare Transition for Youth Living With HIV: Outcomes from a Prospective Multi-site Study.

PURPOSE: Youth living with HIV (YLHIV) in the United States (U.S.) account for nearly one-third of new HIV infections and face significant barriers to care engagement; only 25% are virally suppressed. Healthcare transition (HCT) from pediatric/adolescent to adult-oriented care can be particularly disruptive. Accordingly, we prospectively examined HCT processes at 14 distinct geographical sites across the U.S. METHODS: We collected Audio Computer-Assisted Self-Interviews data and abstracted electronic medical records from 135 HCT-eligible YLHIV at baseline and 9-month follow-up. Descriptive analyses and multilevel modeling were conducted. Data also included qualitative interviews with 28 adolescent and 30 adult providers across 14 adolescent and 20 adult clinics, respectively. Interviews were analyzed using the constant comparative method; this analysis focused on specific HCT recommendations. RESULTS: At baseline, youth were primarily age 24 (78.8%), male (76.8%), black (78.0%), identified as a sexual minority (62.9%), had attended an HIV appointment in the past 3 months (90.2%), had Medicaid for insurance (65.2%), and were always or mostly always adherent to their antiretroviral therapy (65.9%). At the 9-month follow-up only 37% of YLHIV successfully transitioned to adult care. Both individual-level (insurance status and disclosure-related stigma) and clinic-level (adolescent clinic best practices) factors were significant. Adolescent and adult clinic staff offered recommendations to support HCT; these focused primarily on clinical changes. CONCLUSIONS: This study highlights the complex set of individual- and clinic-level factors associated with HCT. Addressing these key factors is essential for developing streamlined, comprehensive, and context-specific HCT protocols to support continuous care engagement for YLHIV.

Preliminary Impact of the weCare Social Media Intervention to Support Health for Young Men Who Have Sex with Men and Transgender Women with HIV.

Young racial/ethnic minority men who have sex with men (MSM) and transgender women with HIV often have poor health outcomes. They also utilize a wide array of social media. Accordingly, we developed and implemented weCare, a social media intervention utilizing Facebook, texting, and GPS-based mobile social and sexual networking applications to improve HIV-related care engagement and health outcomes. We compared viral load suppression and clinic appointment attendance among 91 participants during the 12-month period before and after weCare implementation. McNemar's chi-square test analyses were conducted comparing the pre- and postintervention difference using paired data. Since February 2016, intervention staff and 91 intervention participants (79.1% African American and 13.2% Latino, mean age = 25) exchanged 13,830 messages during 3,758 conversations (average: 41.3 conversations per participant) across a variety of topics, including appointment reminders, medication adherence, problem solving, and reducing barriers. There were significant reductions in missed HIV care appointments (68.0% vs. 53.3%, p = 0.04) and increases in viral load suppression (61.3% vs. 88.8%, p < 0.0001) 12 months postimplementation. Our results highlight the initial success of weCare in improving care engagement and viral suppression. Social media is an important tool, especially for young MSM and transgender women, to support individual- (e.g., viral suppression) and community- (e.g., reduced transmission efficiency) level health. It may also be a useful tool for improving engagement with biomedical HIV prevention tools (e.g., PrEP use).

Adolescent and Adult HIV Providers' Definitions of HIV-Infected Youths' Successful Transition to Adult Care in the United States.

It is important for both individual- and population-level health that HIV-infected individuals progress through the Care Continuum. However, HIV-infected youth frequently disengage from care during transition from pediatric/adolescent to adult care; only 50% remain in adult care after 1 year. Understanding how providers define and approach a successful healthcare transition can improve the delivery of HIV-related services during critical years of HIV treatment. We conducted 58 staff interviews across 14 Adolescent Trials Network clinics (n = 30) and 20 adult clinics (n = 28). We used the constant comparative method to examine how providers defined and approached youths' successful transition. Providers identified four components critical to successful transition: (1) clinical outcomes (e.g., medication adherence and viral suppression); (2) youth knowing how to complete treatment-related activities (e.g., refilling prescriptions and making appointments); (3) youth taking responsibility for treatment-related activities and their overall health (e.g., "when they stop reaching out to the adolescent [clinic] to solve all their problems."); and (4) youth feeling a connection and trust toward the adult clinic (e.g., "they feel safe here"), with some providers even prioritizing connectedness over clinical outcomes (e.g., "Even if they're not taking meds but are connected [to care], …that's a success."). The identification of key components of successful transition can guide focused interventions and resources to improve youth maintenance in the HIV Care Continuum as they transition to adult care. Identifying what facilitates successful transitions, and the gaps that interventions can target, will help to ensure HIV-infected youth remain healthy across their lifespan.