Sexual and reproductive health among forcibly displaced persons in urban environments in low and middle-income countries: scoping review findings.

BACKGROUND: Most forcibly displaced persons are hosted in low- and middle-income countries (LMIC). There is a growing urbanization of forcibly displaced persons, whereby most refugees and nearly half of internally displaced persons live in urban areas. This scoping review assesses the sexual and reproductive health (SRH) needs, outcomes, and priorities among forcibly displaced persons living in urban LMIC. METHODS: Following The Joanna Briggs Institute scoping review methodology we searched eight databases for literature published between 1998 and 2023 on SRH needs among urban refugees in LMIC. SHR was operationalized as any dimension of sexual health (comprehensive sexuality education [CSE]; sexual and gender based violence [GBV]; HIV and STI prevention and control; sexual function and psychosexual counseling) and/or reproductive health (antental, intrapartum, and postnatal care; contraception; fertility care; safe abortion care). Searches included peer-reviewed and grey literature studies across quantitative, qualitative, or mixed-methods designs. FINDINGS: The review included 92 studies spanning 100 countries: 55 peer-reviewed publications and 37 grey literature reports. Most peer-reviewed articles (n = 38) discussed sexual health domains including: GBV (n = 23); HIV/STI (n = 19); and CSE (n = 12). Over one-third (n = 20) discussed reproductive health, including: antenatal, intrapartum and postnatal care (n = 13); contraception (n = 13); fertility (n = 1); and safe abortion (n = 1). Eight included both reproductive and sexual health. Most grey literature (n = 29) examined GBV vulnerabilities. Themes across studies revealed social-ecological barriers to realizing optimal SRH and accessing SRH services, including factors spanning structural (e.g., livelihood loss), health institution (e.g., lack of health insurance), community (e.g., reduced social support), interpersonal (e.g., gender inequitable relationships), and intrapersonal (e.g., low literacy) levels. CONCLUSIONS: This review identified displacement processes, resource insecurities, and multiple forms of stigma as factors contributing to poor SRH outcomes, as well as producing SRH access barriers for forcibly displaced individuals in urban LMIC. Findings have implications for mobilizing innovative approaches such as self-care strategies for SRH (e.g., HIV self-testing) to address these gaps. Regions such as Africa, Latin America, and the Caribbean are underrepresented in research in this review. Our findings can guide SRH providers, policymakers, and researchers to develop programming to address the diverse SRH needs of urban forcibly displaced persons in LMIC. Most forcibly displaced individuals live in low- and middle-income countries (LMICs), with a significant number residing in urban areas. This scoping review examines the sexual and reproductive health (SRH) outcomes of forcibly displaced individuals in urban LMICs. We searched eight databases for relevant literature published between 1998 and 2023. Inclusion criteria encompassed peer-reviewed articles and grey literature. SRH was defined to include various dimensions of sexual health (comprehensive sexuality education; sexual and gender-based violence; HIV/ STI prevention; sexual function, and psychosexual counseling) and reproductive health (antenatal, intrapartum, and postnatal care; contraception; fertility care; and safe abortion care). We included 90 documents (53 peer-reviewed articles, 37 grey literature reports) spanning 100 countries. Most peer-reviewed articles addressed sexual health and approximately one-third centered reproductive health. The grey literature primarily explored sexual and gender-based violence vulnerabilities. Identified SRH barriers encompassed challenges across structural (livelihood loss), health institution (lack of insurance), community (reduced social support), interpersonal (gender inequities), and individual (low literacy) levels. Findings underscore gaps in addressing SRH needs among urban refugees in LMICs specifically regarding sexual function, fertility care, and safe abortion, as well as regional knowledge gaps regarding urban refugees in Africa, Latin America, and the Caribbean. Self-care strategies for SRH (e.g., HIV self-testing, long-acting self-injectable contraception, abortion self-management) hold significant promise to address SRH barriers experienced by urban refugees and warrant further exploration with this population. Urgent research efforts are necessary to bridge these knowledge gaps and develop tailored interventions aimed at supporting urban refugees in LMICs.

A Bayesian network analysis to examine the effects of HIV stigma processes on self-concept and depressive symptoms among persons living with HIV.

OBJECTIVE: This study examines the relationships between HIV stigma dimensions, self-related mechanisms, and depressive symptoms among persons living with HIV. BACKGROUND: HIV stigma hinders the well-being of individuals living with HIV, which is linked to depressive symptoms and increased risk of poor clinical outcomes. However, the mechanisms underlying stigma's impact on depression are poorly understood. Psychosocial theories propose that experiencing HIV stigma leads to internalized stigma, impacting self-concept and mental health. METHOD: Using Bayesian network analysis, we explored associations among HIV stigma processes (experienced, anticipated, internalized, perceived community stigma, and HIV status disclosure) and self-related mechanisms (self-esteem, fear of negative evaluation [FNE], self-blame coping, and social exclusion), and depressive symptoms. RESULTS: Our diverse sample of 204 individuals, primarily men, gay/bisexual, Black, and lower-middle SES, who experienced stigma showed increased anticipated, internalized, and perceived community stigma, FNE, and depressive symptoms. Internalized stigma contributed to self-blame coping and higher depressive symptoms. Anticipated and perceived community stigma and FNE correlated with increased social exclusion. DISCUSSION: This study investigates potential mechanisms through which HIV stigma may impact depression. Identifying these mechanisms establishes a foundation for future research to inform targeted interventions, enhancing mental health and HIV outcomes among individuals living with HIV, especially from minority backgrounds. Insights gained guide evidence-based interventions to mitigate HIV stigma's detrimental effects, ultimately improving overall well-being and health-related outcomes for people with HIV.

Intersectional Stigma, Fear of Negative Evaluation, Depression, and ART Adherence Among Women Living with HIV Who Engage in Substance Use: A Latent Class Serial Mediation Analysis.

Women Living with HIV (WLHIV) who use substances face stigma related to HIV and substance use (SU). The relationship between the intersection of these stigmas and adherence to antiretroviral therapy (ART), as well as the underlying mechanisms, remains poorly understood. This study aimed to examine the association between intersectional HIV and SU stigma and ART adherence, while also exploring the potential role of depression and fear of negative evaluation (FNE) by other people in explaining this association. We analyzed data from 409 WLHIV collected between April 2016 and April 2017, Using Multidimensional Latent Class Item Response Theory analysis. We identified five subgroups (i.e., latent classes [C]) of WLHIV with different combinations of experienced SU and HIV stigma levels: (C1) low HIV and SU stigma; (C2) moderate SU stigma; (C3) higher HIV and lower SU stigma; (C4) moderate HIV and high SU stigma; and (C5) high HIV and moderate SU stigma. Medication adherence differed significantly among these classes. Women in the class with moderate HIV and high SU stigma had lower adherence than other classes. A serial mediation analysis suggested that FNE and depression symptoms are mechanisms that contribute to explaining the differences in ART adherence among WLHIV who experience different combinations of intersectional HIV and SU stigma. We suggest that FNE is a key intervention target to attenuate the effect of intersectional stigma on depression symptoms and ART adherence, and ultimately improve health outcomes among WLHIV.

Complementing the United States Household Food Security Survey Module with Items Reflecting Social Unacceptability.

BACKGROUND: Social unacceptability of food access is part of the lived experience of food insecurity but is not assessed as part of the United States Household Food Security Survey Module (HFSSM). OBJECTIVES: The objectives were as follows: 1) to determine the psychometric properties of 2 additional items on social unacceptability in relation to the HFSSM items and 2) to test whether these 2 items provided added predictive accuracy to that of the HFSSM items for mental health outcomes. METHODS: Cross-sectional data used were from the Intersection of Material-Need Insecurities and HIV and Cardiovascular Health substudy of the Multicenter AIDS Cohort Study/Women's Interagency HIV Study Combined Cohort Study. Data on the 10-item HFSSM and 2 new items reflecting social unacceptability were collected between Fall 2020 and Fall 2021 from 1342 participants from 10 United States cities. The 2 social unacceptability items were examined psychometrically in relation to the HFSSM-10 items using models from item response theory. Linear and logistic regression was used to examine prediction of mental health measured by the 20-item Center for Epidemiologic Studies Depression scale and the 10-item Perceived Stress Scale. RESULTS: The social unacceptability items were affirmed throughout the range of severity of food insecurity but with increasing frequency at higher severity of food insecurity. From item response theory models, the subconstructs reflected in the HFSSM-10 and the subconstruct of social unacceptability were distinct, not falling into one dimension. Regression models confirmed that social unacceptability was distinct from the subconstructs reflected in the HFSSM-10. The social unacceptability items as a separate scale explained more (∼1%) variation in mental health than when combined with the HFSSM-10 items in a single scale, and the social unacceptability subconstruct explained more (∼1%) variation in mental health not explained by the HFSSM-10. CONCLUSIONS: Two social unacceptability items used as a separate scale along with the HFSSM-10 predicted mental health more accurately than did the HFSSM-10 alone.

Missed Opportunities in HIV Testing in Turkiye: Implications for Late Diagnoses.

BACKGROUND: Late diagnosis of HIV infection is a major global problem. In Turkiye, only 41%-50% of people living with HIV are diagnosed, suggesting that many opportunities for HIV testing might be missed. SETTING: The aim of this study was to determine the missed testing opportunities for HIV in healthcare settings in Turkiye and the predictors for missed opportunities (MOs). METHODS: The study included patients with a new HIV diagnosis, presenting to care between January 2018 and December 2020. They were given a verbal questionnaire face to face, by a telephone call or an online meeting for visits to a health care setting within the year before their diagnosis. Electronic medical records were also examined. RESULTS: The sample included 198 patients with at least 1 visit to any health care setting, with a total of 1677 visits. Patients had an indication for HIV testing in 51.3% (861/1677) of the visits; an HIV test was not offered in 77.9% (671/861) and was considered a MO. The highest number of MOs was in emergency departments (59.8%) (180/301). The most common reason for visiting was constitutional symptoms and indicator conditions (55.4%) (929/1677). University graduates and those with a CD4+ T-cell count <200/mm 3 were more likely to have a MO. CONCLUSIONS: Many opportunities to diagnose HIV at an early stage are missed in health care settings in Turkiye. Considering the rapidly increasing number of new diagnoses in the last decade, urgent action needs to be taken.

Longitudinal Associations of Experienced and Perceived Community Stigma With Antiretroviral Therapy Adherence and Viral Suppression in New-to-Care People With HIV: Mediating Roles of Internalized Stigma and Depression Symptoms.

BACKGROUND: Although cross-sectional studies have suggested that HIV-related stigma and depression symptoms may result in poor HIV treatment and health outcomes, few studies have investigated potential longitudinal mechanisms in these relationships. Furthermore, longitudinal effects of HIV-related stigma on health outcomes have not been examined in people with HIV (PWH) newly initiating HIV clinical care. We examined longitudinal associations between experienced and perceived community stigma and health outcomes (antiretroviral therapy [ART] adherence and viral load), mediated by internalized stigma and depression symptoms among new-to-care PWH in the United States. SETTING/METHODS: Data were obtained from 371 PWH who initiated HIV medical care at 4 HIV sites at baseline and 48 weeks later between December 2013 and 2018. Validated measures were used to assess experienced stigma, perceived community stigma, internalized stigma, depression symptoms, and ART adherence, and viral load was obtained from medical records at the final study visit. RESULTS: Serial mediation models revealed significant indirect effects of experienced stigma and perceived community stigma on ART adherence and on viral suppression, first through internalized stigma and then through depression symptoms. CONCLUSIONS: These results suggest that PWH may tend to internalize HIV-related stigma when they experience acts of stigmatization or perceive negative attitudes in society, which in turn may result in negative effects on psychological and physical well-being. These findings about how stigma in society may be an antecedent mechanism for PWH to develop internalized stigma, which in turn affects individual health outcomes, can be used to tailor both individual-level and community-level interventions.

Cognitive prescriptions for reducing dementia risk factors among Black/African Americans: feasibility, acceptability, and preliminary efficacy.

OBJECTIVES: Black/African Americans (B/AAs) have double the risk of Alzheimer's disease and related dementia than Whites, which is largely driven by health behaviors. This study examined the feasibility, acceptability, and preliminary efficacy of a pilot randomized clinical trial of an individualized multidomain health behavior intervention among middle-aged and older B/AAs (dubbed Cognitive Prescriptions [CogRx]). DESIGN: Thirty-nine community-dwelling B/AA participants aged 45-65 without significant cognitive impairment were randomized to one of three groups: CogRx, Psychoeducation, or no-contact control. The Psychoeducation and CogRx groups received material on dementia prevalence, prognosis, and risk factors, while the CogRx group additionally received information on their risk factor profile across the five CogRx domains (physical, cognitive, and social activity, diet, sleep). This information was used for developing tailored 3-month goals in their suboptimal areas. RESULTS: The CogRx program had high retention (all 13 CogRx participants completed the 3-month program and 97% of the full sample completed at least 1 follow-up) and was well-received as exhibited by qualitative and quantitative feedback. Themes identified in the positive feedback provided by participants on the program included: increased knowledge, goal-setting, personalization, and motivation. The COVID-19 pandemic was a consistent theme that emerged regarding barriers of adherence to the program. All three groups improved on dementia knowledge, with the largest effects observed in CogRx and Psychoeducation groups. Increases in cognitive, physical, and overall leisure activities favored the CogRx group, whereas improvements in sleep outcomes favored Psychoeducation and CogRx groups as compared to the control group. CONCLUSION: The CogRx program demonstrated feasibility, acceptability, and preliminary efficacy in increasing dementia knowledge and targeted health behaviors. Further refinement and testing of the implementation and effectiveness of similar person-centered dementia prevention approaches are needed on a larger scale in diverse populations. Such findings may have implications for clinical and public health recommendations. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03864536.

Development and Preliminary Validation of the PrEP Empowerment Scale.

Informed by the Health Care Empowerment Model, a measure of PrEP Empowerment was developed and assessed for preliminary reliability and validity. Participants (N = 100) were invited to complete a survey during regular clinic visits. A subset (n = 84) volunteered to provide blood samples to assess plasma tenofovir (TFV) levels for recent PrEP adherence. A five-factor measure explained 70% of the total variance. Associations with internalized PrEP stigma, PrEP adherence self-efficacy, and plasma TFV were assessed. Results supported the multidimensional nature of PrEP Empowerment and reliability and validity. Additional research is needed in populations with varying PrEP experience and greater gender and ethnic representation.

RESUMEN: Basado en el modelo de empoderamiento de atención médica, se desarrolló y evaluó una medida de empoderamiento de la PrEP para determinar su confiabilidad y validez preliminares. Se invitó a los participantes (N = 100) a completar una encuesta durante las visitas regulares a la clínica. Un subconjunto (n = 84) se ofreció como voluntario para proporcionar muestras de sangre para evaluar los niveles de tenofovir (TFV) en plasma para la adherencia reciente a la PrEP. Una medida de cinco factores explicó el 70% de la varianza total. Se evaluaron las asociaciones con el estigma internalizado de la PrEP, la autoeficacia de la PrEP y el TFV plasmático. Los resultados respaldaron la naturaleza multidimensional de PrEP Empowerment y la confiabilidad y validez. Se necesita investigación adicional en poblaciones con diferentes experiencias de PrEP y una mayor representación étnica y de género.

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.

Relationships Between Patient Race and Residential Race Context With Missed Human Immunodeficiency Virus Care Visits in the United States, 2010-2015.

BACKGROUND: Racial inequities exist in retention in human immunodeficiency virus (HIV) care and multilevel analyses are needed to contextualize and address these differences. Leveraging data from a multisite clinical cohort of people with HIV (PWH), we assessed the relationships between patient race and residential characteristics with missed HIV care visits. METHODS: Medical record and patient-reported outcome (PRO; including mental health and substance-use measures) data were drawn from 7 participating Center for AIDS Research Network of Integrated Clinical Systems (CNICS) sites including N = 20 807 PWH from January 2010 through December 2015. Generalized estimating equations were used to account for nesting within individuals and within census tracts in multivariable models assessing the relationship between race and missed HIV care visits, controlling for individual demographic and health characteristics and census tract characteristics. RESULTS: Black PWH resided in more disadvantaged census tracts, on average. Black PWH residing in census tracts with higher proportion of Black residents were more likely to miss an HIV care visit. Non-Black PWH were less likely to miss a visit regardless of where they lived. These relationships were attenuated when PRO data were included. CONCLUSIONS: Residential racial segregation and disadvantage may create inequities between Black PWH and non-Black PWH in retention in HIV care. Multilevel approaches are needed to retain PWH in HIV care, accounting for community, healthcare setting, and individual needs and resources.

The Relationship Between HIV Pre-exposure Prophylaxis Stigma and Treatment Adherence Among Current HIV Pre-exposure Prophylaxis Users in the Southeastern U.S.

Despite efficacy in HIV prevention, Pre-exposure Prophylaxis (PrEP) is underutilized in the US, especially among populations at highest risk. PrEP-related stigma may play a role. We developed measures of PrEP-related stigma dimensions and PrEP adherence. We administered them to current PrEP users. We hypothesized that PrEP-related stigma would negatively impact PrEP adherence. Questionnaire measures were developed using data from previous qualitative work and existing validated HIV-related stigma measures. The resultant survey was administered to current PrEP users from two Birmingham, Alabama PrEP clinics. Plasma tenofovir disoproxil fumarate levels were collected to measure PrEP adherence. Exploratory factor analyses were performed to determine the factor structure of each PrEP-related stigma dimension (internalized, perceived, experienced, anticipated, disclosure concerns). Separate binary logistic (or linear) regressions were performed to assess associations between PrEP-related stigma dimensions and adherence (treatment adherence self-efficacy, self-reported adherence, and plasma tenofovir levels), adjusting for education, race, and time on PrEP. In 2018, 100 participants completed the survey, with 91 identifying as male and 66 as white. Only internalized stigma was associated with lower self-reported PrEP adherence. Exploratory mediation analyses suggested that the association between all stigma dimensions and self-reported PrEP adherence is mediated by PrEP adherence self-efficacy. No associations were found between any PrEP-related stigma measures and plasma tenofovir levels. Internalized PrEP stigma may reduce PrEP adherence, possibly by reducing PrEP adherence self-efficacy among experienced PrEP users. Further investigation of how stigma dimensions affect PrEP adherence in populations at risk for HIV may shed light on drivers of PrEP underutilization.

Living with HIV during COVID-19: knowledge and worry about COVID-19, adherence to COVID-19-related precautions, and HIV health outcomes.

The COVID-19 pandemic has been profound impacts on mental and physical health of individuals with chronic diseases. Thus, it is important to understand the effects of the COVID-19 pandemic on people living with HIV. We aimed to assess the association between COVID-19-related knowledge and worry, HIV-related health practices and outcomes, and adherence to precautions related to COVID-19, and possible associations of these factors with HIV treatment outcomes (ART adherence and viral load). A cross-sectional survey was conducted between October 2020 and February 2021 among 291 PLWH at two large university hospital HIV clinics in Izmir, Turkey. Additionally, the most recent HIV-RNA load, CD4 count was recorded using medical records. Logistic regression analyses were performed to determine predictors of self-reported adherence to COVID-19-related precautions, ART adherence and undetectable viral load. COVID-19-related worry, COVID-19-related knowledge, and ART adherence were significant predictors of adherence to COVID-19-related precautions. Furthermore, adherence to COVID-19-related precautions was a significant predictor of both ART adherence and undetectable viral load. Findings provide a unique aspect of the interrelations of COVID and living with HIV. Since health behaviors and outcomes for COVID-19 and HIV seem to be interrelated, treatment practices and interventions that address these simultaneously may enhance their efficacy.

A new approach for SPN removal: nearest value based mean filter.

In this study, a new adaptive filter is proposed to eliminate salt and pepper noise (SPN). The basis of the proposed method consists of two-stages. (1) Changing the noisy pixel value with the closest pixel value or assigning their average to the noisy pixel in case there is more than one pixel with the same distance; (2) the updating of the calculated noisy pixel values with the average filter by correlating them with the noise ratio. The method developed was named as Nearest Value Based Mean Filter (NVBMF), because of using the pixel value which the closest distance in the first stage. Results obtained with the proposed method: it has been compared with the results obtained with the Adaptive Frequency Median Filter, Adaptive Riesz Mean Filter, Improved Adaptive Weighted Mean Filter, Adaptive Switching Weight Mean Filter, Adaptive Weighted Mean Filter, Different Applied Median Filter, Iterative Mean Filter, Two-Stage Filter, Multistage Selective Convolution Filter, Different Adaptive Modified Riesz Mean Filter, Stationary Framelet Transform Based Filter and A New Type Adaptive Median Filter methods. In the comparison phase, nine different noise levels were applied to the original images. Denoised images were compared using Peak Signal-to-Noise Ratio, Image Enhancement Factor, and Structural Similarity Index Map image quality metrics. Comparisons were made using three separate image datasets and Cameraman, Airplane images. NVBMF achieved the best result in 52 out of 84 comparisons for PSNR, best in 47 out of 84 comparisons for SSIM, and best in 36 out of 84 comparisons for IEF. In addition, values nearly to the best result were obtained in comparisons where the best result could not be reached. The results obtained show that the NVBMF can be used as an effective method in denoising SPN.

Resilience and Optimism as Moderators of the Negative Effects of Stigma on Women Living with HIV.

Resilience and optimism may not only have main effects on health outcomes, but may also moderate and buffer negative effects of stressors. We examined whether dispositional resilience and optimism moderate the associations between HIV-related stigma in health care settings and health-related outcomes (trust in HIV health care providers and depression symptoms) among women living with HIV (WLHIV). One thousand four hundred five WLHIV in nine US cities completed validated questionnaires for cross-sectional analyses. Higher self-reported experienced and anticipated stigma and lower resilience and optimism were associated with higher depression symptoms and with lower trust in HIV providers. Importantly, resilience moderated the effects of experienced stigma (but not of anticipated stigma): When resilience was high, the association of experienced stigma with higher depression symptoms and lower trust in HIV providers was weaker compared with when resilience was low. Further, significant moderation effects suggested that when optimism was high, experienced and anticipated stigma was both less strongly associated with depression symptoms and with lower trust in one's HIV care providers compared with when optimism was low. Thus, the effects of experienced stigma on depression symptoms and provider trust were moderated by both resilience and optimism, but the effects of anticipated stigma were moderated only by optimism. Our findings suggest that in addition to their main effects, resilience and optimism may function as buffers against the harmful effects of stigma in health care settings. Therefore, optimism and resilience may be valuable intervention targets to reduce depression symptoms or improve trust in providers among populations that experience or anticipate stigma, such as WLHIV.

Impact of harm reduction care in HIV clinical settings on stigma and health outcomes for people with HIV who use drugs: study protocol for a mixed-methods, multisite, observational study.

INTRODUCTION: Our previous pilot work suggests relational harm reduction strengthens relationships between people with HIV (PWH) who use drugs and their healthcare providers and improves HIV health outcomes. However, there is limited research examining ways that structural (eg, strategies like syringe service programmes) and/or relational (patient-provider relationship) harm reduction approaches in HIV clinical settings can mitigate experiences of stigma, affect patient-provider relationships and improve outcomes for PWH who use drugs. Our mixed methods, multisite, observational study aims to fill this knowledge gap and develop an intervention to operationalise harm reduction care for PWH who use drugs in HIV clinical settings. METHODS AND ANALYSIS: Aim 1 will explore the relationship between healthcare providers' stigmatising attitudes towards working with PWH who use drugs and providers' acceptance and practice of structural and relational harm reduction through surveys (n=125) and interviews (n=20) with providers. Aim 2 will explore the interplay between patient-perceived harm reduction, intersectional stigma and clinical outcomes related to HIV, hepatitis C (if applicable) and substance use-related outcomes through surveys (n=500) and focus groups (k=6, total n=36) with PWH who use drugs. We will also psychometrically evaluate a 25-item scale we previously developed to assess relational harm reduction, the Patient Assessment of Provider Harm Reduction Scale. Aim 3 will use human-centred design approaches to develop and pretest an intervention to operationalise harm reduction care for PWH who use drugs in HIV clinical settings. ETHICS AND DISSEMINATION: This study was approved via expedited review by the University of Pittsburgh Institutional Review Board (STUDY21090002). Study findings will be presented in peer-reviewed journals and public health conferences as well as shared with patient participants, community advisory boards and harm reduction organisations. TRIAL REGISTRATION NUMBER: NCT05404750.

T-cell activation state differentially contributes to neuropsychiatric complications in women with HIV.

Neuropsychiatric complications are common among women with HIV (WWH). The pathophysiological mechanisms underlying these complications are not fully known but likely driven in part by immune modulation. We examined associations between T-cell activation states which are required to mount an effective immune response (activation, co-stimulation/normal function, exhaustion, senescence) and neuropsychiatric complications in WWH. 369 WWH (78% HIV RNA undetectable/<20cp/mL) enrolled in the Women's Interagency HIV Study completed neuropsychological testing and measures of depression (Center for Epidemiological Studies Depression Scale-CES-D), self-reported stress levels (Perceived Stress Scale-10), and post-traumatic stress (PTSD Checklist-Civilian Scale). Multiparametric flow cytometry evaluated T-cell activation state. Partial least squares regressions were used to examine T-cell phenotypes and neuropsychiatric outcome associations after confounder adjustment. In the total sample and among virally suppressed (VS)-WWH, CD4+ T-cell exhaustion was associated with poorer learning and attention/working memory (P's < 0.05). In the total sample, CD4+ T-cell activation was associated with better attention/working memory and CD8+ T-cell co-stimulation and senescence was associated with poorer executive function (P's < 0.05). For mental health outcomes, in the total sample, CD4+ T-cell activation was associated with more perceived stress and CD4+ T-cell exhaustion was associated with less depressive symptoms (P's < 0.05). Among VS-WWH, CD4+ senescence was associated with less perceive stress and CD8+ T-cell co-stimulation and senescence was associated with higher depression (P's < 0.05). Together, results suggest the contribution of peripheral CD4+ and CD8+ T-cell activation status to neuropsychiatric complications in WWH.

Internalized HIV-Related Stigma and Neurocognitive Functioning Among Women Living with HIV.

The prevalence of HIV-associated neurocognitive impairment persists despite highly effective antiretroviral therapy (ART). In this study we explore the role of internalized stigma, acceptance of negative societal characterizations, and perceptions about people living with HIV (PLWH) on neurocognitive functioning (executive function, learning, memory, attention/working memory, psychomotor speed, fluency, motor skills) in a national cohort of women living with HIV (WLWH) in the United States. We utilized observational data from a multicenter study of WLWH who are mostly African American living in low-resource settings. Neurocognitive function was measured using an eight-test battery. A multiple linear regression model was constructed to investigate the relationship between internalized stigma and overall neurocognitive functioning (mean of all neurocognitive domain standardized T-scores), adjusting for age, education, race, previous neuropsychological battery scores, illicit drug use, viral load, and years on ART. Our analysis revealed that internalized HIV-related stigma is significantly associated with worse performance on individual domain tests and overall neurocognitive performance (B = 0.27, t = 2.50, p = 0.01). This suggests HIV-related internalized stigma may be negatively associated with neurocognitive functioning for WLWH. This finding highlights a specific psychosocial factor associated with poor neurocognitive function that may be targeted to better promote the health of PLWH. Future research on the longitudinal relationship between these variables and the effects of other stigma dimensions on poor neurocognitive function would provide further insights into the pathways explaining the relationship between internalized stigma and neurocognition.

Intersectional stigmas are associated with lower viral suppression rates and antiretroviral therapy adherence among women living with HIV.

OBJECTIVES: To explore the associations between intersectional poverty, HIV, sex, and racial stigma, adherence to antiretroviral therapy (ART), and viral suppression among women with HIV (WHIV). DESIGN: We examined intersectional stigmas, self-report ART adherence, and viral suppression using cross-sectional data. METHODS: Participants were WHIV ( N  = 459) in the Women's Adherence and Visit Engagement, a Women's Interagency HIV Study substudy. We used Multidimensional Latent Class Item Response Theory and Bayesian models to analyze intersectional stigmas and viral load adjusting for sociodemographic and clinical covariates. RESULTS: We identified five intersectional stigma-based latent classes. The likelihood of viral suppression was approximately 90% lower among WHIV who experienced higher levels of poverty, sex, and racial stigma or higher levels of all intersectional stigmas compared with WHIV who reported lower experiences of intersectional stigmas. ART adherence accounted for but did not fully mediate some of the associations between latent intersectional stigma classes and viral load. CONCLUSION: The negative impact of intersectional stigmas on viral suppression is likely mediated, but not fully explained, by reduced ART adherence. We discuss the research and clinical implications of our findings.

Biopsychosocial Health Outcomes and Experienced Intersectional Stigma in a Mixed HIV Serostatus Longitudinal Cohort of Aging Sexual Minority Men, United States, 2008‒2019.

Objectives. To determine whether intersectional stigma is longitudinally associated with biopsychosocial outcomes. Methods. We measured experienced intersectional stigma (EIS; ≥ 2 identity-related attributions) among sexual minority men (SMM) in the United States participating in the Multicenter AIDS Cohort Study. We assessed longitudinal associations between EIS (2008‒2009) and concurrent and future hypertension, diabetes, dyslipidemia, antiretroviral therapy adherence, HIV viremia, health care underutilization, and depression symptoms (2008‒2019). We conducted causal mediation to assess the contribution of intersectional stigma to the relationship between self-identified Black race and persistently uncontrolled outcomes. Results. The mean age (n = 1806) was 51.8 years (range = 22-84 years). Of participants, 23.1% self-identified as Black; 48.3% were living with HIV. Participants reporting EIS (30.8%) had higher odds of hypertension, dyslipidemia, diabetes, depression symptoms, health care underutilization, and suboptimal antiretroviral therapy adherence compared with participants who did not report EIS. EIS mediated the relationship between self-identified Black race and uncontrolled outcomes. Conclusions. Our findings demonstrate that EIS is a durable driver of biopsychosocial health outcomes over the life course. Public Health Implications. There is a critical need for interventions to reduce intersectional stigma, help SMM cope with intersectional stigma, and enact policies protecting minoritized people from discriminatory acts. (Am J Public Health. 2022;112(S4):S452-S462. https://doi.org/10.2105/AJPH.2022.306735).

Methods in HIV-Related Intersectional Stigma Research: Core Elements and Opportunities.

Researchers are increasingly recognizing the importance of studying and addressing intersectional stigma within the field of HIV. Yet, researchers have, arguably, struggled to operationalize intersectional stigma. To ensure that future research and methodological innovation is guided by frameworks from which this area of inquiry has arisen, we propose a series of core elements for future HIV-related intersectional stigma research. These core elements include multidimensional, multilevel, multidirectional, and action-oriented methods that sharpen focus on, and aim to transform, interlocking and reinforcing systems of oppression. We further identify opportunities for advancing HIV-related intersectional stigma research, including reducing barriers to and strengthening investments in resources, building capacity to engage in research and implementation of interventions, and creating meaningful pathways for HIV-related intersectional stigma research to produce structural change. Ultimately, the expected payoff for incorporating these core elements is a body of HIV-related intersectional stigma research that is both better aligned with the transformative potential of intersectionality and better positioned to achieve the goals of Ending the HIV Epidemic in the United States and globally. (Am J Public Health. 2022;112(S4):S413-S419. https://doi.org/10.2105/AJPH.2021.306710).