A Provider-Focused Intervention to Increase Universal HIV Testing among Adolescents in School-Based Health Centers.

We describe a provider-focused intervention to increase universal HIV testing among adolescent users in a network of School-Based Health Centers (SBHC) and compare the rate of HIV test offer and acceptance for SBHCs with and without the HIV testing intervention. The intervention was implemented at the six largest SBHCs in the 12-site network and included system- and staff-level initiatives, including an implementation coach to support SBHC associates. Rates of HIV test offer and acceptance at six sites in the Intervention Cohort were compared to that at the six sites in a Non-Intervention Cohort which was not randomly selected but had comparable distributions by age, gender and race/ethnicity. The model showed an intervention effect for universal HIV test offer, but no overall effect for test acceptance. Analyzing the intervention effect by whether a patient had a history of sexual activity, the intervention was very effective early in its implementation at increasing test offer to those with no history of sexual activity, and late in its implementation at increasing test acceptance for those with no or unknown sexual activity. Increasing and sustaining universal HIV testing in SBHCs may benefit from using Implementation Science frameworks to guide adaptation of the intervention.

The sexual and reproductive health covariates of early menarche among adolescent girls.

INTRODUCTION: Research suggests that girls who reach menarche at an early age are at greater risk for negative sexual and reproductive health (SRH) outcomes than their later-maturing counterparts, but very little research has examined this issue in sub-Saharan Africa, especially in West Africa. The goal of the current study was to determine whether early menarche was associated with any SRH outcomes in a sample of Ghanaian girls. METHODS: The study data were drawn from the baseline assessment of a longitudinal study involving two age cohorts (13-14 and 18-19 years) of 700 adolescent girls from Ghana. Logistic regressions were used to assess the association between early menarche (before age 13) and seven SRH outcomes (adolescent sexual activity, early sexual initiation, inconsistent condom use, transactional sex, sexual violence, multiple sexual partners, and adolescent pregnancy). RESULTS: Early menarche was significantly associated with adolescent sexual activity (odds ratio [OR] = 6.4; 95% confidence interval [CI] 2.1-19.7), and sexual violence (OR = 3.2; 95% CI 1.6-6.2) in the younger cohort and early sexual initiation (OR = 3.2; 95% CI 1.19-8.61) and multiple sexual partners (OR = 3.7; 95% CI 1.39-9.87) in the older cohort. Early menarche was also associated with transactional sex and teen pregnancy in the full sample. CONCLUSIONS: These findings suggest the need for special attention to the needs of early-maturing girls in SRH programming. Interventions are needed to delay adolescent sexual activity in girls with early menarche. Efforts to prevent sexual violence among adolescent girls in Ghana may benefit from targeting and addressing the specific needs of early-maturing girls.

Information, Motivation and Behavioral Skills as Mediators Between Sexual Minority Stigma and Condomless anal Sex Among Black South African Men Who have Sex with Men.

We assessed pathways between sexual minority stigma and condomless anal intercourse (CAI) among two samples of Black South African men who have sex with other men (MSM). Two cross-sectional surveys were conducted in Tshwane, South Africa; one among 199 Black MSM and another among 480 Black MSM. Men reported on external and internalized experiences of sexual minority stigma, mental health, alcohol use, information-motivation-behavioral skills (IMB) model constructs, and CAI. Structural equation modeling was used to test whether external and internalized stigma were directly and indirectly associated with CAI. In both studies, external stigma and internalized stigma were associated with CAI through IMB model constructs. These results suggest a pathway through which stigma contributes to HIV risk. For HIV prevention efforts to be effective, strengthening safer sex motivation and thus decreasing sexual risk behavior likely requires reducing sexual minority stigma that MSM experience and internalize.

HIV and Intersectional Stigma Reduction Among Organizations Providing HIV Services in New York City: A Mixed-Methods Implementation Science Project.

Stigma remains a pervasive barrier to Ending the HIV Epidemic (EHE) in New York City (NYC). As part of an EHE implementation science planning process, we mapped multi-level HIV-related stigma-reduction activities, assessed their evidence base, and characterized barriers and facilitators. We interviewed and surveyed a convenience sample of 27 HIV prevention and/or treatment services organizations in NYC, March-August, 2020, using an embedded mixed-methods design. The greatest facilitators of stigma reduction included integration of health services, hiring staff who represent the community, and trainings. Intersecting stigmas were primarily addressed through the integration of HIV with mental health and substance use services. Barriers were multilevel, with organizational structure and capacity most challenging. A strong base of stigma-reduction activities was utilized by organizations, but intersectional frameworks and formal evaluation of activities' impact on stigma were lacking. Effectiveness-implementation hybrid research designs are needed to evaluate and increase the uptake of effective stigma-reduction approaches in NYC.

The social and sexual lives of Black sexual minority men 30 years of age and older in South Africa.

BACKGROUND: Black sexual minority men (SMM) ages 30 and older are under-represented in HIV studies in sub-Saharan Africa, despite being at increased risk of HIV infection and contributing to potential onward HIV transmission. To better understand the social and sexual lives of older Black South African SMM, we conducted in-depth interviews with SMM who were > 30 years old. METHODS: From March-September 2016, we recruited a convenience sample of 37 SMM ages 30 and older by partnering with an LGBTQ+ organization in Tshwane, Pretoria. Men were interviewed about various aspects of their lives, including their sexual orientation, social connectedness, experiences with stigma and perspectives on participating in research. RESULTS: Participants described their experiences with their sexual identities, cultural and social implications of disclosure, and their perspective on South Africa's political perspectives on the LGBTQ+ community. Men described how these experiences influence their trust in research and comfort participating in studies. CONCLUSIONS: Inferences drawn from these findings provide direction on how to improve middle-aged SMM's representation in research, such as recruiting a higher proportion of older and middle-aged SMM to serve as seed participants and building stronger community partnerships to disseminate study findings to settings where data collection is conducted.

Solidarity, support and competition among communities of female and male sex workers in Mombasa, Kenya.

Female and male sex workers are at elevated risk for HIV infection, psychological distress and other adverse health outcomes. It is therefore important to understand how sex workers' social relationships with one another might inform psychosocial support services for this population. We conducted semi-structured interviews to examine the formation and nature of social networks of 25 female and 25 male sex workers recruited from bars and clubs in Mombasa, Kenya. Relationships between and among female and male participants were often formed based on a mutual understanding of the challenging nature of sex work. Both groups described their relationships in terms of friendship and brotherhood/sisterhood and highlighted the following benefits of sex worker social networks: economic benefits, access to information about HIV/STIs and protection, and support against violence from clients and law enforcement agents. Social networks were often threatened by competition for clients and hence could result in conflict. However, sex workers explained that their sense of solidarity and reliance on one another for health, protection and economic well-being helped minimise conflict. The social networks of sex workers could therefore be used to leverage or optimise access to HIV prevention and care.

African Same-Sex Sexualities and Gender Diversity: A Framing Note.

This article introduces the concept of African same-sex sexualities and gender diversity which refers to variation pertinent to gender expressions and identities, sexual expression and sexual orientation. The article describes the emerging and evolving African scholarly production evident in the last two decades and describes key underlying themes that bring together this special issue.

Perceived HIV Risk Among Black MSM Who Maintain HIV-Negativity in New York City.

Black men who have sex with men (MSM) are disproportionately burdened by the HIV epidemic. Although there has been an increased focus on reducing HIV prevalence in Black MSM, little attention has been given to how and why Black MSM are able to remain HIV-negative, beyond believing that they are lucky. The purpose of this qualitative study was to explore how Black MSM try to stay HIV-negative. Guided by constructivist grounded theory and a strengths-based approach, we conducted in-depth interviews to explicate how Black MSM demonstrate resilience by staying seronegative amidst high seroprevalence. Results from this study suggest that it is their perceptions of HIV risk that translate into protective strategies that enable them to prevent infection. Our study offers insight into their reasoning processes that guide their efforts to stay HIV-negative.

RESUMEN: Los hombres Afro-Americanos que tienen sexo con hombres (HAASH) son desaproporcionalmente afectados por la epidemia del VIH. Aunque ha habido un mayor enfoque en la reducción del VIH en HAASH, no se ha prestado tanta atención a los que son VIH negativos. Muchos HAASH son seronegativos y es importante identificar como siguen siéndolos a pesar de que HAASH crean que es por suerte. El propósito de este estudio cualitativo fue explorar como HAASH tratan de mantenerse VIH negativos. Guiados por "constructivist grounded theory" y un enfoque en las fortalezas, llevamos a cabo entrevistas individuales para explicar como pueden mantenerse seronegativos a pesar de una alta seroprevalencia. Los resultados de este estudio sugieren que sus percepciones del riesgo son los que se convierten en estrategias de protección que les permite prevenir la infección. Nuestro estudio ofrece información sobre sus procesos de razonamiento que guían sus esfuerzos para mantenerse VIH negativos.

"I Couldn't Afford to Resist": Condom Negotiations Between Male Sex Workers and Male Clients in Mombasa, Kenya.

Male sex workers in Kenya face a disproportionate burden of HIV and often engage in condomless sex with their commercial partners, yet little is known about how condom negotiations between male sex workers and clients take place. We conducted semi-structured interviews with 25 male sex workers and 11 male clients of male sex workers in Mombasa, Kenya, to examine barriers and facilitators to condom use and how condom use negotiation takes place in these interactions. Participants reported positive attitudes toward condom use and perceived condom use to be a health-promoting behavior. Barriers to condom use included extra-payment for condomless sex, low perceived HIV/STI risk with some sexual partners, perceived reduced pleasure associated with using condoms, alcohol use, and violence against male sex workers by clients. Future interventions should address individual- and structural-level barriers to condom use to promote effective condom use negotiation between male sex workers and male clients.

Types of Group Sex and Their Association with Different Sexual Risk Behaviors Among HIV-Negative Men Who Have Sex with Men.

The current study sought to identify types of group sex acts among HIV-negative men who have sex with men (MSM) and assess their association with different sexual risk behaviors using cross-sectional data of group sex acts reported during 6 waves (2015-2018) of the Amsterdam MSM Cohort Study. Latent class analysis was performed to identify group sex types based on size, familiarity with partners, location, planning, and drug use. Associations between group sex types and sexual behaviors were evaluated using logistic regression with generalized estimating equations, employing the sample mean as a reference. Data at the level of group sex acts were analyzed, while correcting variance estimations for repeated measurements within MSM. A total of 392 MSM engaged in group sex ≥ 1 times, totaling 1033 group sex acts. Four types of group sex emerged: familiar (29%), intimate (27%), impromptu (36%), and party (8%). Familiar group sex (characterized by high proportions of mostly known partners, occurring in private places and involving drug use) had an increased adjusted odds of risky fingering (aOR 1.6, 95%CI 1.3-2.0) and of risky fisting and/or use of sex toys (aOR 2.3, 95%CI 1.6-3.1). Intimate group sex (characterized by high proportions of threesomes, occurring in private places, and not involving drug use) had a decreased adjusted odds of risky fisting and/or use of sex toys (aOR 0.6, 95%CI 0.4-0.9). Impromptu group sex (characterized by high proportions of spontaneity, mostly unknown partners, and taking place in public places) had a decreased adjusted odds of risky fisting and/or use of sex toys (aOR 0.5, 95%CI 0.3-0.7) and of condomless anal intercourse (CAI) (OR 0.6, 95%CI 0.5-0.8). Party group sex (characterized by high proportions of larger groups, mostly unknown partners, and being planned) had an increased adjusted odds of risky fisting and/or use of sex toys (aOR 1.6, 95%CI 1.0-2.7) and of CAI (aOR 1.5, 95%CI 1.1-2.1). The identified types of group sex reflect different dynamics and characteristics, with some types riskier for STIs and others riskier for HIV. HIV and STI prevention efforts could be tailored accordingly. For example, in certain type of public sex environments (e.g., cruising parks), traditional HIV and STI prevention efforts, such as promoting of condom use and PrEP, might be sufficient. However, in other settings (e.g., private parties), where group sex is more likely to be planned and where behaviors such as fisting, sharing of sex toys, and CAI are more likely to take place, which carry different levels of risk for HIV and STI transmission, including that of Hepatitis C, different approaches might be needed, such as broader HIV and STI prevention education efforts or targeting the organizers of group sex events.

Southern African Lesbian and Bisexual Women Responses to Symptoms of Sexually Transmitted Infections.

Sexually transmitted infection (STI) in lesbian and bisexual women is a relatively unexplored topic, particularly for women from low- and middle-income countries. Despite perceptions that women who have sex with women (WSW) are at negligible risk of contracting STI, existing research demonstrates that WSW do become infected with STI. Given the opposition between assumptions of invulnerability and the observed risks, we explored how WSW would respond to symptoms of STI (i.e., wait until symptoms passed, see a medical doctor, and inform sexual partners). We used data collected as part of a collaboration between academic researchers and community-based LGBTQ organizations in Botswana, Namibia, South Africa, and Zimbabwe. Chi-squared tests were used to test whether participants' responses to hypothetical STI symptoms varied in relation to several intrapersonal, interpersonal, and structural factors. Multivariable logistic regression (backward) was used to assess whether these variables were independently associated with women's responses. Most women would be proactive in response to potential STI symptoms and would see a medical doctor. However, most women would not inform their sexual partner of symptoms of STI. Findings demonstrate several intrapersonal, interpersonal, and structural factors that influence WSW's health agency, and show a clustering of high-risk factors among women who would not be proactive about their health. Our findings suggest the need for improved health and health care of WSW in Southern Africa.

Sexual violence experiences among black gay, bisexual, and other men who have sex with men and transgender women in South African townships: contributing factors and implications for health.

This study examined experiences with sexual violence among Black African gay, bisexual, and other men who have sex with men (GBMSM) and transgender women (TGW) in townships surrounding Pretoria, South Africa. Of 81 GBMSM and TGWs interviewed, 17 reported to have experienced sexual violence perpetrated by other men. Qualitative analysis of interviews revealed the social and relational context of these experiences as well as their psychological and health consequences. The described context included single- and multiple-perpetrator attacks in private and public spaces, bias-motivated attacks, and violence from known partners. Several participants reported refusing propositions for sex as a reason for being victimized. HIV-positive individuals were overrepresented among survivors compared to the sample as a whole. Following victimization, participants described feelings of pain, fear, anger and self-blame. The results demonstrate the need for interventions designed to (a) prevent sexual violence against GBMSM and TGW in this population, and (b) reduce the negative psychological and health outcomes of sexual victimization. The discussion also highlights the need to examine more closely the link between experiences of sexual violence and risk for HIV infection.

Intentional and Unintentional Condom Breakage and Slippage in the Sexual Interactions of Female and Male Sex Workers and Clients in Mombasa, Kenya.

We examined why male condoms broke or slipped off during commercial sex and the actions taken in response among 75 female and male sex workers and male clients recruited from 18 bars/nightclubs in Mombasa, Kenya. Most participants (61/75, 81%) had experienced at least one breakage or slippage during commercial sex. Many breakages were attributed to the direct actions of clients. Breakages and slippages fell into two main groups: those that were intentionally caused by clients and unintentional ones caused by inebriation, forceful thrusting during sex and incorrect or non-lubricant use. Participant responses included: stopping sex and replacing the damaged condoms, doing nothing, getting tested for HIV, using post-exposure prophylaxis and washing. Some sex workers also employed strategies to prevent the occurrence of condom breakages. Innovative client-oriented HIV prevention and risk-reduction interventions are therefore urgently needed. Additionally, sex workers should be equipped with skills to recognize and manage breakages.

Gender Expression and Mental Health in Black South African Men Who Have Sex with Men: Further Explorations of Unexpected Findings.

Unlike studies conducted in Western countries, two studies among Black South African men who have sex with men (MSM) found no support for the association between gender nonconformity and mental distress, even though gender-nonconforming men experienced more discrimination and discrimination was associated with mental distress (Cook, Sandfort, Nel, & Rich, 2013; Sandfort, Bos, Knox, & Reddy, 2016). In Sandfort et al., gender nonconformity was assessed as a continuous variable, validated by comparing scores between a categorical assessment of gender presentation (masculine, feminine, no preference). Using the same dataset, we further explored this topic by (1) testing differences between gender expression groups in sexual minority stressors, resilience factors, and mental distress; (2) testing whether the impact of elevated discrimination in the feminine group was counterbalanced by lower scores on other stressors or higher scores on resilience factors; and (3) exploring whether relationships of stressors and resilience factors with mental distress varied between gender expression groups. Controlling for demographics, we found several differences between the gender expression groups in the stressors and resilience factors, but not in mental distress. We found no support for the idea that the lack of differences in mental distress between the gender expression groups was a consequence of factors working in opposite directions. However, internalized homophobia had a differential impact on depression in feminine men compared to masculine men. In our discussion of these findings, we explored the meaning of our participants' self-categorization as it might relate to gender instead of sexual identities.

Substance Use and Sexual Risk Behavior Among Black South African Men Who Have Sex With Men: The Moderating Effects of Reasons for Drinking and Safer Sex Intentions.

Research studies suggest an association between substance use and sexual risk behavior, but are not completely consistent. The moderating effects of other psychosocial factors might help explain these inconsistencies. The current study therefore assessed whether substance use is associated with sexual risk behavior, and whether this relationship is modified by expectancies about the effects of alcohol, reasons for consuming alcohol, or intentions to engage in safe sex. A cross-sectional survey was conducted among 480 black South African men who have sex with men recruited using respondent-driven sampling. In multivariable analyses, the effect of alcohol use on unprotected receptive anal intercourse (URAI) was modified by drinking to enhance social interaction (R2 change = 0.03, p < 0.01). The effect of drug use on URAI was modified by safe sex intentions (R2 change = 0.03, p < 0.001). Alcohol use was positively associated with URAI only among those who drink to enhance social interaction (ß = 0.08, p < 0.05). Drug use was positively associated with URAI only among those with high safe sex intentions (ß = 0.30, p < 0.001). Our findings suggest that efforts to minimize the impact of substance use on HIV risk behavior should target men who drink to enhance social interaction and men who intend to engage in safer sex. Efforts made to increase safer sex intentions as a way to reduce HIV risk behavior should additionally consider the effects of substance use.

Correlates of Sexual Risk among Recent Gay and Bisexual Immigrants from Western and Eastern Africa to the USA.

We examined correlates of sexual risk among gay and bisexual men, who recently migrated from western and eastern African countries to the USA and lived in New York City and who are HIV negative or of unknown status. These men migrate from countries where same-sex sexuality is socially rejected and mostly illegal contributing to the motivation to migrate. Their background might predispose these men to engagement in sexual risk practices, while they are not specifically addressed in HIV prevention programming. Participants (N = 62) reported in face-to-face interviews on pre- and postmigration experiences, psychosocial determinants of sexual risk, and current sexual practices. Operationalization of sexual risk was based on the number of men with whom they had condomless receptive and/or insertive anal sex. Over a third of the men reported always having used condoms in the past year; among the other men, sexual risk varied. Multivariate analyses showed that sexual risk was lower among men with a stronger motivation to avoid HIV infection and higher among men who currently engaged in transactional sex. Further analyses indicated that housing instability was independently associated with reduced motivation to avoid HIV infection and with engagement in transactional sex in the USA. In recent western and eastern African gay and bisexual immigrants to the USA, structural factors, including housing instability, are strongly associated with sexual risk.

Breakage is the norm: use of condoms and lubrication in anal sex among Black South African men who have sex with men.

This paper explores condom use and lubrication practices among Black men who have sex with men in South African townships. Results are from 81 in-depth individual interviews conducted among a purposive sample from four townships surrounding Pretoria as part of a larger qualitative study. Awareness that condoms should be used to have safer anal sex was ubiquitous. Fewer men reported that lubricants should be used to facilitate anal intercourse. Partner pressure and partner distrust were the most common barriers cited for not using condoms and lubricants. Knowledge about condom-lubricant compatibility was rare. Condom problems were a norm, with widespread expectations of condom failure. Men's subjectivities - their perceptions of and preferences for specific brands, types and flavours of condoms and lubricants - influenced engagement with such safer-sex technologies. However, what was available in these settings was often neither what men needed nor preferred. Findings show the need to enhance access to appropriate and comprehensive: safer-sex supplies, health services and health education, and underline the importance of efforts to develop targeted programmes relevant to experiences of men who have sex with men in the South African context.

Is Group Sex a Higher-Risk Setting for HIV and Other Sexually Transmitted Infections Compared With Dyadic Sex Among Men Who Have Sex With Men?

BACKGROUND: Group sex has been suggested as a potential high-risk setting for HIV and other sexually transmitted infections (STIs) among men who have sex with men (MSM). We investigated whether group sex is associated with lower condom use during anal sex and higher proportions of STIs compared with dyadic sex among HIV-negative MSM between 2009 and 2012. METHODS: Cross-sectional data from 7 data waves of the Amsterdam Cohort Studies were used. The sample consisted of 465 MSM who either reported both group and dyadic sex (at n = 706 visits) or dyadic sex only (at n = 1339 visits) in the preceding 6 months. Logistic regression with generalized estimating equations was used to investigate the association between sexual setting (group vs. dyadic sex), condomless anal sex, and STI. RESULTS: Group sex was reported at 35% (706/2045) of visits. Condomless sex was more often reported during dyadic than group sex (odds ratio, 3.64 95% confidence interval, 2.57-5.16). Men who had group sex were more likely diagnosed as having gonorrhea compared with men with dyadic sex (odds ratio, 1.71; 95% confidence interval, 1.08-2.97), but this effect was not retained in the multivariate model. CONCLUSIONS: Results demonstrate within-person differences in sexual behavior during group and dyadic sex among MSM. Men were more likely to use condoms during group sex than during dyadic sex. Thus, for some, group sex may not necessarily be risky for HIV infection compared with dyadic sex. However, group sex may be a higher-risk setting for acquiring STIs other than HIV, such as gonorrhea. Group sex encounters should be recognized as distinct sexual settings with specific risk characteristics that need to be addressed accordingly.

Gender Nonconformity, Discrimination, and Mental Health Among Black South African Men Who Have Sex with Men: A Further Exploration of Unexpected Findings.

Using data from a study about HIV risk among Black South African MSM, we aimed to ascertain whether unexpected findings about the relationship between gender nonconformity, discrimination, and mental health in this population, as reported by Cook, Sandfort, Nel, and Rich (2013), could be replicated, and to explore more in-depth how gender nonconformity relates to health. Cook et al. found that feminine men were not more likely to be depressed despite the observation that they were more likely to be discriminated against and that discrimination increased the likelihood of depression. This is in contrast to what studies among gay and bisexual men in Western countries have consistently shown. In the current study, 196 Black South African MSM (ages between 18 and 40; M age, 26.65 years) were surveyed. Assessments included stressors (identity confusion, internalized homophobia, and sexual orientation-based discrimination) and resilience factors (openness about one's sexual orientation, social support, and identification with the gay community). We observed that gender-nonconforming men were not more likely to be depressed despite having experienced more discrimination, which was associated with depression. The same relationships were observed when considering anxiety as the mental health outcome. We found an indirect negative effect of gender nonconformity on depression through internalized homophobia, suggesting that, in this population, internalized homophobia masks the effect of discrimination on mental distress. Implications for the sexual minority stress model, used to guide our analyses, are discussed. Further research is needed to disentangle the complex relationship between gender nonconformity and mental health among MSM populations.

HIV testing practices of South African township MSM in the era of expanded access to ART.

While men who have sex with men (MSM) in Africa are at high risk for HIV infection, few of those already infected know their status. Effectively promoting frequent HIV testing-of increasing importance with the expanding accessibility of antiretroviral treatment-requires an understanding of the testing practices in this population. To understand men's HIV testing practices, including their behavior, experiences, and perceptions, we conducted in-depth interviews with 81 black South African MSM (ages 20-39), purposively recruited from four townships. Many men in the sample had tested for HIV. While ever having tested seemed to facilitate repeat testing, men still expressed a high level of discomfort with testing. It was common to test after having engaged in risky behavior, thus increasing anxiety about testing that was already present. Fear that they might test HIV positive caused some men to avoid testing until they were clearly sick, and others to avoid testing completely. HIV testing may increase in this population if it becomes a routine practice, instead of being driven by anxiety-inducing incidents. Mobilization through social support might facilitate frequent testing while education about current treatment options is needed.