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

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

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

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

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

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

Syndemic factors associated with adult sexual HIV risk behaviors in a sample of Latino men who have sex with men in New York City.

OBJECTIVE: Syndemic theory has been proposed as a framework for understanding the role of multiple risk factors driving the HIV epidemic among sexual and gender minority individuals. As yet, the framework has been relatively absent in research on Latinos/as. METHODS: We used logistic regression to assess relationships among cumulative syndemic conditions - including clinically significant depression, high-risk alcohol consumption, discrimination, and childhood sexual abuse - engagement with multiple partners and condomless anal intercourse (CAI) in a sample of 176 Latino men who have sex with men (MSM) in New York City. RESULTS: In bivariate analyses, an increase in the number of syndemic factors experienced was associated with an increased likelihood of reporting multiple partners and CAI. In multivariable analyses, participants with 2, 3, and 4 factors were significantly more likely to report multiple partners than those with 0 (aOR=4.66, 95% CI [1.29, 16.85); aOR=7.28, 95% CI [1.94, 27.28] and aOR=8.25, 95% CI [1.74, 39.24] respectively; p<0.05. Regarding CAI, only participants with 3 and 4 factors differed from those with 0 aOR=7.35, 95% CI [1.64, 32.83] and OR=8.06, 95% CI [1.39, 46.73] respectively. CONCLUSIONS: Comprehensive approaches that address syndemic factors, and capitalize on resiliency, are needed to address the sexual health needs of Latino MSM.

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

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

Measuring stigma among health care and social service providers: The HIV/AIDS Provider Stigma Inventory.

Initial validation of the HIV/AIDS Provider Stigma Inventory (HAPSI), piloted on a sample of 174 nursing students, supported the psychometric qualities of a suite of measures capturing tendencies to stigmatize and discriminate against people living with HIV/AIDS (PLHA). Derived from social psychology and mindfulness theories, separate scales addressing awareness, acceptance, and action were designed to include notions of labeling, stereotyping, outgrouping, and discriminating. These were enhanced to capture differences associated with personal characteristics of PLHA that trigger secondary stigma (e.g., sexual orientation, injection drug use, multiple sex partners) and fears regarding instrumental and symbolic stigma. Reliabilities were strong (coefficients α for 16 of 19 resulting measures ranged from 0.80 to 0.98) and confirmatory factor analyses indicated good model fit for two multidimensional (Awareness and Acceptance) and one unidimensional (Action) measure. Evidence of convergent construct validity supported accuracy of primary constructs. Implications for training and professional socialization in health care are discussed.

Magic Johnson doesn't worry about how to pay for medicine: experiences of black men who have sex with men living with HIV.

Despite high and rapidly growing incidence of HIV, little is known about the everyday lived experiences of HIV-positive black men who have sex with men. Lack of empirical knowledge about members of this group is especially problematic as HIV-positive individuals continue to live in a world of hope, fear, waiting and wondering, which can heavily influence their everyday lives. In this exploratory study, we examine the everyday lives of HIV-positive black gay, bisexual and other men who have sex with men, particularly how being a racial minority may influence the ways that they manage living with the illness. Our goal was to provide a forum from which black men could share their personal experiences regarding the various aspects of living with HIV. In doing so, we identified five themes that may be unique to black men or experienced differently by black men due, in the USA, to their racial minority status.

Formation of personal HIV disclosure policies among HIV-positive men who have sex with men.

Given the increasing emphasis on "prevention with positives" programs designed to promote HIV transmission risk reduction among people living with HIV/AIDS, better understanding of influences upon serostatus disclosure in sexual situations is needed. Based on grounded theory analyses of individual interviews, this exploratory research hypothesizes and interprets how 15 HIV-positive men who have sex with men (MSM) formed personal HIV disclosure policies for sexual situations. Participants described five elements influencing development of their personal policies, including: (1) making sense of having been infected, (2) envisioning sex as an HIV-positive man, (3) sorting through feelings of responsibility for others, (4) responding to views of friends and the gay community, and (5) anticipating reactions and consequences of disclosure. The article concludes with implications for current initiatives for prevention with positives.

AIDS stigma in health services in the Eastern Caribbean.

Stigma obstructs HIV/AIDS prevention and care worldwide, including in the Caribbean, where the prevalence of AIDS is second only to sub-Saharan Africa. To contextualise the experience of AIDS stigma in health services in Grenada and Trinidad and Tobago, we conducted eight focus groups with 51 people living with HIV/AIDS (PLHA), families, and service providers. Quasi-deductive content analysis revealed consonance with Western and Northern conceptualisations of AIDS stigma wherein stigma is enacted upon marginalized populations and reinforced through psycho-sociological processes comparing 'in' and 'out' groups. Socially constructed to be physically contagious and socially deviant, PLHA are scorned by some service providers, especially when they are perceived to be gay or bisexual. PLHA and providers identified passive neglect and active refusal by hospital and clinic staff to provide care to PLHA. Institutional practices for safeguarding patient confidentiality are perceived as marginally enforced. Interventions are needed to reduce provider stigma so the public will access HIV testing and PLHA will seek treatment.

Enacting personal HIV disclosure policies for sexual situations: HIV-positive gay men's experiences.

Given successes in treating HIV/AIDS, there are increasing numbers of sexually active HIV-positive people. Although there is a current public health emphasis on testing interventions to reduce HIV transmission by people who know they are HIV positive, understanding how people enact decisions to disclose their HIV seropositivity is needed. HIV Disclosure Decision Making in Sexual Situations, a grounded theory based on interviews with 15 HIV-positive gay men, hypothesizes and interprets a two-part process wherein HIV-positive gay men form personal disclosure policies that they contextualize to various dating and sexual situations. In this article, the author depicts the second part of the grounded theory with its five interlocking components of the process of enacting HIV disclosure in sexual situations.

Single-session motivational enhancement counseling to support change toward reduction of HIV transmission by HIV positive persons.

Given the enormous successes in treating HIV disease with antiretroviral therapies, there is a burgeoning population of healthy, sexually active HIV+ men and women. Because HIV prevention counseling has focused traditionally on persons at risk of becoming infected, there is an urgent mandate to explore ways to engage HIV+ persons in transmission risk reduction counseling. Using two case examples, this article presents an overview of motivational interviewing in a single counseling session as a promising treatment for addressing ambivalence about safer sex with HIV+ persons.

Awareness, acceptance, and action: an emerging framework for understanding AIDS stigmatizing attitudes among community leaders in Barbados.

AIDS stigma must be acknowledged and reduced to advance HIV prevention and HIV/AIDS care in a variety of settings worldwide, including in the West Indies where national epidemics are thought to be growing rapidly. Regarded by international health organizations as a formidable barrier to service delivery and receipt, AIDS stigma refers to prejudice and discrimination directed toward people living with HIV/AIDS (PLHA), persons perceived as being at risk for HIV infection, and the informal and formal service providers who care for PLHA. However, there is little evidence of successful antistigma interventions in the literature. Furthermore, beyond studies of willingness in various professions to serve clients or patients with HIV/AIDS, the stigmatizing attitudes and behaviors of service delivery personnel, paraprofessionals and volunteers have been inadequately studied. This paper uses data obtained during an AIDS awareness workshop with sports coaches in Barbados to illustrate principles of an antistigma intervention framework being developed for social service and health personnel. The Awareness/Acceptance/Action Model (AAAM) draws on principles of mindfulness, rooted in ancient Asian traditions, and recently adapted to a range of physical and mental health interventions in Western contexts. Mindfulness techniques encourage awareness of one's current state and environment, acceptance of the implications of one's attitudes and behaviors, and the development of intentional responses rather than habitually patterned reactions. In this initial effort, community leaders were guided through a series of self-reflective exercises focusing AAAM principles on their tendencies toward AIDS stigma, and exploring more compassionate and functional alternatives.