Do syndemic conditions predict HIV medication adherence among urban African American men?

Much progress has been made in advancing antiretroviral (ART) adherence, yet disparities remain. To explore relationships of syndemic conditions - co-occurring health conditions caused by combinations of biological, social, and structural factors - to ART adherence among African American men, we used data from longitudinal assessments of 302 African American men enrolled in a study designed to increase physical activity and healthy eating. Syndemic conditions included alcohol dependency, drug dependency, depression, post-traumatic stress disorder, and unstable housing. A syndemic conditions variable was operationalized to indicate the presence of 0-5 conditions. About 55% of participants had 1 or more syndemic conditions. Age and marriage were positively associated with ART adherence, whereas number of syndemic conditions was negatively associated with adherence during the 12-month period. The interaction of being married and the syndemic conditions variable significantly predicted greater adherence. Similarly, the interaction of more education and the syndemic conditions variable predicted greater adherence. In multiple regression models, the syndemic conditions variable remained significant (-0.018) in predicting adherence; however, there was no significant interaction among the 5 conditions. This study lends evidence to syndemics literature indicating deleterious consequences of negative life experiences on health outcomes.

South African Fathers Involvement and Their Adolescents' Sexual Risk Behavior and Alcohol Consumption.

Although considerable research has examined the influence of parent-adolescent relationships on the sexual health of adolescents, there is a great need for research to understand the influence of fathers on their children's HIV sexual risk behavior, particularly in sub-Saharan Africa. We examined how the residence and the involvement of fathers are related to their children's HIV sexual risk and alcohol consumption behaviors. A cross-sectional survey was completed by 175 sixth-grade adolescents in the Eastern Cape Province, South Africa. Analyses showed that adolescents living with their fathers had fewer sexual partners (B = - 0.606, SE = 0.299, p = .043) and consumed alcohol less frequently (B = - 0.642, SE = 0.294, p = .029). Adolescents who spent more quality days with their fathers in the past 30 days had fewer sexual partners (B = - 0.103, SE = 0.039, p = .008) and had condomless sex less frequently (B = - 0.097, SE = 0.047, p = 0.041). It was also found that there were significant father-residence × child-gender interactions on sexual debut (B = 1.132, SE = 0.564, p = .045) and on frequency of condomless sex (B = - 2.140, SE = 0.924, p = .021). These interactions indicate that boys living with their fathers were less likely to have had vaginal intercourse than girls and that girls living with their fathers were less likely to have unprotected sex than boys. This study highlights the importance of South African fathers' roles in their adolescent children's HIV sexual risk and alcohol drinking behaviors and the need to promote father-child relationships for adolescent health. The results suggest that health programs aiming to reduce South African adolescents' HIV sexual risk behaviors and alcohol consumption consider strategies that target their fathers.

Transhealth Information Project: A Peer-Led HIV Prevention Intervention to Promote HIV Protection for Individuals of Transgender Experience.

Individuals of transgender experience (ITE) in the United States face an elevated risk of HIV infection. Several conditions have been attributed to the high HIV incidence and prevalence within this group, including experiences of discrimination, unemployment, incarceration, stigma, and elevated rates of sexual risk and substance use. In response to these needs, the Gay and Lesbian Latino AIDS Education Initiative and Prevention Point Philadelphia, two local community-based organizations in Philadelphia, developed the Transhealth Information Project (TIP). TIP is a peer-led six-session hybrid individual- and group-based intervention emphasizing leadership, social and structural interventions, and HIV risk reduction that incorporates other evidence-based practices for HIV prevention and care. Since 2003, TIP has served over 1,500 ITE and linked them to HIV prevention and care services. TIP has an established record of reaching ITE and linking them to HIV prevention services and HIV primary care. TIP's utilization speaks to the need for interventions to respond to the complex, interacting syndemic factors that cumulatively determine HIV vulnerability among ITE.

Prospective Predictors of Multiple Sexual Partners Among African American Men Who Have Sex with Men.

Studies show that having sex with multiple partners increases the risk of acquiring and transmitting sexually transmitted diseases, including HIV. The present article reports prospective predictors of having multiple sexual partners among 505 African American men in Philadelphia who have sex with men (MSM) who participated in an intervention trial and attended a 6-month follow-up. Participants completed audio computer-assisted surveys of demographics, sexual behavior, and Reasoned Action Approach and Social Cognitive Theory mediators concerning multiple partners. We analyzed the incidence of self-reported multiple partners at the 6-month follow-up, controlling for treatment condition and baseline levels of the theoretical variables. The odds of having multiple partners decreased with increasing age (p < .03). Participants who said they were HIV positive had lower odds of having multiple partners (p < .009). The more pride participants reported in their identities as black or African American men, the lower the odds that they reported having multiple partners (p < .02). Adverse outcome expectancies accruing to multiple partners fully mediated the effect of black pride and partially mediated the effects of age on the odds of having multiple partners. Modifiable factors such as perceived negative outcome expectancies regarding having multiple sex partners should be addressed in designing interventions and prevention programs with the goal of decreasing the number of sexual partners among African American MSM.

What's In an Identity Label? Correlates of Sociodemographics, Psychosocial Characteristics, and Sexual Behavior Among African American Men Who Have Sex With Men.

African American men who have sex with men (AAMSM) are vastly overrepresented among people with HIV/AIDS. Using data from 595 AAMSM in Philadelphia, we explored differences in sociodemographics, psychosocial characteristics related to beliefs about ethnicity, sexuality and masculinity, and sexual behavior with men and women by self-reported sexual identity (gay, bisexual, down low, straight). Roughly equivalent numbers identified as gay (40.6 %) and bisexual (41.3 %), while fewer identified as straight (7.6 %) or down low (10.5 %), with significant differences in age, income, history of incarceration, HIV status, alcohol and drug problems, childhood sexual abuse, and connection to the gay community evident among these groups. Analysis of psychosocial characteristics theorized to be related to identity and sexual behavior indicated significant differences in masculinity, homophobia, and outness as MSM. Gay and straight men appeared to be poles on a continuum of frequency of sexual behavior, with bisexual and down low men being sometimes more similar to gay men and sometimes more similar to straight men. The percentage of men having total intercourse of any kind was highest among down low and lowest among gay men. Gay men had less intercourse with women, but more receptive anal intercourse with men than the other identities. There were no significant differences by identity in frequency of condomless insertive anal intercourse with men, but gay men had significantly more condomless receptive anal intercourse. There were significant differences by identity for condomless vaginal and anal intercourse with women. This study demonstrates the importance of exploring differences in types of sex behavior for AAMSM by considering sexual identity.

Child Sexual Abuse and Adult Mental Health, Sexual Risk Behaviors, and Drinking Patterns Among Latino Men Who Have Sex With Men.

One in five Latino men who have sex with men has experienced child sexual abuse. Although concerning in itself, child sexual abuse may increase an individuals' likelihood of depression and risk-taking in adult life, including engagement in HIV risk behaviors and alcohol and substance use. It is therefore urgent that researchers and practitioners better understand the long-term effects of child sexual abuse. We utilized logistic and linear regression to assess associations between child sexual abuse (operationalized as forced or coerced sexual activity before age 17) and depression, sexual behaviors, and drinking patterns in a sample of 176 adult Latino men who have sex with men from New York City. Over one-fifth (22%) of participants reported child sexual abuse. In multivariable models, participants with histories of child sexual abuse were significantly more likely than participants without such histories to screen for clinically significant depressive symptoms and heavy drinking and reported more anal sex acts, male sexual partners, and incidents of condomless anal intercourse in the previous three months. These findings confirm a high prevalence of child sexual abuse among Latino men who have sex with men and associations between child sexual abuse and adulthood depressive symptoms, high-risk alcohol consumption, and sexual risk behaviors. We recommend that providers who serve Latino men who have sex with men incorporate child sexual abuse screenings into mental health, HIV prevention, and substance use treatment programs, utilizing approaches that are inclusive of resilience.

Childhood Sexual Abuse and Sociodemographic Factors Prospectively Associated with Intimate Partner Violence Perpetration Among South African Heterosexual Men.

BACKGROUND: Intimate partner violence directed at women by men continues to be a global concern. However, little is known about the factors associated with perpetrating intimate partner violence among heterosexual men. PURPOSE: History of childhood sexual abuse and other sociodemographic variables were examined as potential factors associated with severe intimate partner violence perpetration toward women in a sample of heterosexual men in South Africa. METHODS: Longitudinal logistic generalized estimating equations examined associations of childhood sexual abuse and sociodemographic variables at baseline with intimate partner violence perpetration at subsequent time points. RESULTS: Among participants with a steady female partner, 21.81 % (190/ 871) reported perpetrating intimate partner violence in the past year at baseline. Having a history of childhood sexual abuse (p < .001), binge drinking (p = .002), being employed (p = .050), and more difficulty controlling sexual impulses in order to use a condom (p = .006) at baseline were associated with self-reported intimate partner violence perpetration in the past year at subsequent time points. CONCLUSIONS: With high levels of recent severe physical and/or sexual intimate partner violence perpetration in South Africa, comprehensive interventions are urgently needed. To more fully address gender-based violence, it is important to address associated factors, including exposure to childhood sexual abuse that could impact behavior later in life and that have long-lasting and deleterious effects on men and their female partners.

Efficacy and Mediation of a Theory-Based Physical Activity Intervention for African American Men Who Have Sex with Men: A Randomized Controlled Trial.

BACKGROUND: Few trials have tested physical-activity interventions among sexual minorities, including African American men who have sex with men (MSM). PURPOSE: We examined the efficacy and mediation of the Being Responsible for Ourselves (BRO) physical-activity intervention among African American MSM. METHOD: African American MSM were randomized to the physical-activity intervention consisting of three 90-min one-on-one sessions or an attention-matched control intervention and completed pre-intervention, immediately post-intervention, and 6- and 12-month post-intervention audio computer-based surveys. RESULTS: Of the 595 participants, 503 completed the 12-month follow-up. Generalized estimating equation models revealed that the intervention increased self-reported physical activity compared with the control intervention, adjusted for pre-intervention physical activity. Mediation analyses suggested that the intervention increased reasoned action approach variables, subjective norm and self-efficacy, increasing intention immediately post-intervention, which increased physical activity during the follow-up period. CONCLUSIONS: Interventions targeting reasoned action approach variables may contribute to efforts to increase African American MSM's physical activity. CLINICAL TRIAL REGISTRATION: The trial was registered with the ClinicalTrials.gov Identifier NCT02561286 .

Risky Trade: Individual and Neighborhood-Level Socio-Demographics Associated with Transactional Sex among Urban African American MSM.

There is a clear, persistent association between poverty and HIV risk and HIV infection. Low educational attainment, neighborhood disadvantage, and residential instability are ways in which poverty is instrumentally experienced in urban America. We investigated the role of lived poverty at both the individual and neighborhood levels in transactional sex behavior among African American men who have sex with men (MSM) residing in urban neighborhoods. Using population-averaged models estimated by generalized estimating equation (GEE) models, we identified individual-level and neighborhood-level factors that are associated with exchanging sex for drugs and/or money. We tested the association between neighborhood and individual-level socioeconomic status and HIV risk behavior by combining area-based measures of neighborhood quality from the US Census with individual survey data from 542 low-income African American MSM. The primary outcome measure was self-reported transactional sex defined as exchanging sex for drugs or money. Individual-level covariates included high school non-completion, income, and problem drug use. Neighborhood-level covariates were high school non-completion and poverty rates. The findings suggested that educational attainment is associated with both the individual level and neighborhood level. Participants were more likely to engage in transactional sex if they did not complete high school (OR = 1.78), and similarly if their neighbors did not complete high school (OR = 7.70). These findings suggest potential leverage points for both community-level interventions and advocacy for this population, particularly related to transactional sex and education, and will aid HIV prevention efforts that seek to address the contextual constraints on individual risk behavior.

Relationship Factors Associated with Sexual Risk Behavior and High-Risk Alcohol Consumption Among Latino Men Who Have Sex with Men: Challenges and Opportunities to Intervene on HIV Risk.

The HIV epidemic continues to be a major public health concern, affecting communities with varying prevention and treatment needs. In the U.S., Latino men who have sex with men (MSM) bear a disproportionate burden of HIV incidence. While recent studies have highlighted the relevance of relationship factors for HIV transmission among MSM generally, the unique needs and experiences of Latino MSM have received relatively little attention. Consequently, associations between relationship factors and HIV risk among Latino MSM remain unknown. This mixed-method study examined relationship status and dynamics and potential HIV-related risk behaviors among Latino MSM. Quantitative analyses with 240 Latino MSM investigated associations between relationship status and engagement in condomless anal intercourse (CAI). Focus groups with 20 Latino male couples and 10 health service providers explored the impact of relationship dynamics on sexual behaviors, as well as opportunities to intervene on HIV risk. The majority of participants were predominantly Spanish speaking, most screened positive for high-risk alcohol consumption in the past month, more than half engaged in CAI in the past 3 months, and a majority reported multiple sexual partners in this period. Among participants in same-sex relationships (n = 175), approximately half reported multiple partners in the previous 3 months and more than two-thirds reported CAI in this time period. Being in a same-sex relationship was positively associated with high-risk alcohol consumption and being age 30 or older and negatively associated with having multiple partners. Moreover, being in a same-sex relationship significantly increased the likelihood that participants would report engaging in CAI. Qualitative analyses identified themes related to relationship dynamics and sexual behavior, as well as opportunities to intervene on HIV risk. Despite the challenges encountered by Latino male couples, most participants expressed commitment to and support for their partners. As such, prevention efforts involving Latino male couples must address relationship dynamics and the role they play in sexual health, including safer sex practices.

Retention of South African Adolescents in a 54-Month Longitudinal HIV Risk Reduction Trial.

Retention of participants in clinical trials is a central concern of HIV/STI behavioral researchers and research sponsors. This article describes the strategies used for addressing the challenges in retaining South African adolescents for a 54-month longitudinal study. The objective of the South African adolescent health promotion long-term follow-up trial was to test the sustainability of the effects of an HIV/STI risk reduction intervention, "Let Us Protect Our Future," on young adolescents as they aged into middle and late adolescence. Inaccurate contact information, invalid mobile telephone numbers, lack of transportation, transitory family addresses, and family relocation were among the challenges to retaining participants. Despite a significant gap in time of 36 months between the main trial and the long-term follow-up study, 99.2% of 1057 participants were retained. Solutions used for retaining the adolescents are discussed with suggestions offered for retaining adolescents in longitudinal HIV/STI prevention clinical trials in low resource countries.

Associations between psychosocial factors and incidence of sexually transmitted disease among South African adolescents.

BACKGROUND: Adolescents living in South Africa are at high risk for HIV and other sexually transmitted diseases (STDs). The present study sought to identify correlates of curable STD incidence among a cohort of adolescents in Eastern Cape Province, South Africa. METHODS: Data were collected in conjunction with an HIV/STD prevention intervention randomized controlled trial. At 54 months postintervention, curable STD incidence (gonorrhea, chlamydial infection, and trichomoniasis) was assayed and self-report measures of potential correlates of STD incidence were collected. RESULTS: Participants were adolescents reporting at least 1 sexual partner in the past 3 months (n = 659). As expected, univariate analyses revealed that girls were more likely than boys to have an STD. In addition, intimate partner violence, unprotected sex, and having older partners were associated with incident STD. In Poisson multiple regression analyses, sex (risk ratio [RR], 4.00; 95% confidence interval [CI], 2.51-6.39), intimate partner violence (RR, 1.23; 95% CI, 1.12-1.35), unprotected sex (RR, 1.42; 95% CI, 1.09-2.01), and multiple partners (RR, 1.70; 95% CI, 1.11-2.61), but not partner's age (RR, 1.00; 95% CI, 0.94-1.07) were associated with incident STD, adjusting for 42-month STD prevalence. Binge drinking, forced sex, and age were unrelated to STD incidence in both analyses. Interactions between sex and the hypothesized correlates were nonsignificant, suggesting that sex did not modify these relationships. CONCLUSIONS: Interventions to reduce HIV/STD incidence among adolescents in South Africa should address the risk associated with sex, unprotected sex, intimate partner violence, and multiple partnerships.

Mediation of an efficacious HIV risk reduction intervention for South African men.

"Men, Together Making a Difference!" is an HIV/STD risk-reduction intervention that significantly increased self-reported consistent condom use during vaginal intercourse compared with a health-promotion attention-control intervention among men (N = 1181) in Eastern Cape Province, South Africa. The present analyses were designed to identify mediators of the intervention's efficacy. The potential mediators were Social Cognitive Theory (SCT) constructs that the intervention targeted, including several aspects of condom-use self-efficacy, outcome expectancies, and knowledge. Mediation was assessed using a product-of-coefficients approach where an α path (the intervention's effect on the potential mediator) and a ß path (the potential mediator's effect on the outcome of interest, adjusting for intervention) were estimated independently in a generalized estimating equations framework. Condom-use negotiation self-efficacy, technical-skill self-efficacy, and impulse-control self-efficacy were significant mediators. Although not mediators, descriptive norm and expected friends' approval of condom use predicted subsequent self-reported condom use, whereas the expected approval of sexual partner did not. The present results suggest that HIV/STD risk-reduction interventions that draw upon SCT and that address self-efficacy to negotiate condom use, to apply condoms correctly, and to exercise sufficient control when sexually aroused to use condoms may contribute to efforts to reduce sexual risk behavior among South African men. Future research must examine whether approaches that build normative support for condom use among men's friends are also efficacious.

On the Efficacy and Mediation of a One-on-One HIV Risk-Reduction Intervention for African American Men Who Have Sex with Men: A Randomized Controlled Trial.

We examined the efficacy and mediation of Being Responsible for Ourselves (BRO), an HIV/STI risk-reduction intervention for African American men who have sex with men (MSM), the population with the highest HIV-diagnosis rate in the US. We randomized African American MSM to one of two interventions: BRO HIV/STI risk-reduction, targeting condom use; or attention-matched control, targeting physical activity and healthy diet. The interventions were based on social cognitive theory, the reasoned-action approach, and qualitative research. Men reporting anal intercourse with other men in the past 90 days were eligible and completed pre-intervention, immediately post-intervention, and 6 and 12 months post-intervention surveys. Of 595 participants, 503 (85 %) completed the 12-month follow-up. Generalized-estimating-equations analysis indicated that, compared with the attention-matched control intervention, the BRO intervention did not increase consistent condom use averaged over the 6- and 12-month follow-ups, which was the primary outcome. Although BRO did not affect the proportion of condom-protected intercourse acts, unprotected sexual intercourse, multiple partners, or insertive anal intercourse, it did reduce receptive anal intercourse compared with the control, a behavior linked to incident HIV infection. Mediation analysis using the product-of-coefficients approach revealed that although BRO increased seven of nine theoretical constructs it was designed to affect, it increased only one of three theoretical constructs that predicted consistent condom use: condom-use impulse-control self-efficacy. Thus, BRO indirectly increased consistent condom use through condom-use impulse-control self-efficacy. In conclusion, although BRO increased several theoretical constructs, most of those constructs did not predict consistent condom use; hence, the intervention did not increase it. Theoretical constructs that interventions should target to increase African American MSM's condom use are discussed.

Cluster-randomized controlled trial of an HIV/sexually transmitted infection risk-reduction intervention for South African men.

OBJECTIVES: We tested the efficacy of a sexual risk-reduction intervention for men in South Africa, where heterosexual exposure is the main mode of HIV transmission. METHODS: Matched-pairs of neighborhoods in Eastern Cape Province, South Africa, were randomly selected and within pairs randomized to 1 of 2 interventions based on social cognitive theory and qualitative research: HIV/sexually transmitted infection (STI) risk-reduction, targeting condom use, or attention-matched control, targeting health issues unrelated to sexual risks. Sexually active men aged 18 to 45 years were eligible. The primary outcome was consistent condom use in the past 3 months. RESULTS: Of 1181 participants, 1106 (93.6%) completed the 12-month follow-up. HIV and STI risk-reduction participants had higher odds of reporting consistent condom use (odds ratio [OR] = 1.32; 95% confidence interval [CI] = 1.03, 1.71) and condom use at last vaginal intercourse (OR = 1.40; 95% CI = 1.08, 1.82) than did attention-control participants, adjusting for baseline prevalence. No differences were observed on unprotected intercourse or multiple partnerships. Findings did not differ for sex with steady as opposed to casual partners. CONCLUSIONS: Behavioral interventions specifically targeting men can contribute to efforts to reduce sexual risk behaviors in South Africa.

Theory-based behavioral intervention increases self-reported physical activity in South African men: a cluster-randomized controlled trial.

OBJECTIVE: To determine whether a health-promotion intervention increases South African men's adherence to physical-activity guidelines. METHOD: We utilized a cluster-randomized controlled trial design. Eligible clusters, residential neighborhoods near East London, South Africa, were matched in pairs. Within randomly selected pairs, neighborhoods were randomized to theory-based, culturally congruent health-promotion intervention encouraging physical activity or attention-matched HIV/STI risk-reduction control intervention. Men residing in the neighborhoods and reporting coitus in the previous 3 months were eligible. Primary outcome was self-reported individual-level adherence to physical-activity guidelines averaged over 6-month and 12-month post-intervention assessments. Data were collected in 2007-2010. Data collectors, but not facilitators or participants, were blind to group assignment. RESULTS: Primary outcome intention-to-treat analysis included 22 of 22 clusters and 537 of 572 men in the health-promotion intervention and 22 of 22 clusters and 569 of 609 men in the attention-control intervention. Model-estimated probability of meeting physical-activity guidelines was 51.0% in the health-promotion intervention and 44.7% in attention-matched control (OR=1.34; 95% CI, 1.09-1.63), adjusting for baseline prevalence and clustering from 44 neighborhoods. CONCLUSION: A theory-based culturally congruent intervention increased South African men's self-reported physical activity, a key contributor to deaths from non-communicable diseases in South Africa. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01490359.

Optimism and education buffer the effects of syndemic conditions on HIV status among African American men who have sex with men.

The present study sought to replicate effects of the number of syndemic psychosocial health conditions on sexual risk behavior and HIV infection among a sample of high-risk African American men who have sex with men (MSM) and to identify resilience factors that may buffer these effects. We used baseline data from an HIV risk-reduction trial to examine whether a higher number of syndemic conditions was associated with higher rates of self-reported sexual risk behavior and HIV infection. Using logistic regression models, we tested for interactions between number of syndemic conditions and several potential resilience factors to identify buffering effects. Replicating previous studies, we found significant associations between numbers of syndemic conditions and higher rates of sexual risk behavior and HIV infection. Surprisingly, we also replicated a previous finding (Stall et al., Am J Public Health, 93(6):939-942, 2003) that the effects of syndemic burden on HIV status fell off at the highest levels of syndemic conditions. Among a variety of potential resilience factors, two-optimism and education-buffered the syndemic effect on HIV prevalence. This is, to our knowledge, the first paper to identify resilience factors buffering against syndemic effects among MSM. It also constitutes a significant contribution to the literature regarding prevention among black MSM. These results point to the need to identify HIV-positive black MSM and provide effective treatment for them and to develop interventions addressing both syndemic and resilience factors.

Protective factors and HIV risk behavior among South African men.

The primary mode of HIV transmission in South Africa is heterosexual sexual behavior. HIV prevention research specifically focusing on men in South Africa is limited. We assessed self-reported HIV risk behaviors in 1,181 men ages 18 to 45 years in randomly selected neighborhoods in Eastern Cape Province, South Africa. Older men were less likely to report having multiple partners. Religiosity was a protective factor for condom use and unprotected sex with steady partners. Discussing using condoms was a protective factor for condom use and unprotected sex with both steady and casual partners. Having a child was associated with decreased condom use with steady partners and employment was associated with decreased condom use with casual partners. The findings suggest the need for HIV risk-reduction behavioral interventions tailored for South African men with regard to age, religiosity, and types of sexual partners. Implications for the development of such interventions are discussed.

Prospective Predictors of Blood Pressure Among African American Men Living with HIV.

Little is known about the predictors of blood pressure (BP) among African American men living with HIV. We examined whether age and body mass index (BMI) are associated with higher blood pressure (BP) and whether being married and muscular endurance are associated with lower BP among African American men living with HIV. Second, we examined whether being married moderated the effects of the other predictors on BP. Finally, we examined whether BMI mediated the relationship between muscular endurance and BP. This article is a prospective secondary analysis of data from a randomized controlled trial of a health-promotion intervention for African American men living with HIV. We measured the participants' BP pre-intervention and three, six, and 12 months post-intervention. Generalized estimating equations linear regression analyses examined whether marital status, age, BMI, and muscular endurance predicted BP post-intervention, adjusting for pre-intervention BP and the intervention. Older age, higher BMI, and lower muscular endurance predicted higher BP post-intervention, adjusting for the intervention and baseline BP. Although marital status did not predict post-intervention BP, it moderated the negative effect of higher BMI. The positive relation of BMI to BP was weaker among married men than unmarried men. Muscular endurance had an indirect impact on BP mediated through BMI. Public health efforts targeting older African American men with HIV should focus on increasing muscular endurance in this population to lower BMI as a strategy to reduce cardiovascular disease risk in this population.

Long-term mediation of a sexual risk-reduction intervention for South African adolescents.

OBJECTIVE: Black adolescents in South Africa are disproportionately affected by HIV. A cluster-randomized controlled experiment examining the effects of a sexual risk-reduction intervention successfully reduced self-reported intercourse and unprotected intercourse. Based on long-term follow-up assessments, the present research examines theoretical constructs that could potentially mediate the intervention effects and how time and gender, respectively, moderated the mediation. METHOD: The behavioral outcome was measured by asking whether participants had had any vaginal sex in the past 3 months. Mediation and moderated mediation were tested based on the 3-, 6-, 12-, 42-, and 54-month postintervention outcomes. RESULTS: Three variables through which the sexual risk-reduction intervention had a significant mediated effect on the behavioral outcome were identified: abstinence career opportunities outcome expectancy (α × ß product = -0.086, 95% asymmetric confidence interval [ACI] [-0.126, -0.047]), expected parental approval of sexual intercourse (α × ß product = -0.061, [-0.102, -0.025]), and self-efficacy to avoid sexual-risk situations (α × ß product = -0.022, [-0.049, -0.001]). The moderated mediation analysis showed that gender moderated the intervention's effects on abstinence prevention outcome expectancy (B = -0.186, SEB = 0.079, p = .019), expected parental approval of sexual intercourse (B = 0.143, SEB = 0.058, p = .013), and self-efficacy to avoid sexual-risk situations (B = -0.293, SEB = 0.112, p = .009). The moderated mediation analysis also revealed that time moderated the effects of the intervention on abstinence career opportunities outcome expectancy (B = -0.293, SEB = 0.106, p = .006), self-efficacy to avoid sexual-risk situations (B = 0.335, SEB = 0.060, p < .001), and cultural myths regarding HIV transmission (B = 0.138, SEB = 0.042, p = .001); and the association between four theoretical constructs and the behavioral outcome: abstinence career opportunities outcome expectancy (B = -0.267, SEB = 0.104, p = .001), self-efficacy to refuse sex (B = -0.132, SEB = 0.043, p = .002), self-efficacy to avoid sexual-risk situations (B = -0.093, SEB = 0.055, p = .009), and HIV risk-reduction knowledge (B = -0.286, SEB = 0.134, p = .003). CONCLUSIONS: The present study identifies theoretical constructs that mediated the intervention effects on the sexual behavior among South African adolescents for an extended period of time. The findings also reveal gender differences in psychological mechanisms initiated by a sexual risk-reduction intervention and the long-term temporal dynamics of the intervention. (PsycInfo Database Record (c) 2023 APA, all rights reserved).