Associations Between Alcohol Use, Antiretroviral Therapy Use, and Viral Load Suppression Among People Living with HIV in Rural Central Uganda.

Alcohol use among people living with HIV (PWH) is common and may negatively affect engagement in HIV care. We evaluated the relationships between alcohol use, ART use, and viral suppression among PWH in Uganda. PATH/Ekkubo was a trial evaluating a linkage to HIV care intervention in four Ugandan districts, Nov 2015-Sept 2021. Our analytical sample included: (1) baseline data from individuals not enrolled in the intervention trial (previously diagnosed HIV+); and 12-month follow-up data from the control group (newly diagnosed or previously diagnosed, but not in care). Level of alcohol use was categorized using the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C): none (AUDIT-C = 0), low (women = 1-2, men = 1-3), medium (women = 3-5, men = 4-5), high/very high (6-12). Multivariable logistic regression models evaluated associations between alcohol use, ART use and viral suppression (a viral load of < 20); we also stratified by gender. Among 931 PWH, medium (OR: 0.43 [95% CI 0.25-0.72]) and high/very high (OR: 0.22 [95% CI 0.11-0.42]) levels of alcohol use were associated with lower odds of being on ART. In a sub-sample of 664, medium use (OR: 0.63 [95% CI 0.41-0.97]) was associated with lower odds of viral suppression. However, this association was not statistically significant when restricting to those on ART, suggesting the relationship between alcohol use and viral suppression is explained by ART use. Among men, high/very high, and among women, medium alcohol use levels were associated with lower odds of being on ART and being virally suppressed. Interventions for PWH who use higher levels of alcohol may be needed to optimize the benefits of Uganda's Universal Test and Treat strategy.

Stigmatization of food insecurity helps explain the association between food insecurity and medication nonadherence among people living with HIV.

Food insecurity is an established barrier to antiretroviral therapy (ART) adherence among people living with HIV (LWHIV). While insufficient access to food reliably impedes medication adherence, the link between food insecurity and ART nonadherence has not been fully explained. In addition, depression is reliably associated with both food insecurity and ART nonadherence, but again the link between food insecurity and depression is not understood. A potential explanatory mechanism in the associations among food insecurity, depression and ART nonadherence is the experience of food insecurity stigma (FI-stigma). The current study tested FI-stigma in relation to depression as explanatory mechanisms in the association between food insecurity and ART nonadherence. Men and women (n = 495) LWHIV in the southeastern United States completed confidential surveys that included measures of food insecurity, FI-stigma, depression, and ART adherence. Results from the serial mediation model indicated significant direct effects of food insecurity and depression on ART adherence. In addition, food insecurity was indirectly associated with ART adherence through FI-stigma and depression symptoms. Results suggest that the stigmatization of food insecurity predicts increased depression which in turn predicts ART nonadherence, with both FI-stigma and depression symptoms partially mediating the relationship between food insecurity and ART nonadherence. Interventions aimed to reduce food insecurity should include it's associated stigma to improve treatment adherence among people LWHIV.

The three-item patient-reported instrument for retrospective adherence in resource constrained settings: reliability, validity and potential utility.

INTRODUCTION: Patient-report instruments remain the most feasible and sustainable approaches for monitoring medication adherence in clinical settings. However, questions of their reliability and validity persist. Studies suggest that the 3-item instrument for retrospective adherence (IRA) developed by Wilson et al. offers a viable option for clinically monitoring medication adherence. Here we report the reliability and validity of the IRA among patients recruited from community-based HIV clinics and antiretroviral therapy (ART) dispensaries in a resource constrained township in Cape Town, South Africa. METHODS: Women (n = 794) and men (n = 228) receiving ART completed the IRA at three time points: (a) in a face-to-face administration at enrollment (b) in1-week phone interview and (c) 1-month phone interview. Participants also provided contemporaneous blood samples for HIV viral load testing as a clinical outcome and unannounced phone-based pill counts as an objective assessment of ART adherence. RESULTS: The IRA was internally consistent and showed evidence of time stability. The IRA also demonstrated validity with respect to pill count adherence, correlates of adherence, and HIV viral load. Response operating curve analysis yielded an area under the curve of 0.646, using 75% adherence as the cut-off, with 0.637 sensitivity and 0.567 specificity. CONCLUSIONS: The IRA demonstrated reliability, construct validity and criterion validity in a resource constrained setting, supporting use of the IRA in research and clinical care.

Randomized Clinical Trial of Stigma Counseling and HIV Testing Access Interventions to Increase HIV Testing Among Black Sexual Minority Men and Transwomen.

Advances in HIV prevention tools have outpaced our ability to ensure equitable access to these tools. Novel approaches to reducing known barriers to accessing HIV prevention, such as stigma and logistical-related factors, are urgently needed. To evaluate the efficacy of a randomized controlled trial with four intervention arms to address barriers to HIV/STI testing uptake (primary outcome) and PrEP use, depression, and HIV test results (secondary outcomes). We tested a 2 × 2 research design: main effect 1-stigma-focused vs. health information evaluation-focused counseling, main effect 2-offering HIV/STI testing appointments in person vs. at home with a counselor via video chat, and the interaction of the main effects. Participants (N = 474) residing in the southeastern USA were screened and enrolled in a longitudinal trial. Intervention efficacy was established using generalized linear modeling with binomial or Poisson distributions. Intervention efficacy demonstrated an increase in HIV/STI testing uptake when testing was made available at home with a counselor via video chat vs. in person (83% vs. 75% uptake, p < .05), and participants were also more likely to test positive for HIV over the course of the study in the at-home condition (14.5% vs. 9.4%, p < .05). Stigma-focused counseling resulted in lower depression scores and greater uptake of PrEP among participants < 30 years of age when compared with health information counseling (15.4% vs. 9.6%, p < .05). In order to prevent further disparities between HIV prevention advances and access to HIV prevention tools, we must prioritize improvements in linking people to care. Novel interventions, such as those proposed here, offer a practical, evidence-based path to addressing long-standing barriers to HIV prevention strategies. Trial registration: NCT03107910.

Medical mistrust as a barrier to HIV prevention and care.

Medical mistrust is fueled by conspiracy theories and histories of healthcare systems abuse and is a known determinant of health outcomes in minority populations. Plagued by multiple and pervasive conspiracy theories, HIV/AIDS has proven to be particularly hampered by medical mistrust. The current paper systematically reviews the literature on medical mistrust among people at risk for or living with HIV infection. The bulk of evidence from 17 studies supports medical mistrust as a barrier to HIV testing, engagement in prevention and care services, treatment uptake and adherence, and clinical outcomes. While findings mostly indicate that medical mistrust is a barrier to HIV prevention and care, some studies report null results and others suggest that medical mistrust may actually improve some HIV-related outcomes. Additionally, most of the reviewed literature was cross-sectional. Thus longitudinal, theory-driven research is needed to reconcile inconsistent findings and determine long term outcomes of medical mistrust. Interventions may then be developed to reduce the negative consequences associated with medical mistrust.

Phone-Delivered Intervention to Improve HIV Care for Young People Living With HIV: Trial to Inform Implementation and Utility.

BACKGROUND: Phone-delivered counseling has demonstrated improved health outcomes for people living with HIV. However, counseling is hampered by a lack of guidance on the frequency and duration of intervention in relation to clinical benefits. The added benefits of bidirectional (ie, interactive) vs. unidirectional (ie, passive) text messages to augment counseling are also unknown. We conducted a clinical trial of adaptive phone counseling along with either bidirectional or unidirectional text messaging for people living with HIV. METHODS: A community sample of 425 young people (aged 16-36 years) living with HIV in Georgia, USA, received weekly phone counseling sessions with the number of sessions determined by the participant and their counselor. Participants were subsequently randomized to either (1) weekly bidirectional text messages with their counselor or (2) weekly automated unidirectional text message reminders. Participants were followed for 16 months to assess 3 primary outcomes: antiretroviral therapy (ART) adherence, HIV care engagement, and HIV suppression. RESULTS: Participants demonstrated improved clinical outcomes over the follow-up period, with 74% of those who were not taking ART initiating treatment, 65% of those on ART improving adherence, and 47% who had detectable viral loads at baseline attaining viral suppression. The number of sessions completed predicted improved ART adherence, greater care engagement, and HIV suppression over follow-ups. Bidirectional text messages impacted care engagement by moderating the effects of counseling sessions on HIV suppression. CONCLUSIONS: Phone counseling augmented by bidirectional text messages has the potential to improve HIV care for young adults living with HIV.

Geometric approach to measuring intersectional stigma among black sexual minority men: reliability and validity in an HIV prevention context.

BACKGROUND: Stigma and discrimination experiences attributable to multiple intersecting facets of the self (e.g. intersectional stigma) pose substantial challenges to accessing health services, including HIV prevention. While there have been theoretical advances in understanding multiple co-occurring stigmas, there are few psychometric instruments available to assess intersectional stigma. We have developed an approach to assessing intersectional stigma that conceptualises an intersection in geometric terms, defined as the line that connects points on two (or more) stigma dimensions and calculates scores derived from the geometric definition of intersecting lines. METHODS: Following pilot studies to derive items and response formats, we administered newly developed enacted stigma (24-items) and anticipated stigma (17-items) scales with attributions to race and sexual minority status for stigma experiences to a sample of 422 Black sexual minority men at risk for HIV recruited through social media platforms. RESULTS: The enacted and anticipated intersectional stigma scales, including subscales representing discrimination, interpersonal and felt stigma demonstrated evidence for reliability and construct validity. The enacted stigma scales were associated with medical mistrust, whereas the anticipated stigma scales predicted perceived barriers to using pre-exposure prophylaxis for HIV prevention. CONCLUSIONS: The intersectional stigma scales offer greater specificity in measuring stigma experiences attributed to race, sexual minority status and the intersection of racial-sexual minority status.

Amphetamine use and its associations with antiretroviral adherence and viral load among sexual minority men and transgender women living with HIV.

Substance use has complex associations to HIV disease progression. The current study tested the associations between several substances and HIV viral load while accounting for confounders relevant to HIV disease progression and substance use. Young sexual minority men and transgender women living with HIV (LWH) in Georgia (N = 385) completed measures and biological tests for HIV viral load and substance use. Multivariable regression models tested the role of specific drugs (i.e., alcohol, cannabis/THC, cocaine, and combined amphetamine and methamphetamine) directly on viral load and indirectly through antiretroviral (ART) adherence. ART adherence and HIV care self-efficacy were consistently associated with greater HIV suppression. Alcohol and cocaine were not associated with ART adherence or viral load. Cannabis was negatively associated with ART adherence (B = -.053, p = .037) but not viral load. Amphetamine/methamphetamine demonstrated significant direct effects on higher viral load (B = .708, p = .010) while indirectly influencing viral load through a negative association with ART adherence. Our findings support previous research demonstrating amphetamine/methamphetamine use impacts viral load both directly and indirectly through ART adherence. Interventions addressing amphetamine/methamphetamine use by young sexual minority men and transgender women LWH are urgently needed, and future research should focus on determining the mechanisms by which formulations of amphetamine impact HIV replication.Trial registration: ClinicalTrials.gov identifier: NCT03665532.

Novel Latent Profile Analysis of a Test of Concept, Stigma Intervention to Increase PrEP Uptake Among Black Sexual Minority Men.

BACKGROUND: Pre-exposure prophylaxis (PrEP) has demonstrated efficacy for HIV prevention, yet uptake of PrEP among populations in urgent need of prevention tools (eg, Black sexual minority men) is limited, and stigma and medical mistrust remain strong barriers to accessing PrEP. PURPOSE: To evaluate a test of concept brief intervention to address stigma and medical mistrust as barriers to PrEP uptake using novel latent profile analysis. METHODS: Participants (N = 177) residing in the southeastern US were randomized to 1 of 4 arms to establish the potential impact of a brief, stigma focused counseling intervention (referred to as Jumpstart ) to increase PrEP uptake. We estimated intervention effect size (Cramer's V) for PrEP uptake and then explored differential intervention effects across latent profiles of psychosocial barriers to PrEP use. RESULTS: The intervention resulted in small, but meaningful effect size, with self-reported PrEP uptake increasing across Jumpstart conditions with the control condition reporting 24% uptake and Jumpstart plus text/phone calls (the most intensive intervention arm) reporting 37% uptake, and a similar pattern emerging for biologically confirmed PrEP use. Among participants 30 and older, Jumpstart participants were more likely to move to a postintervention profile with fewer barriers than control participants and reported the highest uptake of PrEP. CONCLUSIONS: Addressing social/emotional barriers to PrEP uptake is an essential component of bridging the gap between advances being made in biomedical forms of HIV prevention, and establishing and supporting access to those advances.

COVID-19 health information trust and prejudicial attitudes predict healthcare disruptions in the first year of COVID-19 among people living with HIV.

Cross-sectional studies have reported that people living with HIV experienced disruptions to social relationships and healthcare during the first year of the COVID-19 pandemic. Furthermore, individuals with less trust in public health sources of COVID-19 information as well as those who held greater COVID-19 prejudicial attitudes experienced greater healthcare disruptions in the early months of COVID-19. To examine changes in trust and prejudicial attitudes in relation to healthcare disruptions during the first year of COVID-19, we followed a closed cohort of 115 men and 26 women ages 18 to 36 living with HIV over the first year of the COVID-19 pandemic. Findings confirmed that a majority of individuals continued to experience disruptions to their social relationships and healthcare over the course of the first year of COVID-19. In addition, trust in COVID-19 information from the CDC and state health department diminished over the year as did COVID-19 prejudicial attitudes. Regression models showed that lower trust in the CDC and health department and greater prejudicial attitudes toward COVID-19 early in the pandemic predicted greater healthcare disruptions over the year. In addition, greater trust in the CDC and health department early in COVID-19 predicted better antiretroviral therapy adherence later in the year. Results support an urgent need to regain and sustain trust in public health authorities among vulnerable populations.

The emergence and persistence of the anti-vaccination movement.

Vaccine hesitancy is a significant threat to public health and the anti-vaccination movement has played a significant role in communicable disease outbreaks. This commentary discusses the history and tactics of vaccine denialists and anti-vaccination groups. Anti-vaccination rhetoric is robust on social media platforms, and vaccine hesitancy has proven to impede the uptake of both established and new vaccines. Effective counter-messaging is needed to preemptively discredit vaccine denialists and reduce their influence on vaccine uptake. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Prepandemic Predictors of Medication Adherence and HIV Viral Load During the First Year of COVID-19.

ABSTRACT: Studies have reported significant immediate impacts of the COVID-19 pandemic on the social relationships and health care of people living with HIV. This study followed a closed cohort of young people living with HIV over the first year of the COVID-19 pandemic. Participants were men and women (N = 140) age 36 years and younger who were living with HIV and had demonstrated suboptimal adherence to antiretroviral therapy, unsuppressed HIV viral load, or active substance use in a run-in study. The results confirmed that participants continued to experience significant disruptions to their social relationships and health care over the course of the first year of the COVID-19 pandemic. There was evidence for sustained impacts on transportation, housing stability, and food security during the first year of COVID-19. Multivariable models showed that greater pre-COVID-19 social support predicted greater antiretroviral therapy adherence and greater HIV suppression (lower viral load) over the first year of the COVID-19 pandemic. Efforts to plan and prepare people living with HIV for future social crises, including future pandemics, should emphasize building and sustaining social support.

Lifetime prevalence of syphilis infection among predominantly Black sexual and gender minorities living with HIV in Atlanta, Georgia: a cross-sectional analysis.

OBJECTIVES: Syphilis infection disproportionately impacts Black sexual and gender minorities (SGM) in the United States. The extent of this impact among those living with HIV has been minimally examined. This study sought to examine lifetime syphilis prevalence and associated factors in a community sample of predominantly Black SGM living with HIV in the Southeastern US. DESIGN: Participants (N = 174) enrolled in a stigma-mitigation trial for people living with HIV in Atlanta, Georgia, completed a sub-study involving testing for Treponema pallidum antibodies, indicative of lifetime syphilis infection. We performed chi-square and Fisher's exact tests to assess sociodemographic and healthcare differences by presence/absence of lifetime syphilis infection. RESULTS: Most participants identified as non-Hispanic Black (n = 142/174; 81.6%) and cisgender male (n = 146/174; 83.9%). More than two thirds (n = 120/174) identified as gay/homosexual. We documented a 55.7% (n = 97/174) lifetime prevalence of syphilis infection and observed differences by sexual identity, with 77.3% (n = 75/97) of those screening positive reporting gay/homosexual identity relative to 58.4% (n = 45/77) of those screening negative (chi-square[1] = 7.8, p < 0.010). CONCLUSION: Findings underscore how syphilis prevention efforts have missed the most marginalized, warranting a renewed, comprehensive strategy for improving the sexual health of Black SGM. Embedding targeted, respectful community engagement, expanded testing access, and healthcare provider training into broader sexual health and psychosocial wellness efforts is needed.

Rejection-identification and increased use of geosocial networking apps to meet male sexual partners among Black men who have sex with men.

Objective: The use of geosocial networking (GSN) apps to meet male sexual partners may contribute to HIV infection risk for Black men who have sex with men (MSM), but the psychosocial underpinnings of this behavior are not understood. In social psychology, the Rejection-Identification Model posits that identification with a socially stigmatized group emerges as a means of coping in response to perceived stigmatization-which can shape behavior. This study tested the Rejection-Identification process as a facilitator of increased use of GSN apps to meet male sexual partners among Black MSM who use these apps. Method: Black MSM (N = 103; Mage = 29.8) reporting a male sexual partner from a GSN app in the past year were recruited nationally from Grindr and Facebook. Participants completed an online survey in which they reported sociodemographic information, measures of racial stigma and Black identity, and characteristics of their past-year male sexual partners. Results: Participants in this sample reported that most of their past-year male partners came from GSN apps (Mpercent = 82.3), and results from hypothesis testing showed that greater perceived devaluation of Black people in society (i.e., public racial stigma) was associated with an increased percentage of GSN-met partners. In line with the Rejection-Identification Model, this relationship was mediated by greater Black identity centrality. Conclusions: Findings highlight psychosocial correlates of increased GSN app use to meet male sexual partners among Black MSM, which may place Black MSM at increased risk for HIV infection. Results also point to the possibility that these factors may be harnessed to develop HIV prevention strategies for Black MSM. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Perceived sensitivity to medicines and medication concerns beliefs predict intentional nonadherence to antiretroviral therapy among young people living with HIV.

Objective: Among the sources of antiretroviral therapy (ART) nonadherence are patient decisions to skip or stop taking their medications, often stemming from medication beliefs and concerns about side- effects. While individuals who perceive greater sensitivity to medicines may be prone to medication concerns, understanding how these factors contribute to HIV treatment adherence requires further research. The current study tested the direct and indirect effects of perceived sensitivity to medicines on intentional nonadherence to ART, and whether medication concerns mediate this association.Methods: A sample of 418 younger (< 36 years of age) people living with HIV was recruited through community outreach to complete assessments of perceived sensitivity to medicines, medication concerns beliefs, adherence assessed by unannounced phone- based pill counts and HIV viral load, as well as monthly follow- up assessments of intentional nonadherence over a 15- month period.Results: Analyses at baseline and prospective Poisson regression models conducted over 15- months converged to show that perceived sensitivity to medicines significantly predicted intentional nonadherence to ART through medication concerns.Conclusions: These findings suggest that people who perceive greater sensitivity to medicines are prone to greater medication concerns that are related to intentional nonadherence. Cognitive behavioral interventions are needed to resolve medication concerns and reduce intentional nonadherence among people receiving ART.

A novel psychometric approach to assessing intersectional hiv stigma: the geometric intersectional stigma scales.

Recent advances in stigma theories have emphasized intersectionality, but there are currently few approaches to measuring intersectional HIV stigma. Here we present a novel approach to assessing intersectional HIV stigma. Black/African American sexual minority men living with HIV (N = 437) completed newly developed measures of enacted and anticipated stigma along with a battery of instruments to examine construct validity. For each endorsed stigma item, participants rated three personal attributes ascribed to the stigma experiences, specifically race, same-sex sexual behavior, and HIV status. Based on the notion that intersecting orthogonal dimensions such as attributions for experiencing stigma can be conceptualized geometrically, we used the Pythagorean Theorem to calculate intersectional stigma scores. Results showed that the enacted and anticipated stigma scales and the assessment of intersectional stigma attributes demonstrated acceptable response rates, internal consistency and a pattern of associations with correlates that suggests construct validity. In separate tests of construct validity, regression models predicting medication adherence indicated varied results among stigma measures, demonstrating clear advantages to separating the assessment of stigma experiences from the attributes to which stigma experiences are ascribed. Findings from this geometric approach to assessing intersectional HIV stigma were promising and warrant further investigation.

Prevalence and correlates of depressive symptoms, and points of intervention, in rural central Uganda: results from a cross-sectional population-based survey of women and men.

OBJECTIVES: The present study aimed to identify the prevalence and correlates of depressive symptoms and potential intervention points among women and men from a population-based sample in rural central Uganda. DESIGN: A cross-sectional study. SETTING: Four districts in rural Uganda. PARTICIPANTS: Women and men aged 15-59 residing in four districts in rural Uganda accepting home-based HIV testing who completed a baseline survey at the time of testing. PRIMARY OUTCOME MEASURES: Depressive symptoms measured by the 10-item Center for Epidemiological Studies Depression Scale using a cut-off score of 13 for significant depressive symptoms. RESULTS: Among a sample of 9609 women and 6059 men, 1415 (14.7%) women and 727 (12.0%) men met criteria for significant depressive symptoms. Having ever received mental health services was associated with lower odds of significant depressive symptoms (women: adjusted OR (adjOR)=0.32, 95% CI=0.22 to 0.47; men: adjOR=0.36, 95% CI=0.18 to 0.62). Having received outpatient (women: adjOR=3.64, 95% CI=3.14 to 4.22; men: adjOR=3.37, 95% CI=2.78 to 4.07) or inpatient (women: adjOR=5.44, 95% CI=4.24 to 6.97; men: adjOR=3.42, 95% CI=2.21 to 5.28) care in the prior 6 months was associated with greater odds of significant depressive symptoms. For women only, known HIV positive status (adjOR=1.37, 95% CI=1.05 to 1.77), and for men only, alcohol misuse (adjOR=1.38, 95% CI=1.12 to 1.70), were associated with increased odds of significant depressive symptoms. CONCLUSION: Our findings suggest that depression screening within outpatient and inpatient settings may help to identify people in need of mental health services. Routine screening in outpatient or inpatient clinics along with the implementation of evidence-based interventions could ultimately help close the mental health gap for depression in this and similar settings.