Beliefs Among Veteran Firearm Owners Regarding Whether Clinicians Should Discuss Firearm Safety With Patients.

Importance: Veterans are at increased risk of suicide, and guidelines recommend assessing firearm access and counseling to reduce access among patients with elevated suicide risk. How veterans view such discussions is critical to the effectiveness of these interactions. Objective: To assess whether veteran firearm owners believe clinicians should deliver firearm counseling when patients or their family members are being cared for in specific clinical contexts that suggest heightened risk of firearm injury. Design, Setting, and Participants: In this cross-sectional study, data were from a probability-based online survey of self-identified veterans who reported owning at least 1 firearm (National Firearms Survey, July 1 to August 31, 2019) and were weighted to generate nationally representative estimates. Data were analyzed from June 2022 to March 2023. Main Outcomes and Measures: Participants were asked, "As part of routine care, should physicians and/or other health care professionals talk with their patients about firearms and firearm safety if their patient or their patient's family member (is at risk of suicide; has mental health or behavioral problems; is abusing or addicted to alcohol or drugs; is a victim of domestic violence; has Alzheimer's disease or another dementia; or is going through a hard time)." Response options included "No," "Yes, sometimes," and "Yes, always." In addition, responses were dichotomized as "Yes, at least sometimes" and "No." Results: Of 4030 adults who completed the survey (65% completion rate), 678 (mean [SD] age, 64.7 [13.1] years; 638 [92.9%] male) identified as veteran firearm owners. Across the 6 clinical contexts, support for clinicians "at least sometimes" discussing firearm safety as part of routine care ranged from 73.4% (95% CI, 69.1%-77.3%) when someone is "going through a hard time" to 88.2% (95% CI, 84.8%-90.9%) when someone has "mental health or behavioral problems." When a patient or family member is at risk for suicide, 79.4% (95% CI, 75.5%-82.8%) of veteran firearm owners responded that clinicians should "at least sometimes" discuss firearms and firearm safety. Conclusions and Relevance: This study's findings suggest that most veteran firearm owners believe that clinicians should provide firearm counseling during routine care when a patient or family member is at heightened risk of firearm injury. These findings belie concerns that discussing firearm access with veteran firearm owners is an unacceptable practice.

Firearm Ownership Among a Nationally Representative Sample of U.S. Veterans.

INTRODUCTION: This study aimed to identify the prevalence and correlates of firearm ownership in a large, contemporary, nationally representative sample of U.S. military veterans. METHODS: Data were analyzed from the 2022 National Health and Resilience in Veterans Study (N=2,326; mean age=60.2 years). Weighted independent-sample t-tests and chi-square analyses were conducted to compare veterans who did with those who did not report firearm ownership on sociodemographic, military, and psychiatric variables. A multivariable logistic regression analysis using backward elimination was conducted to identify the characteristics independently associated with firearm ownership, and a relative importance analysis was conducted to quantify the relative variance in firearm ownership that was explained by each of the statistically significant main effects. RESULTS: Of the total 2,326 veterans, 1,217 (weighted 50.9%, 95% CI=48.0%, 53.9%) reported owning any firearms. Male sex, conservative political ideology, living in rural area, home ownership, cumulative trauma burden, and lifetime history of alcohol use disorder were most strongly associated with firearm ownership. CONCLUSIONS: This study provides an updated characterization of the prevalence and correlates of firearm ownership among the U.S. veterans. Results of this nationally representative study suggest that firearm ownership in this group may be higher than previously reported and underscore the importance of targeted suicide prevention efforts promoting firearm safety among vulnerable segments of this population.

Randomized controlled trial of a theory-informed mHealth intervention to support ART adherence and viral suppression among women with HIV in Mombasa, Kenya: preliminary efficacy and participant-level feasibility and acceptability.

BACKGROUND: Mobile Health ("mHealth") interventions have shown promise in improving HIV treatment outcomes for stigmatized populations. This paper presents the findings from a randomized controlled trial to assess the efficacy, participant-level feasibility and acceptability of a theory-informed mHealth intervention, Motivation Matters!, designed to improve viral suppression and ART adherence among HIV-seropositive women who engage in sex work in Mombasa, Kenya. METHODS: A total of 119 women were randomized between the intervention and standard of care control. The primary outcome examined viral suppression (≤ 30 copies/mL) six months following ART initiation. ART adherence was assessed monthly using a visual analogue scale. Participant-level feasibility was measured through response rates to study text messages. Acceptability was assessed through qualitative exit interviews. RESULTS: Six months following treatment initiation, 69% of intervention and 63% of control participants were virally suppressed (Risk Ratio [RR] = 1.09, 95% Confidence Interval [95% CI] (0.83, 1.44). Among women who were viremic at baseline and endorsed engagement in sex work, 74% of women in the intervention arm compared with 46% of women in the control arm achieved viral suppression at month six RR = 1.61, 95% CI (1.02, 2.55). Adherence was higher in intervention versus control participants every month. All participants responded to at least one message, and there was a 55% overall response rate to intervention text messages. Qualitative exit interviews suggested high acceptability and perceived impact of the intervention. CONCLUSION: The improvements in ART adherence and viral suppression, combined with encouraging data on feasibility and acceptability, provides preliminary evidence that Motivation Matters! could support ART adherence and viral suppression in women who engage in sex work. TRIAL REGISTRATION: This trial was registered with ClinicalTrials.gov (NCT02627365, 10/12/2015; http://clinicaltrials.gov ).

Suicidal Thoughts and Behaviors in Older U.S. Military Veterans: Results From the National Health and Resilience in Veterans Study.

OBJECTIVE: To identify the prevalence and correlates associated with suicidal thoughts and behaviors (STBs) in a nationally representative sample of older (55+) US military veterans. METHODS: Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study (N = 3,356; mean age = 70.6). Self-report measures of past-year suicidal ideation (SI), lifetime suicide plan, lifetime suicide attempt(s), and future suicide intent were examined in relation to sociodemographic, neuropsychiatric, trauma, physical health, and protective factors. RESULTS: A total of 6.6% (95% CI = 5.7%-7.8%) of the sample endorsed past-year SI, 4.1% (CI = 3.3%-5.1%) a lifetime suicide plan, 1.8% (CI = 1.4%-2.3%) a lifetime suicide attempt, and 0.9% (CI = 0.5%-1.3%) future suicide intent. Higher levels of loneliness and lower levels of purpose in life were most strongly associated with past-year SI; lifetime history of major depressive disorder with suicide plan and suicide attempt; and frequency of past-year SI and more negative expectations regarding emotional aging with future suicide intent. CONCLUSION: These findings provide the most up-to-date nationally representative prevalence estimates of STBs among older military veterans in the United States. Several modifiable vulnerability factors were found to be associated with suicide risk in older US military veterans, suggesting that these factors may be targets for intervention in this population.

Adaptation of a social vulnerability index for measuring social frailty among East African women.

BACKGROUND: The number of older women living with HIV in Africa is growing, and their health outcomes may be adversely impacted by social frailty, which reflects deficits in social resources that accumulate over the lifespan. Our objective was to adapt a Social Vulnerability Index (SVI) originally developed in Canada for use in a study of older women living with or without HIV infection in Mombasa, Kenya. METHODS: We adapted the SVI using a five-step process: formative qualitative work, translation into Kiswahili, a Delphi procedure, exploration of potential SVI items in qualitative work, and a rating and ranking exercise. Four focus group discussions (FGD) were conducted (three with women living with HIV and one with HIV-negative women), and two expert panels were constituted for this process. RESULTS: Themes that emerged in the qualitative work were physical impairment with aging, decreased family support, a turn to religion and social groups, lack of a financial safety net, mixed support from healthcare providers, and stigma as an added burden for women living with HIV. Based on the formative FGD, the expert panel expanded the original 19-item SVI to include 34 items. The exploratory FGD and rating and ranking exercise led to a final 16-item Kenyan version of the SVI (SVI-Kenya) with six domains: physical safety, support from family, group participation, instrumental support, emotional support, and financial security. CONCLUSIONS: The SVI-Kenya is a holistic index to measure social frailty among older women in Kenya, incorporating questions in multiple domains. Further research is needed to validate this adapted instrument.

A network analysis of risk factors for suicide in Iraq/Afghanistan-era veterans.

Suicidal ideation (SI) is a prevalent issue in the veteran population. A number of factors have been identified as risk factors for suicidal ideation (SI) in veterans, including suicide attempts, depression, posttraumatic stress disorder (PTSD), and drug use. However, clinicians' ability to predict suicide is poor, particularly given the interplay between various factors such as previous suicide attempts. As such, there is a gap in our knowledge of which factors most saliently predict suicide risk and which should be targets for interventions designed to lower SI. Network analysis, a method allowing for an examination of how variables relate within the context of a network of factors, may bridge this gap by simultaneously evaluating the interrelationships between risk factors for suicide in veterans. Current study used network analysis and data from 2268 Iraq/Afghanistan-era military veterans to examine the relationships between suicidal ideation and several factors related to suicide risk, such as past suicide attempts, PTSD symptoms, depression, drug use, trauma exposure. Partial correlation network results showed suicidal ideation to be strongly related to depression, with smaller connections to past suicide attempts and anger. Additionally, past suicide attempts was strongly related to history of childhood trauma and weakly related to problematic drug use and PTSD symptoms. These results offer valuable information for both predicting suicide risk and differentiating targets for interventions lowering suicide risk in veterans.

Nonsuicidal Self-Injury Disorder, Borderline Personality Disorder, and Lifetime History of Suicide Attempts among Male and Female Veterans with Mental Health Disorders.

BACKGROUND: Expanding on research that has identified nonsuicidal self-injury (NSSI) as a strong predictor of suicide risk, the present study examined NSSI disorder (NSSID) and borderline personality disorder (BPD) as unique contributors to lifetime suicide attempts. To our knowledge, the present study represents the first exploration of these associations among veterans. METHODS: Participants included 124 male (74%) and female (26%) veterans diagnosed with at least one mental health disorder. Posttraumatic stress disorder (93%) and major depression (86%) were the most common mental health diagnoses. Large proportions of the sample met criteria for NSSID (48%) and BPD (40%). Suicide attempts were reported by 28% of the sample. Chi-square tests determined the bivariate associations among NSSID, BPD, history of suicide attempts, and other variables. Significant diagnostic (i.e., MDD, BPD, and NSSID) and demographic (i.e., age) characteristics were included as covariates in a logistic regression model examining the associations of BPD and NSSID with suicide attempts. RESULTS: BPD, Χ2=11.1, p<0.001, and NSSID, Χ2=13.9, p<0.001, were uniquely associated with suicide attempts. When all significant predictors were included in the final model, only NSSID emerged as a significant contributor to suicide attempts, OR = 4.9, p < 0.001. LIMITATIONS: Causality cannot be determined from cross-sectional analyses. CONCLUSION: These findings highlight NSSID as a powerful and unique correlate of suicide attempts among veterans, beyond the associations of established diagnostic risk factors. Improving our understanding of the relationship between NSSID and suicide risk has the potential to inform suicide prevention efforts and improve clinical outcomes among veterans.

How Stigma Toward Anal Sexuality Promotes Concealment and Impedes Health-Seeking Behavior in the U.S. Among Cisgender Men Who Have Sex with Men.

Gay, bisexual, and other men who have sex with men (MSM) experience alarming HIV disparities alongside sub-optimal engagement in HIV interventions. Among MSM, stigma toward anal sexuality could interfere with engagement in HIV prevention, yet few studies have examined MSM perspectives on anal sex stigma or its health-related sequelae. Guided by theory, we aimed to characterize anal sex stigma, related sexual concerns, and barriers to health seeking, like concealment. We elicited community input by purposively interviewing 10 experts in MSM health and then 25 racially, ethnically, and geographically diverse cisgender MSM. Participants reported experienced, internalized, and anticipated forms of anal sex stigma that inhibited health seeking. Experienced stigma, including direct and observed experiences as well as the absence of sex education and information, contributed to internalized stigma and anticipation of future devaluation. This process produced psychological discomfort and concealment of health-related aspects of anal sexuality, even from potentially supportive sexual partners, social contacts, and health workers. Participants characterized stigma and discomfort with disclosure as normative, pervasive, and detrimental influences on health-seeking behavior both during sex and within healthcare interactions. Omission of information appears to be a particularly salient determinant of sexual behavior, inhibiting prevention of harm, like pain, and leading to adverse health outcomes. The development of measures of anal sex stigma and related sexual concerns, and testing their impact on comfort with disclosure, sexual practices, and engagement in health services could identify modifiable social pathways that contribute to health disparities among MSM, like those seen in the HIV epidemic.

Diagnostic Correlates of Nonsuicidal Self-Injury Disorder among Veterans with Psychiatric Disorders.

With its recent inclusion in the Diagnostic and Statistical Manual, nonsuicidal self-injury disorder (NSSID) has received limited research attention, especially in samples of military veterans. The present study sought to identify diagnostic predictors of NSSID within a veteran sample. Study participants included 124 veterans with at least one psychiatric diagnosis. Chi-square tests and t-tests evaluated bivariate associations between NSSID and twenty diagnostic correlates. Logistic regression models identified psychiatric disorders that were unique correlates of NSSID among veterans. Veterans with lifetime NSSID (n = 59) met criteria for a greater number of lifetime disorders than veterans with other psychiatric disorders. Bivariate associations were noted between NSSID and borderline personality disorder, depression, obsessive-compulsive disorder, generalized anxiety disorder, and cannabis use disorder. In the logistic regression model, only borderline personality disorder (AOR = 7.67) and obsessive-compulsive disorder (AOR = 3.23) continued to be associated with NSSID. The present study represents the first examination of the association between NSSID and psychiatric disorders among veterans. The findings shed light on psychiatric disorders associated with lifetime NSSID in veterans, with special consideration toward obsessive-compulsive disorder as a risk factor for NSSID.

Does Stigma Toward Anal Sexuality Impede HIV Prevention Among Men Who Have Sex With Men in the United States? A Structural Equation Modeling Assessment.

INTRODUCTION: Men who have sex with men (MSM) are suboptimally engaged in efficacious HIV interventions, due in part to stigma. AIM: We sought to validate the Anal Health Stigma Model, developed based on theory and prior qualitative data, by testing the magnitude of associations between measures of anal sex stigma and engagement in HIV prevention practices, while adjusting for covariates. METHODS: We conducted a cross-sectional online survey of 1,263 cisgender MSM living in the United States and analyzed data with structural equation modeling. We tested a direct path from Anal Sex Stigma to Engagement in HIV Prevention alongside 2 indirect paths, 1 through Anal Sex Concerns and another through Comfort Discussing Anal Sexuality with Health Workers. The model adjusted for Social Support, Everyday Discrimination, and Sociodemographics. MAIN OUTCOME MEASURE: Engagement in HIV Prevention comprised an ad hoc measure of (i) lifetime exposure to a behavioral intervention, (ii) current adherence to biomedical intervention, and (iii) consistent use of a prevention strategy during recent penile-anal intercourse. RESULTS: In the final model, anal sex stigma was associated with less engagement (ß = -0.22, P < .001), mediated by participants' comfort talking about anal sex practices with health workers (ß = -0.52; ß = 0.44; both P < .001), adjusting for covariates (R2 = 67%; χ2/df = 2.98, root mean square error of approximation = 0.040, comparative fit index = 0.99 and Tucker-Lewis index = 0.99). Sex-related concerns partially mediated the association between stigma and comfort (ß = 0.55; ß = 0.14, both P < .001). Modification indices also supported total effects of social support on increased comfort discussing anal sex (ß = 0.35, P < .001) and, to a lesser degree, on decreased sex-related concerns (ß = -0.10; P < .001). CLINICAL IMPLICATIONS: Higher stigma toward anal sexuality is associated with less engagement in HIV prevention, largely due to discomfort discussing anal sex practices with health workers. STRENGTH & LIMITATIONS: Adjustment for mediation in a cross-sectional design cannot establish temporal causality. Self-report is vulnerable to social desirability and recall bias. Online samples may not represent cisgender MSM in general. However, findings place HIV- and health-related behaviors within a social and relational context and may suggest points for intervention in health-care settings. CONCLUSION: Providers' willingness to engage in discussion about anal sexuality, for example, by responding to questions related to sexual well-being, may function as social support and thereby bolster comfort and improve engagement in HIV prevention. Kutner BA, Simoni JM, King KM, et al. Does Stigma Toward Anal Sexuality Impede HIV Prevention Among Men Who Have Sex With Men in the United States? A Structural Equation Modeling Assessment. J Sex Med 2020;17:477-490.

Depression and anxiety among HIV-positive men who have sex with men and men who have sex with women in China.

China is experiencing an emerging HIV epidemic among men who have sex with men (MSM). Minority stress theory posits that marginalized populations experience additional stress, which influences experiences of psychological distress and health outcomes. This study aimed to understand psychological distress of MSM relative to men who have sex with women (MSW) in an urban Chinese setting. Cross-sectional survey data were collected from 162 HIV-positive Chinese men receiving HIV treatment at Beijing's Ditan Hospital. Multiple linear regression with imputation was used to identify correlates of psychological distress. Relative to MSW, MSM were younger, more educated, and less likely to be in a relationship or have children. While both groups reported clinically elevated levels of depression and anxiety, sexual behavior was not associated with either outcome. Higher endorsement of depression symptomology was associated with worse reported physical health (ß = -1.37, p < .05) and greater endorsement of maladaptive coping (ß = 2.39, p < .05), whereas higher endorsement of anxiety symptomology was associated with greater endorsement of adaptive coping (ß = 0.78, p < .05), diminished physical health (ß = -0.86, p < .05), and a high school or greater level of education (ß = 4.13, p < .05). These findings suggest that interventions targeting coping strategies may address psychological distress among HIV-positive Chinese men.

Alcohol Use and Antiretroviral Therapy Non-Adherence Among Adults Living with HIV/AIDS in Sub-Saharan Africa: A Systematic Review and Meta-Analysis.

Antiretroviral therapy (ART) is efficacious in improving clinical outcomes among people living with HIV (PLWH) and reducing HIV transmission when taken regularly. Research examining modifiable factors associated with ART non-adherence is critical for informing novel intervention development in settings with high HIV prevalence. Alcohol use has been linked with ART non-adherence in studies in sub-Saharan Africa; however, no review has pooled estimates across studies. We reviewed studies of alcohol use and ART non-adherence conducted in sub-Saharan Africa. We searched PubMed, CINAHL, EMBASE, and PsycINFO through August 2019 with terms related to ART non-adherence, alcohol use, and sub-Saharan Africa. One author reviewed titles/abstracts (n = 754) and two authors reviewed full texts (n = 308) for inclusion. Discrepancies were resolved by group consensus. Studies were retained if they quantitatively measured associations between alcohol use and ART non-adherence or viral non-suppression. We defined ART non-adherence using the definitions from each parent study (e.g., patients with > 5% missed ART doses during the previous four, seven or 30 days were considered non-adherent). A random effects meta-analysis was conducted to pool associations and we conducted additional analyses to assess between-study heterogeneity and publication bias and sensitivity analyses to determine robustness of our results when considering only certain study designs, alcohol use or ART scales, or studies that used viral non-suppression as their primary outcome. Of 56 articles meeting our inclusion criteria, 32 articles were included in the meta-analysis. All studies measured alcohol use via self-report. ART non-adherence was assessed using self-report, pill counts, or pharmacy records and definition of non-adherence varied depending on the measure used. Individuals who used alcohol had twice the odds of ART non-adherence compared with those who did not use alcohol (34% non-adherence among alcohol users vs. 18% among non-users; pooled odds ratio: 2.25; 95% confidence interval: 1.87-2.69; p < 0.001). We found evidence of a high degree of heterogeneity between studies (Cochrane Q statistic: 382.84, p< 0.001; I2 proportion: 91.9%) and evidence of publication bias. However, the magnitude of our pooled odds ratio was consistent across a number of sensitivity analyses to account for heterogeneity and publication bias. In a secondary analysis with studies using viral non-suppression as their primary outcome, we also estimated a statistically significant pooled effect of alcohol use on viral non-suppression (pooled odds ratio: 2.47; 95% confidence interval: 1.58-3.87). Evidence suggests alcohol use is associated with ART non-adherence in Sub-Saharan Africa, potentially hindering achievement of the UNAIDS 90-90-90 HIV treatment targets.

Iterative Development of an mHealth Intervention to Support Antiretroviral Therapy Initiation and Adherence Among Female Sex Workers in Mombasa, Kenya.

Nurses have an integral role to play in achieving the 95-95-95 goals to stem the HIV epidemic. We used the Information-Motivation-Behavioral Skills (IMB) theoretical model to develop a nurse-delivered, mHealth intervention to support antiretroviral therapy adherence among female sex workers living with HIV in Mombasa, Kenya. Twenty-three purposively sampled female sex workers living with HIV participated in 5 focus group discussions to iteratively develop the message content as well as the format and structure of the nurse-delivered, text-based intervention. Focus group discussion interview guides were developed in accordance with the IMB model. Transcripts were analyzed according to IMB themes, and findings were used to develop the intervention. Information-oriented texts addressed concerns and misconceptions; motivation-oriented texts reinforced women's desires to feel healthy enough to engage in activities; and behavioral skills-oriented texts included strategies to remember medication doses. The nurse-delivered, theory-based, culturally tailored intervention to support medication adherence was evaluated.

Beginning to envision a life worth living: An introduction to pretreatment sessions in dialectical behavior therapy.

The pretreatment phase in dialectical behavior therapy (DBT) sets the critical foundation for working with multiproblem, often highly suicidal clients. Despite the importance of this stage of treatment, very little has been written to aid DBT clinicians in navigating these early sessions most effectively. This article describes the functions and goals of pretreatment in DBT and research relevant to strategies employed in pretreatment. Additionally, a case example of a pretreatment session in DBT is provided, and challenges commonly encountered in pretreatment are discussed, along with recommendations for overcoming those challenges. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Health Behavior Theory to Enhance eHealth Intervention Research in HIV: Rationale and Review.

PURPOSE OF REVIEW: Optimal design and evaluation of eHealth interventions requires the specification of behavioral targets and hypothesized mechanisms of action-both of which can be enhanced with the use of established health behavior theories (HBTs). In this paper, we describe the major HBTs and examine their use in studies of eHealth interventions for HIV prevention and treatment and assess the contribution of HBT in developing and evaluating eHealth interventions. RECENT FINDINGS: Based on our review of the literature, we argue the field can benefit from more systematic selection, application, and reporting of HBT. We highlight theories specifically designed for eHealth and describe ways that HBT can be used by researchers and practitioners to improve the rigor and impact of eHealth interventions for individuals living with or at risk for HIV. This brief overview of HBTs and their application to eHealth intervention in HIV research has underscored the importance of a theoretically intentional approach. The theory should be used to inform the design of the eHealth intervention; the intervention should not determine the theory. A theory-driven iterative model of eHealth intervention development may not only improve our repertoire of effective strategies but also has the potential to expand our theoretical and empirical knowledge of health behavior change.

HIV Viral Suppression Trends Over Time Among HIV-Infected Patients Receiving Care in the United States, 1997 to 2015: A Cohort Study.

Background: Because HIV viral suppression is essential for optimal outcomes and prevention efforts, understanding trends and predictors is imperative to inform public health policy. Objective: To evaluate viral suppression trends in people living with HIV (PLWH), including the relationship of associated factors, such as demographic characteristics and integrase strand transfer inhibitor (ISTI) use. Design: Longitudinal observational cohort study. Setting: 8 HIV clinics across the United States. Participants: PLWH receiving clinical care. Measurements: To understand trends in viral suppression (≤400 copies/mL), annual viral suppression rates from 1997 to 2015 were determined. Analyses were repeated with tests limited to 1 random test per person per year and using inverse probability of censoring weights to address loss to follow-up. Joint longitudinal and survival models and linear mixed models of PLWH receiving antiretroviral therapy (ART) were used to examine associations between viral suppression or continuous viral load (VL) levels and demographic factors, substance use, adherence, and ISTI use. Results: Viral suppression increased from 32% in 1997 to 86% in 2015 on the basis of all tests among 31 930 PLWH. In adjusted analyses, being older (odds ratio [OR], 0.76 per decade [95% CI, 0.74 to 0.78]) and using an ISTI-based regimen (OR, 0.54 [CI, 0.51 to 0.57]) were associated with lower odds of having a detectable VL, and black race was associated with higher odds (OR, 1.68 [CI, 1.57 to 1.80]) (P < 0.001 for each). Similar patterns were seen with continuous VL levels; when analyses were limited to 2010 to 2015; and with adjustment for adherence, substance use, or depression. Limitation: Results are limited to PLWH receiving clinical care. Conclusion: HIV viral suppression rates have improved dramatically across the United States, which is likely partially attributable to improved ART, including ISTI-based regimens. However, disparities among younger and black PLWH merit attention. Primary Funding Source: National Institutes of Health.

Achieving Broad Participation in Congregational Health Surveys at African American and Latino Churches.

Congregation-based health program evaluations often rely on surveys, but little documentation is available regarding specific methods and challenges. Here we describe methods used to achieve acceptable response rates (73-79%) to a survey of HIV-related attitudes and behaviors in 2 African American and 3 Latino churches in high HIV prevalence communities in Los Angeles County. Survey participation was enhanced by: conducting survey sessions at church-based meetings (e.g., women's Bible study) and after worship services; employing diverse survey staff; providing participation incentives for pastors, church coordinators, and survey participants; and working collaboratively and respectfully with congregational leaders. Achieving broad participation in church-based surveys on sensitive health topics is feasible when done collaboratively with congregational leaders and with a flexible protocol, which permits tailoring survey approaches to cultural and organizational contexts and leverages available resources appropriately.

Process Evaluation of a Peer-Driven, HIV Stigma Reduction and HIV Testing Intervention in Latino and African American Churches.

Purpose: Faith-based organizations may be effective in addressing HIV-related disparities, but few interventions have been implemented across diverse churches. The Facilitating Awareness to Increase Testing for HIV (FAITH) intervention harnessed peer leadership to decrease HIV stigma and promote HIV testing in African American and Latino congregations. A pilot study found more consistent effects among Latino congregations. This process evaluation evaluates implementation of FAITH to better understand the pilot study's findings. Methods: Data sources included HIV education and peer leader workshop evaluation forms, participant views of the community's perspective of HIV, and peer leader follow-up interviews. Data were triangulated with systematic observation notes and analyzed using process-related themes of recruitment, reach, context, implementation, dose-delivered, and fidelity. Results: At the Latino churches (compared to the African American church), facilitators spent more time addressing community-based misconceptions about HIV. The peer leader model was well received, especially among Latino participants, and most said that after the workshop they felt comfortable speaking with others about HIV-related topics. Latino peer leaders reported speaking with up to 20 people within their social networks (particularly with family members); African Americans reported up to 4. Implementation challenges at the African American church may have contributed to the limited intervention effects. Nevertheless, we found the peer motivator model feasible and acceptable across diverse faith settings. Conclusion: Peer-based models within faith settings are promising for addressing HIV. However, differences among groups in HIV knowledge, social network characteristics and norms, and church preferences may influence overall effectiveness.

An Exploratory Study of HIV Risk Behaviors and Testing among Male Sex Workers in Beirut, Lebanon.

Male sex workers (MSW) are a particularly high-risk subset of men who have sex with men in Lebanon and report higher numbers of sex partners and lower rates of condom use. The purpose was to explore the factors influencing sexual risk behaviors and HIV testing among MSW. Qualitative interviews were conducted with 16 MSW living in Beirut and working in bathhouses (hammam) or as escorts; content analysis identified emergent themes. Escorts reported more consistent condom use with clients and HIV testing than hammam MSW, with influential factors including HIV risk knowledge and perceived risk susceptibility, job security, and internalized stigma and related feelings of self-worth and fatalism regarding health and HIV risk. In contrast, both groups of MSW typically opted not to condoms with nonclient sex partners, in an effort to differentiate sex for work versus pleasure. The uptake of HIV testing was limited by concerns about the confidentiality of the test results and fear of repercussions of a positive test result for their health and employment. The respondents described an insular existence within the sex work culture, in part to limit exposure to stigma, which has implications for access to support as well as the influence of peer norms regarding sexual risk behavior and health seeking behaviors such as HIV testing. Further research is needed to tailor prevention and HIV testing efforts to reflect the distinct sexual health "cultures" that distinguish these two populations of MSW in Lebanon.