Disrupting the Path from Depression to Loneliness: Multilevel Resilience among Older Sexual Minority Men with and without HIV.

Existing studies examining resilience among sexual minority men (SMM) have been limited by only analyzing 1 level of resilience. We therefore investigated the impact of multiple levels of resilience on the bidirectional relationship between loneliness and depression symptoms among older SMM. Loneliness, depression symptoms, and multilevel resilience scores were collected across 3 time points (October 2016 to March 2017 [T1]; October 2017 to March 2018 [T2]; and October 2018 to March 2019 [T3]) among 1,264 SMM aged 40 years and older living with and without HIV. Longitudinal mediation models were used to test the mediating effect of the multilevel resilience factors at T2 on the bidirectional relationship between loneliness and depression symptoms, adjusting for sociodemographic covariates. The multilevel resilience factors were negatively associated with loneliness and depression symptoms at T1. The individual-level global resilience factor was associated with decreased odds of depression symptoms (odds ratio [OR] = 0.50; 95% CI, 0.32-0.78), while the interpersonal-level relationship confidence (OR = 0.43; 95% CI, 0.24-0.77) and reliability (OR = 0.36; 95% CI, 0.15-0.84) factors were associated with decreased odds of loneliness at T3. The total effect of loneliness at T1 on depressive symptoms at T3 was ß = 0.20 (95% CI, 0.11-0.28) and was reduced to ß = 0.08 (95% CI, -0.04 to 0.20) after the inclusion of the multilevel resilience factors. The total effect of depressive symptoms at T1 on loneliness at T3 was similar (ß = 0.21; 95% CI, 0.13-0.28) with the direct effect of ß = 0.01 (95% CI, -0.08 to 0.11) after the inclusion of the multilevel resilience factors. Regarding specific indirect effects, individual-level global resilience (depression symptoms at T3 only) as well as the interpersonal-level relationship reliability and confidence (loneliness at T3 model only) factors were statistically significant. Multilevel resilience factors mediated the bidirectional relationship between loneliness and depression symptoms. Mental health interventions should consider implementing resilience-informed strategies that mitigate depression symptoms and loneliness among older SMM.

RESUMEN: Los estudios existentes que examinan la resiliencia entre los hombres de minorías sexuales (HSH) se han visto limitados por analizar sólo 1 nivel de resiliencia. Por lo tanto, investigamos el impacto de múltiples niveles de resiliencia en la relación bidireccional entre la soledad y los síntomas de depresión entre los hombres mayores de minorías sexuales. Se recopilaron datos sobre soledad, síntomas de depresión y resiliencia multinivel a lo largo de 3 puntos temporales (octubre de 2016 a marzo de 2017 [T1]; octubre de 2017 a marzo de 2018 [T2]; y octubre de 2018 a marzo de 2019 [T3]) entre 1,264 SMM de 40 años o más que viven con y sin VIH. Se utilizaron modelos de mediación longitudinal para probar el efecto mediador de los factores de resiliencia multinivel en T2 sobre la relación bidireccional entre la soledad y los síntomas de depresión, ajustando por covariables sociodemográficas. Los factores de resiliencia multinivel se asociaron negativamente con la soledad y los síntomas de depresión en T1. El factor de resiliencia global a nivel individual se asoció con menores probabilidades de síntomas de depresión (odds ratio [OR] = 0,50; IC 95%, 0,32 − 0,78), mientras que el factor de confianza en las relaciones a nivel interpersonal (OR = 0.43; 95% CI, 0.24­0.77) y los factores de fiabilidad (OR = 0.36; 95% CI, 0.15­0.84) se asociaron con menores probabilidades de soledad en T3. El efecto total de la soledad en T1 sobre los síntomas depresivos en T3 fue ß = 0.20 (95% CI, 0.11­0.28) y se redujo a ß = 0.08 (95% CI, -0.04 to 0.20) tras la inclusión de los factores de resiliencia multinivel. El efecto total de los síntomas depresivos en T1 sobre la soledad en T3 fue similar (ß = 0.21; 95% CI, 0.13­0.28) con el efecto directo de ß = 0.01 (95% CI, -0.08 to 0.11) tras la inclusión de los factores de resiliencia multinivel. En cuanto a los efectos indirectos específicos, los factores de resiliencia global a nivel individual (síntomas de depresión sólo en T3) así como la fiabilidad y confianza de las relaciones interpersonales (soledad en el modelo T3 solamente) fueron estadísticamente significativos. Los factores de resiliencia multinivel mediaron la relación bidireccional entre la soledad y los síntomas de depresión. Las intervenciones de salud mental deberían considerar la implementación de estrategias basadas en la resiliencia que mitiguen los síntomas de la depresión y la soledad entre los SMM mayores.

Does Resilience Mediate the Relationship Between Negative Self-Image and Psychological Distress in Middle-Aged and Older Gay and Bisexual Men?

Aging gay and bisexual men may have negative self-images due to body image dissatisfaction and internalized ageism, resulting in psychological distress. Gay and bisexual men with HIV may be at greater risk for distress because of research linking HIV to accelerated aging. We examined associations between self-image and psychological distress, and potential mediating effects (resilience, fitness engagement), and whether these relationships were moderated by HIV serostatus. We tested our hypotheses with structural equation modeling using data from gay and bisexual men with HIV (n = 525, Mage = 57.6) and without HIV (n = 501, Mage = 62.2). We observed significant positive associations between self-image and distress and significant mediation effects (resilience, fitness engagement) that were moderated by HIV serostatus (resilience was only significant for men with HIV). We conclude that resilience interventions may be beneficial in alleviating distress from negative self-image among aging gay and bisexual men with HIV.

The Intersection of Mental Health and Sexual and Gender Minority Identities for Older Adults Living with Human Immunodeficiency Virus: A Narrative Review.

The transition of HIV into a chronic illness has brought to the forefront the pressing need to address the complex web of social determinants of HIV outcomes. A structured literature search and narrative review of studies describing intervention strategies for mental health among sexual/gender minority (SGM) older adults living with HIV (OALWH) published in the last decade identified 2 studies for inclusion. This narrative review identifies age-sensitive and culturally adapted therapies, mindfulness and meditation-based stress reduction, group therapy, digital mental health resources, and psilocybin-assisted group therapy as emerging intervention models tailored to meet the unique needs of SGM OALWH.

"This Is Actually a Really Unique Moment in Time": Navigating Long-Acting HIV Treatment and HIV Cure Research with Analytical Treatment Interruptions-A Qualitative Interview Study in the United States.

Advancements in long-acting (LA) HIV treatment and cure research with analytical treatment interruptions (ATIs) have generated important scientific and implementation questions. There is an urgent need to examine challenges navigating the evolving HIV treatment and cure research landscape. From August to October 2022, we conducted 26 semistructured interviews with biomedical researchers and community members representing a predominantly woman demographic to explore the complexity of navigating the rapidly evolving HIV therapeutic and HIV cure research landscape. We purposively sampled individuals recruited from the AIDS Clinical Trials Group and the Martin Delaney Collaboratories for HIV Cure Research. Audio files were transcribed verbatim and analyzed through a thematic approach, using an inductive and iterative process. Among 26 participants, 10 were biomedical researchers and 16 community members, including 11 were people with HIV. Three main themes emerged: (1) We are at a pivotal moment in the evolving landscape of HIV therapeutics and LA HIV treatment and HIV cure research should not be siloed but considered together; (2) There are challenges with engagement in HIV cure research and in switching between oral daily antiretroviral treatment and LA formulations and, mainly, the prolonged pharmacokinetic tail of these compounds matched with limited patient education about their impacts; and (3) There are unique opportunities as a result of this evolving therapeutic landscape, including the key role of decision support for people with HIV, centering around patient autonomy, and the need to learn from the lived experiences of people with HIV who choose LA treatment and/or participation in HIV cure research. Despite a bias toward the woman gender, our study identifies key considerations for navigating concurrent LA HIV treatment and HIV cure research with ATIs from both community members and biomedical researchers' perspectives. Achieving optimal HIV control remains a formidable challenge, necessitating robust interdisciplinary collaborations and engagement with key stakeholders.

Advance Care Planning Among Sexual Minority Men: Sociodemographic, Health Care, and Health Status Predictors.

Objectives: Advance care planning (ACP) specifies decision-making surrogates and preferences for serious illness or end-of-life medical care. ACP research has largely neglected sexual minority men (SMM), a population that experiences disparities in health care and health status. Methods: We examined formal and informal ACP among SMM ages 40+ in the Multicenter AIDS Cohort Study (N = 1,071). Results: For informal ACP (50%), younger SMM and men with past cardiovascular events had greater odds of planning; single men had lower odds of planning. For formal ACP (39%), SMM with greater socioeconomic status had greater odds of planning; SMM who were younger, of racial/ethnic minority identities, who were single or in a relationship without legal protections, and who lacked a primary care home had lower odds of planning. Discussion: Findings warrant further exploration of both informal and formal planning. More equitable, culturally-humble engagement of SMM may facilitate access, uptake, and person-centered planning.

The Relationship Between Posttraumatic Stress Disorder and Alcohol Misuse and Smoking Among Aging Men Who Have Sex With Men: No Evidence of Exercise or Volunteering Impact.

OBJECTIVES: To determine if the association between posttraumatic stress disorder (PTSD) and substance use (alcohol misuse or smoking tobacco) is mediated/moderated by exercise or volunteering among aging (≥40 years) men who have sex with men (MSM), and if this mediation/moderation differs by HIV serostatus. METHODS: Multicenter AIDS Cohort Study data were used. Three datasets with PTSD measured during different time periods (10/1/2017-3/31/2018, 898 men; 4/1/2018-9/30/2018, 890 men; 10/1/2018-3/31/2019, 895 men) were analyzed. Longitudinal mediation analyses estimated the mediation effect of exercise and volunteering on the outcomes. RESULTS: Nine percent of MSM had evidence of PTSD. There was no statistically significant mediation effect of exercise or volunteering regardless of substance use outcome. The odds of smoking at a future visit among MSM with PTSD were approximately double those of MSM without PTSD. Results did not differ by HIV serostatus. DISCUSSION: There is a particular need for effective smoking cessation interventions for aging MSM with PTSD.

Loneliness and Frailty Among Middle-Aged and Aging Sexual Minority Men Living With or Without HIV: A Longitudinal Cross-Lagged Panel Analysis.

Background and Objectives: Loneliness is associated with frailty among older adults (60+), and there is evidence suggesting that this association may be bidirectional. However, there is limited evidence of this relationship over time among middle-aged and aging sexual minority men. We explored the bidirectional relationship between loneliness and frailty over 2 years among sexual minority men living with or without human immunodeficiency virus (HIV) from the Healthy Aging substudy of the Multicenter AIDS Cohort Study. Research Design and Methods: We used data from 1 118 men (561 living with HIV; 557 living without HIV) aged 40 years or older with measurement of frailty or loneliness at Times 1 (September 2016 to March 2017) and 2 (September 2018 to March 2019). Descriptive statistics were generated. We used autoregressive cross-lagged panel analysis to examine the bidirectional association between frailty and loneliness at both time points while adjusting for time-stable and time-dependent covariates at Time 1. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were generated. Results: The estimated prevalence of loneliness at both time points was 35.5%. The estimated prevalence of frailty at Times 1 and 2 were 7.8% and 12.1%, respectively. Participants reporting loneliness at Time 1 had greater odds of being frail at Time 2 (aOR = 2.14; 95% CI: 1.23-3.73). Frailty at Time 1 was not associated with loneliness at Time 2 (aOR = 1.00; 95% CI: .44-2.25). The autoregressive effects of frailty (aOR = 23.43; 95% CI: 11.94-46) and loneliness (aOR = 13.94; 95% CI: 9.42-20.61) were large. Discussion and Implications: Men who felt lonely had higher odds of being frail 2 years later while the reciprocal association was not shown. This suggests that loneliness preceded frailty and not the other way around. Early and frequent assessments of loneliness may present opportunities for interventions that minimize the risk of frailty among sexual minority men living with and without HIV.

Self-Perception of Aging and Hypertension in a Cohort of Sexual Minority.

Objectives To determine whether self-perception of aging is an important marker of health and hypertension among older sexual minority men. Methods We evaluated associations between self-perception of aging (chronologic-subjective age discrepancy and aging satisfaction) and hypertension among 1,180 sexual minority men (51.6% with HIV/48.4% without HIV) from the Multicenter AIDS Cohort Study using a manifest Markov chain model adjusted for HIV status, age, race/ethnicity, education, smoking status, inhaled nitrite use, diabetes, dyslipidemia, kidney and liver disease. Results The overall prevalence of hypertension increased from 73.1% to 82.6% over three years of follow-up. Older age discrepancy (aOR (adjusted odds ratio): 1.13 95% CI: 0.35-3.69) and low aging satisfaction (aOR: 0.88; 95% CI: 0.31-2.52) were not associated with an increased prevalence of hypertension, regardless of HIV status. Discussion More than 80% of sexual minority men had a diagnosis of hypertension but self-perception of aging was not predictive of incident hypertension.

Perspectives From Community-Based HIV Service Organization Leaders on Priorities in Serving Sexual and Gender Minority Populations.

Sexual and gender minority (SGM) populations experience discrimination and care-related barriers when seeking appropriate sexual health services. Using rapid assessment procedures we conducted site visits with 11 community-based HIV service agencies to identify priorities, assets, and needs related to serving SGM clients and assessed the alignment of these services with the city's local Ending the HIV Epidemic plan. We identified and mapped themes across agencies into the Consolidated Framework for Implementation Research domains of inner and outer settings: client-facing materials; priorities in serving SGM communities; SGM policies and protocols; collecting sexual orientation and gender identity data; training and education; and funding and scope of programs. Rapid assessment procedures can accelerate the collection and interpretation of data to help public health institutions and community partners make timely adaptations when implementing comprehensive and culturally humble sexual health services for SGM communities.

Inclusive and Age-Appropriate Timing of Sexual Health Discussions at Home According to Gay, Bisexual, and Queer Adolescent Males.

PURPOSE: The exclusion of gay, bisexual, and queer (GBQ) adolescent males' specific sexuality concerns in standard classroom education heightens the need for parents to be primary sources of trusted sexual health information. The aim of this study was to collect GBQ adolescent males' suggestions for a comprehensive list and age-appropriateness of topics that parents may use for inclusive discussions at home throughout the elementary, middle school, and high school years. METHODS: Semistructured interviews and card sorts of 48 topics were conducted with a sample of 30 racial and ethnic diverse GBQ adolescents in central North Carolina. Thematic analysis of the interview transcripts and a calculation of card sort responses followed. RESULTS: Topics chosen for elementary-age GBQ youth were focused on core issues about human anatomy, safety, and the continuum of sexual orientations and gender identities. Participants designated the majority of topics for home-based discussions in middle school and emphasized considerations for engaging in sex, relating with others socially, options for HIV/STI risk reduction, issues around interpersonal safety, and pleasure. They reserved topics for high school focused on complex sociorelational issues and technology-based concerns. DISCUSSION: Participants' varied rationale for timing of topics centered on the age-appropriateness and level of details that they deemed acceptable for discussions with parents. To address disproportionate negative sexual and mental health outcomes noted in this youth subgroup, parents should focus on being supportive by providing factual and sequential information crucial for their GBQ childrens' anticipated developmental needs and sexual identity milestones.

Individual-Level Psychosocial Resiliencies as Mediators of the Relationship Between Internalized Homophobia and Depressive Symptoms Among Middle-Aged and Older Men Living With and Without HIV.

Among sexual minority men (SMM), internalized homophobia (IH) has been consistently associated with increased depression symptoms. However, some SMM experiencing IH demonstrate resilience to buffer against depression symptoms. In this analysis, we used the Stress Process Model (SPM) as a conceptual framework to explore individual-level psychosocial resilience (ILPR) factors serving as a buffer of the IH-depression relationship. To utilize the SPM to explore whether four ILPR factors, including volunteerism, optimism, religiosity/spirituality, and global resiliency measure mediate the relationship between IH and depression symptoms among middle-aged and older SMM living with and without HIV. We used exploratory and confirmatory factor analysis to construct measurement models for the four ILPR factors. We examined whether the four ILPR factors mediated the IH-depression relationship. IH was significantly and positively associated with depression symptoms. There was a partial mediation of the IH-depression association by the four ILPR. Specifically, we found statistically significant indirect effects of optimism and the global resilience measure and supporting buffering effects of the IH-depression association. Although, the indirect effects religiosity/spirituality on the IH-depression relationship was significant, it did not support a buffering of effect. The indirect effects of volunteerism were not statistically significant. Our findings highlight the potential role of ILPR factors in the development of resilience against the negative effects of IH. Implications of these results for future research and practice are discussed.

The role of social support on cognitive function among midlife and older adult MSM.

OBJECTIVE: This study examines the association between social support and cognitive function among midlife and older MSM living with or without HIV. DESIGN: We analyzed longitudinal data from participants enrolled from October 2016 to March 2019 in the Patterns of Healthy Aging Study, a substudy of the Multicenter AIDS Cohort Study. METHODS: We conducted a cross-sectional analysis to estimate the association between social support and three measures of cognitive function [Trail Making Test (TMT) Part A, TMT Part B to A ratio, and Symbol Digit Modalities Tasks (SDMT)]. We also used linear mixed-effects models to estimate the association between baseline social support and cognitive function across four subsequent time points. We evaluated a multiplicative interaction term between baseline social support and time, in order to determine whether cognitive trajectories over time vary by baseline social support. RESULTS: Social support was associated with lower TMT Part A scores at baseline and over the subsequent 2 years, indicating better psychomotor ability. Social support was associated with higher SDMT scores at baseline and across 2 years, indicating better information processing. We observed no association between social support and TMT B to A ratio at baseline or across 2 years, indicating no effect on set-shifting ability. Longitudinal cognition outcome trajectories did not vary by the level of baseline social support. CONCLUSION: Social support and cognitive function were associated in this sample over a short time period. Further research should explore causal relationships over the lifespan.

Longitudinal associations of relationship support and strain and internalized homophobia with mental health among middle-aged and older gay and bisexual men.

Objectives: Mental health concerns (e.g. depression, anxiety) that negatively impact gay, bisexual, and other men who have sex with men (GBMSM) persist over the life course and into old age, but less is known about potential contributors to GBMSM's mental health. Close relationships can be a source of risk or resilience from stress, exerting direct relationships on mental health, and may mediate well-established associations between minority stress and mental health. This study examined whether primary partner relationship support and strain were uniquely associated with, and mediated the association between internalized homophobia, and mental health among older GBMSM.Methods: GBMSM (N = 517, M age = 60) from the Multicenter AIDS Cohort Study, who were in primary relationships with men, provided self-report data at four timepoints. We used multilevel modeling to examine longitudinal associations among relationship support and strain and internalized homophobia with depression and anxiety.Results: Relationship strain, but not support, was positively associated with mental health concerns longitudinally. There was a significant, positive indirect effect of internalized homophobia on depression and anxiety through strain, but no support. Internalized homophobia was positively associated with relationship strain, which was positively associated with mental health symptoms longitudinally.Conclusions: Relationship strain was associated with depression and anxiety longitudinally among middle-aged and older GBMSM and mediated associations of internalized homophobia with mental health. The role of partner support warrants further investigation. Mental health interventions are critically needed for older GBMSM and, for partnered GBMSM, should include strategies for reducing relationship strain to foster well-being.

Co-occurring Epidemic Conditions Among Southern U.S. Black Men Who Have Sex with Men in an Online eHealth Intervention.

Black men who have sex with men (BMSM) face disproportionately higher risks for adverse sexual health outcomes compared to their non-Hispanic White counterparts. This disparity can be attributable to overlapping and intersecting risk factors at the individual and structural levels and can be understood through syndemic theory. Using longitudinal data from the HealthMPowerment trial (n = 363), six conditions related to stigma syndemics were indexed as a cumulative risk score: high alcohol use, polydrug use, depression and anxiety symptomology, and experiences of racism and sexual minority stigma. Using Poisson regression, we found a positive association between baseline risk scores and sexual risk behavior (b: 0.32, SE: 0.03, p < 0.001). Using a Generalized Estimating Equation, we also found a 0.23 decrease in the within-participant risk scores at 3-month follow-up (SE: 0.10, p < 0.020). Future work examining how care and prevention trials improve health outcomes in this population is needed.

Grit is associated with psychological health among older sexual minority men.

Objectives: Studies have shown that grit-defined as perseverance and passion for achieving one's long-term goals-is associated with improved health outcomes, including lower levels of psychological distress. However, the psychometric properties of the original Grit Scale (Grit-O Scale) has not been validated among sexual minority men (SMM). The present study aimed to validate the Grit-O Scale among a sample of older SMM and assess the relationships between the Grit-O Scale factors and symptoms of psychological distress.Method: We used data from a single visit of participants in the Multicenter AIDS Cohort Study (MACS) Healthy Aging longitudinal study. The sample included 981 older SMM (mean age = 61, SD = 8.5) with and without HIV. We conducted confirmatory factor analysis (CFA) to identify the two factors of the Grit-O Scale: consistency of interest and perseverance of effort. We also conducted a latent profile analysis (LPA) to identify distinct profiles of psychological distress from self-reported scales of depression, anxiety, and perceived stress.Results:The Grit-O Scale showed acceptable reliability estimates for the items with Cronbach's alpha reliability coefficients ranging from 0.77 to 0.82. The CFA identified the two factors of the Grit-O Scale with acceptable model fit (root mean square error of approximation = 0.058 [95% CI = 0.050, 0.067], comparative fit index = 0.95, Tucker-Lewis Index = 0.93, standardized root mean square residual = 0.07). The LPA yielded three mutually exclusive profiles of psychological distress (profile 1: low stress, anxiety, and depression; profile 2: high stress and depression and low anxiety; and profile 3: high stress, anxiety, and depression). In adjusted multinominal logistic regression analysis, we found that both higher levels of consistency of interest and perseverance of effort factors of the Grit-O Scale were significantly associated with decreased odds of being in profiles 2 and 3 compared with being in profile 1.Conclusion: Our findings support the use of the Grit-O Scale among older SMM. Grit factors could explain variability in the negative psychological symptoms among older SMM and warrant further investigation.Supplemental data for this article is available online at http://dx.doi.org/10.1080/13607863.2022.2032594.

Self-Reported Combination HIV Prevention Strategies Enacted by a Prospective Cohort of Midlife and Older Men Who Have Sex with Men in the United States: A Latent Class Analysis.

Insights into combination HIV prevention (CHP) strategies to reduce HIV incidence among midlife and older adult men who have sex with men (MSM) are limited. The current study is a secondary data analysis evaluating CHP in a sample of sexually active midlife and older adult MSM (N = 566) from the Multicenter AIDS Cohort Study Healthy Aging Substudy. Stratified by HIV serostatus, we used latent class analyses to identify CHP classes based on self-reported sociobehavioral and biobehavioral prevention strategies that participants and their male partners used in the prior 6 months. We identified three CHP classes among men living without HIV (MLWOH), including the following: high CHP overall (43.0%), high anal sex abstention (15.0%), and low prevention overall (42.0%). Among men living with HIV (MLWH), we identified four CHP classes, including the following: high CHP overall (20.9%), high CHP/low condom use (27.1%), high condom reliance (22.3%), and low prevention overall (29.7%). There were small differences by sociodemographic characteristics and sexual behavior practices between the classes; however, poppers use was often linked to being in high CHP groups. Our findings support that CHP is not one-size-fits-all for midlife and older adult MSM. There remains a need to scale up clinical providers' sexual health communication practices to assist midlife and older MSM incorporate prevention strategies, particularly biobehavioral prevention strategies that align with their patients' lived experiences.

The Effect of Discrimination and Resilience on Depressive Symptoms among Middle-Aged and Older Men who have Sex with Men.

This study investigated if homophobic and racist discrimination increased depressive symptoms among 960 middle-aged and older men who have sex with men (MSM) and how resilience moderated these relationships. We used five waves of longitudinal data from the Healthy Aging sub-study of the Multicenter AIDS Cohort Study (MACS). We used linear regression analyses to model depressive symptoms as a function of discrimination. We used linear mixed analyses to model changes in mean resilience scores across visits. We used linear regression analyses to model depressive symptoms as a function of changes in resilience and to test the moderation effects of resilience on the relationship between discrimination and depressive symptoms. The models accounted for repeated measures of resilience. Men who experienced external and internal homophobia had greater depressive symptoms (ß: 2.08; 95% Confidence Interval: 0.65, 3.51; ß: 1.60; 95% Confidence Interval: 0.76, 2.44). Men experienced significant changes in mean resilience levels across visits (F = 2.84, p = 0.02). Men with a greater positive change in resilience had lower depressive symptoms (ß: -0.95; 95% Confidence Interval: -1.47, -0.43). Men with higher average resilience levels had lower depressive symptoms (ß: -5.08; 95% Confidence Interval: -5.68, -4.49). Men's resilience did not moderate the relationship between homophobia and depressive symptoms. Significant associations of external and internal homophobia with greater depressive symptoms present targets for future research and interventions among middle-aged and older MSM. Significant associations of average and positive changes in resilience with lower depressive symptoms provide aims for future research and interventions with this population.

Social identity support, descriptive norms, and economic instability in PrEP engagement for emerging adult MSM in the United States.

Rates of pre-exposure prophylaxis (PrEP) uptake for HIV prevention continue to increase rapidly among men who have sex with men (MSM) in the United States (U.S.); however, these increases have been slower among young MSM. Emerging adulthood (ages 18-25) is a time of transitions and social development, resulting in increased vulnerability to HIV. Analyzing data from a cross-sectional survey of emerging adult MSM (ages 18-25 years; n = 281) in the Mid-Atlantic urban metropolitan region of the U.S., we examined how social identity support, descriptive PrEP norms, and economic instability were related to PrEP engagement. In structural equation models, PrEP norms were directly associated with PrEP engagement (ß = 0.29, 95% CI = [0.12,0.46]) and social identity support was indirectly associated with PrEP engagement through its association with descriptive PrEP norms (ß = 0.18, 95% CI = [0.09,0.28]). Economic instability was not significantly associated with PrEP engagement, although a negative trend was present (ß = -0.19, 95% CI = [-0.39,0.02]). Our results suggest that an integrative socioecological model is appropriate for the study of PrEP engagement among emerging adult MSM. Efforts to increase PrEP engagement should support community capacity building, amplify positive descriptive PrEP norms, and address unmet economic needs.

Strengthening HIV Prevention Services Through an Implementation Science Approach: Perspectives From the HIV Testers in Philadelphia.

BACKGROUND: Strengthening HIV prevention services is a key priority of the Ending the HIV Epidemic plan. Informed by the Consolidated Framework for Implementation Research, we examined HIV testers' perceived barriers and facilitators to implementing HIV prevention services, including testers' strengths and weaknesses; enabling factors within the inner and outer settings; and willingness to adopt potential implementation strategies. METHODS: In 2019, the Penn Center for AIDS Research (CFAR) partnered with the Philadelphia Department of Public Health (PDPH) to examine system-level challenges and opportunities experienced by PDPH-funded HIV testers (individuals conducting HIV testing) in Philadelphia. We recruited HIV testers to complete 2 web surveys (n ≈ 40 each) and in-depth interviews (n = 11). RESULTS: Testers self-reported high HIV testing self-efficacy and competence, despite identifying gaps in their knowledge of STI testing, reporting moderate willingness to recommend pre-exposure prophylaxis, and having insufficient cultural competency when working with priority populations. Testers indicated that educational materials and policies within their agencies might require realignment to affirm sexual and gender minority clients. In qualitative interviews, testers noted challenges to implementing PDPH priorities because limited funding fueled competition between local agencies, deterred interagency partnerships, and limited their ability to serve key populations locally. DISCUSSION: HIV testers are critical partners in addressing agency-level barriers to HIV prevention service provision through multilevel implementation strategies. In partnership with PDPH, we will create and implement a train-the-trainers program consisting of skill-building activities, technical assistance, and capacity-building for all agency personnel to address missed opportunities in HIV prevention. These activities will reinforce scalability and sustainability of PDPH-supported HIV prevention programs.

Explorations of the Role of Digital Technology in HIV-Related Implementation Research: Case Comparisons of Five Ending the HIV Epidemic Supplement Awards.

INTRODUCTION: The use of digital technology in HIV-related interventions and implementation strategies is increasing. Whether the use of technology is to directly improve patient outcomes (ie, part of the intervention) or as part of the strategy to implement interventions has important implications. In this article, we present 5 case studies of projects that feature the use of technology in HIV-related implementation research to identify and describe challenges specific to technology-based implementation research about study design, outcome measurement, implementing in an evolving technology landscape, and equity. METHODS: For each case study, we identified the technological components, classified the components as intervention or implementation strategy, and identified implications for measuring performance and ensuring equity. The Exploration, Preparation, Implementation, and Sustainment framework was used to identify the research stage of each project. RESULTS: Technology is being leveraged across a diverse array of implementation strategies to promote Ending the HIV Epidemic in the United States. The case studies were primarily in the exploration and preparation phases of implementation, yet technology played a different role in each project- developing educational materials, mass media to recruit participants or distribute evidence-based campaigns, providing training, guiding tailoring, and implementing novel methods to democratize intervention development. DISCUSSION: Technology can play multiple roles in HIV-related implementation research projects, including serving as the intervention, being leveraged within implementation strategies, or both. We identified multiple considerations across projects that should be taken into account when measuring success and planning for equitable and sustained impact.