Transactional sex among adults accessing sexual health services in Alabama, 2008-2022: Prevalence, associated risk factors, and associations with HIV, HCV, and STI diagnosis.

BACKGROUND: The U.S. Deep South bears a disproportionate burden of HIV and other STIs. Transactional sex may influence these epidemics, but few studies have estimated its prevalence or correlates in the Deep South. METHODS: We estimated the history of transactional sex among adults accessing an Alabama AIDS Service Organization from 2008-2022, using chi-square tests to examine its sociodemographic and behavioral correlates. We used modified Poisson regression with cluster-robust standard errors to estimate adjusted prevalence ratios (aPR) and 95 % confidence intervals (CI) for the associations between transactional sex and new HIV, hepatitis C (HCV), and STI diagnoses. RESULTS: Transactional sex was reported at 944/20,013 visits (4.7 %) and associated with older age, being a cisgender woman or gender minority, identifying as white, diverse drug use, and sharing of drug equipment. Compared to others, clients reporting transactional sex had increased prevalence of syphilis (apR 3.60, 95 % CI 1.16-11.19) and HCV (aPR 1.53, 95 % CI 1.24-1.88). CONCLUSION: Using 14 years of community-based data, this study is the first to estimate the relationship between transactional sex and HIV, HCV, and STIs in Alabama and highlights the need address STI burden and diverse drug use among people who transact sex in the Deep South.

Exploring differences in perceptions of gentrification, neighborhood satisfaction, social cohesion, and health among residents of two predominantly African American Pittsburgh neighborhoods (n = 60).

BACKGROUND: Gentrification often leads to changes in the social and physical environment of neighborhoods, which social capital theory has found are connected to aspects of resident health and wellbeing. A growing body of literature has explored the impact of gentrification on health and wellbeing of residents. The goal of this study is to qualitatively explore the ways in which gentrification may have impacted perceptions of neighborhood satisfaction, social cohesion, and health of neighborhood residents (n = 60) from two predominantly Black neighborhoods in Pittsburgh, Pennsylvania, one of which experienced Black gentrification during the study's time period. This analysis is unique in its ability to capture experiences of residents who remained in their neighborhood throughout the course of the study, as well as those who moved away from their neighborhood. METHODS: Participants were randomly selected from a larger cohort enrolled in a quasi-experimental study and categorized by whether they lived in a census tract that gentrified, whether they owned or rented their home, and whether they moved from the neighborhood or remained in the same place of residence between 2011 and 2018. Phone interviews lasting approximately 30 min were conducted with participants and were audio recorded and transcribed verbatim. Participants were provided a $40 gift card for their time. Interview data were analyzed using a directed content approach, and Cohen's Kappa was obtained (k = 0.924) to signal good inter-rater reliability. RESULTS: Results showed renters in gentrified census tracts overwhelmingly viewed gentrification trends as a negative change compared to homeowners. Overall, participants from gentrified census tracts reported being relatively satisfied with their neighborhood, though some suggested there were fewer resources in the neighborhood over time; felt their social cohesion had deteriorated over time; and more commonly reflected negative health changes over time. CONCLUSIONS: These findings suggest that while gentrification can bring much needed improvements to neighborhoods, it can also bring other disruptive changes that affect the health and wellbeing of existing residents.

Discrimination and adherence in a cross-sectional study of Latino sexual minority men with HIV: Coping with discrimination as a mediator and coping self-efficacy as a moderator.

Discrimination is associated with antiretroviral therapy non-adherence and reduced well-being among people with HIV. We examined the potential for coping to mediate the associations between intersectional discrimination and non-adherence and coping self-efficacy (confidence in one's ability to cope with discrimination) as a moderator that may buffer the negative effects of discrimination on non-adherence in a cross-sectional convenience sample of 82 Latino sexual minority men with HIV. In bivariate linear regressions, discrimination targeting Latino ethnic origin, undocumented residency status, and sexual orientation were each significantly associated with lower self-reported antiretroviral therapy non-adherence (percentage of prescribed doses taken in the last month) and greater use of disengagement coping (denial, substance use, venting, self-blame, behavioral disengagement). Associations between discrimination targeting Latino ethnicity and non-adherence, and discrimination targeting undocumented residency status and non-adherence, were each mediated by disengagement coping responses. Moderation analyses highlighted significant discrimination by coping self-efficacy interaction effects-both coping self-efficacy for problem solving and stopping unpleasant emotions/thoughts each moderated the associations between Latino discrimination and adherence, between undocumented residency status discrimination and adherence, and between HIV discrimination and adherence. Coping self-efficacy for getting social support moderated the association between undocumented residency status discrimination and adherence. Further, the interaction coefficients across models indicated that the negative effects of discrimination on adherence were attenuated at higher levels of coping self-efficacy. Findings highlight the need for structural interventions that reduce-and ultimately eliminate-discrimination, and interventions that address the harmful effects of discrimination and adherence improvement interventions to enhance coping skills among people faced with intersectional discrimination.

Refining United States Sexual Minority Adult Population Estimates with the Inclusion of "Something Else" and "Don't Know" Survey Responses.

Purpose: To refine estimates of the U.S. sexual minority population, we sought to characterize trends in the odds of respondents selecting "something else" or "don't know" when asked about sexual orientation on the National Health Interview Survey and to reclassify those respondents likely to be sexual minority adults. Methods: Logistic regression was conducted to test whether the odds of selecting "something else" or "don't know" increased over time. A previously established analytic approach was used to identify sexual minority adults among these respondents. Results: Between 2013 and 2018, the percentage of respondents selecting "something else" or "don't know" increased 2.7-fold, from 0.54% to 1.44%. Reclassifying respondents with >50% predicted probabilities of being sexual minorities increased sexual minority population estimates by as much as 20.2%. Conclusion: A growing proportion of adults are selecting "something else" or "don't know." Properly classifying these responses yields more accurate sexual minority population estimates.

Assessing behavioral economic biases among young adults who have increased likelihood of acquiring HIV: a mixed methods study in Baltimore, Maryland.

BACKGROUND: Behavioral economic (BE) biases have been studied in the context of numerous health conditions, yet are understudied in the field of HIV prevention. This aim of this study was to quantify the prevalence of four common BE biases-present bias, information salience, overoptimism, and loss aversion-relating to condom use and HIV testing in economically-vulnerable young adults who had increased likelihood of acquiring HIV. We also qualitatively examined participants' perceptions of these biases. METHODS: 43 participants were enrolled in the study. Data were collected via interviews using a quantitative survey instrument embedded with qualitative questions to characterize responses. Interviews were transcribed and analyzed using descriptive statistics and deductive-inductive content analyses. RESULTS: 56% of participants were present-biased, disproportionately discounting future rewards for smaller immediate rewards. 51% stated they were more likely to spend than save given financial need. Present-bias relating to condom use was lower with 28% reporting they would engage in condomless sex rather than wait one day to access condoms. Most participants (72%) were willing to wait for condom-supported sex given the risk. Only 35% knew someone living with HIV, but 67% knew someone who had taken an HIV test, and 74% said they often think about preventing HIV (e.g., high salience). Yet, 47% reported optimistically planning for condom use, HIV discussions with partners, or testing but failing to stick to their decision. Most (98%) were also averse (b = 9.4, SD ±.9) to losing their HIV-negative status. Qualitative reasons for sub-optimal condom or testing choices were having already waited to find a sex partner, feeling awkward, having fear, or not remembering one's plan in the moment. Optimal decisions were attributed qualitatively to self-protective thoughts, establishing routine care, standing on one's own, and thinking of someone adversely impacted by HIV. 44% of participants preferred delayed monetary awards (e.g., future-biased), attributed qualitatively to fears of spending immediate money unwisely or needing time to plan. CONCLUSION: Mixed methods BE assessments may be a valuable tool in understanding factors contributing to optimal and sub-optimal HIV prevention decisions. Future HIV prevention interventions may benefit from integrating savings products, loss framing, commitment contracts, cues, or incentives.

Food Insecurity During the COVID-19 Pandemic: A Longitudinal Mixed-Methods Study from a Cohort of HIV Clients in Uganda.

The COVID-19 pandemic threatens the food security of people in low-income countries. This is important for people living with HIV (PLWH) because HIV medication should be taken with food to avoid side-effects. We used survey data (n = 314) and qualitative interviews (n = 95) to longitudinally explore how the pandemic impacted food insecurity among PLWH in Kampala, Uganda. Prior to March 2020, 19.7% of respondents were food insecure. Our regression models estimate that food insecurity rose by 9.1 percentage points in our first round of surveys (June-September 2020; p < 0.05; t = 2.17), increasing to 17.2 percentage points in the second round of surveys (July-November 2021; p < 0.05; t = 2.32). Qualitative interviews reveal that employment loss and deteriorating support systems led to reduced meals and purchasing of cheaper foods. Respondents reported continuing to take their HIV medication even in the presence of food insecurity. Strategies for ensuring that PLWH have enough food should be prioritized so that the millions of PLWH in sub-Saharan Africa can take their medication without experiencing uncomfortable side-effects.Clinical Trials Registration Number NCT03494777.

A qualitative exploration of health-related present bias among HIV-positive adults in Uganda.

Decision-making errors such as present bias (PB) can have important consequences for health behaviors, but have been largely studied in the financial domain. We conducted a mixed-method study on PB in the context of ART adherence among clinic-enrolled adults in Uganda (n = 39). Specifically, we quantified PB by asking about preferences between medication available sooner to minimize headaches versus available later to cure headaches. We describe demographic similarities among PB participants and qualitatively explored how participants reflected on their PB (or absence thereof) in the context of health. Participants reporting PB were predominantly male, single/unmarried, older, had higher levels of education and income and more advanced HIV progression. Three common reasons for more present-biased choices provided were: (1) wanting to avoid pain, (2) wanting to return to work, and (3) fear of one's health worsening if s/he did not address their illness immediately. While PB in the financial domain often suggests that poorer individuals are more likely to prefer immediate rewards over their wealthier counterparts, our results suggest poor health is potentially a driving factor of PB. Further research is needed to build on these finding and inform how programs can frame key messages regarding ART adherence to patients displaying PB.Trial registration: ClinicalTrials.gov identifier: NCT03494777.

Rural disparities in the quality of clinical care are notable and larger for males.

PURPOSE: To investigate whether rural-urban differences in quality of care for Medicare Advantage (MA) enrollees vary between females and males. METHODS: Data for this study came from the 2019 Healthcare Effectiveness Data and Information Set. Linear regression was used to investigate urban-rural differences in individual MA enrollee scores on 34 clinical care measures grouped into 7 categories, and how those differences varied by sex (through evaluation of statistical interactions). FINDINGS: Across all 7 categories of measures, scores for rural residents were worse than scores for urban residents. For 4 categories-care for patients with (suspected) chronic obstructive pulmonary disease, avoiding prescription misuse, behavioral health, and diabetes care-the average difference across measures in the category was greater than 3 percentage points. Across all 34 measures, there were 15 statistically significant rural-by-sex interactions that exceeded 1 percentage point. In 11 of those cases, the deficit associated with living in a rural area was greater for males than for females. In 3 cases, the deficit associated with living in a rural area was larger for females than for males. In 1 case involving Follow-up After Hospitalization for Mental Illness, rural residents had an advantage, and it was larger for males than for females. CONCLUSIONS: Interventions may help address patient- (eg, health literacy and patient activation), provider- (eg, workforce recruitment and retention), and structural-level issues contributing to these disparities, especially for rural males.

HIV prevalence among transgender women in Northeast Brazil - Findings from two Respondent Driven Sampling studies.

BACKGROUND: The HIV epidemic still high among key-populations in Brazil, especially among transgender women (TGW). The aim of this study was to investigate the prevalence of HIV infection among TGW and to analyze factors associated with HIV seropositivity across two cross-sectional surveys conducted in Salvador, Bahia, one of the largest urban centers of Brazil. METHODS: The studies were conducted between 2014 and 2016 and 2016-2017 and employed Respondent-Driven Sampling (RDS) sampling, comprising 127 and 161 TGW residents of Salvador, Bahia. The outcome was the positive rapid antigen testing for HIV infection. Odds ratios (OR) and 95% confidence intervals (95%CI) were obtained using binomial logistic regression. RESULTS: The HIV prevalence was 9.0% (95%CI: 4.2-18.2) and 24.3% (95%CI: 16.2-34.9). In the first study, factors associated with HIV prevalence were experiencing discrimination by the family (OR 8.22; 95%CI: 1.49-45.48) and by neighbors (OR 6.55; 95%CI: 1.12-38.14) as well as having syphilis (OR 6.56; 95%CI:1.11-38.65); in the subsequent study gender-based discrimination (OR 8.65; 95%CI:1.45-51.59) and having syphilis (OR 3.13; 95%CI: 1.45-51.59) were associated with testing positive for HIV. CONCLUSION: We found disproportionately high HIV prevalence among TGW, which underscores the context of vulnerability for this population. The data point to the urgency for intensification and expansion of access to HIV prevention and strategies to stop discrimination in health care and services for this population.

Sex differences in Medicare beneficiaries' experiences by low-income status.

OBJECTIVES: Medicare beneficiaries dually eligible for Medicaid are a low-income group who are often in poor health. Little research has examined sex differences in patient experience by dual/low-income subsidy (LIS) status. STUDY DESIGN: Cross-sectional comparison by sex and low-income status. METHODS: We used linear regression to compare 6 case mix-adjusted patient experience measures (on a 0-100 scale) by sex within non-dual/LIS and dual/LIS beneficiary groups among 549,603 respondents 65 years and older to the 2016-2017 Medicare Consumer Assessment of Healthcare Providers and Systems surveys of beneficiary experience with Medicare (mail with telephone follow-up of nonrespondents, 42% response rate). RESULTS: Dual/LIS male beneficiaries reported worse patient experiences on all 6 measures than female beneficiaries, with scores 1 to 2 percentage points lower for 3 measures and less than 1 percentage point lower for the other 3 measures. For 4 of the 6 measures, sex differences among dual/LIS beneficiaries were significantly larger than those among non-dual/LIS beneficiaries. In all 4 instances, the gaps between men and women among dual/LIS beneficiaries favored women; P < .05 for all differences discussed. CONCLUSIONS: Low-income male Medicare beneficiaries are more likely to report poor patient experiences, possibly because of lower health literacy, less patient activation, and smaller social networks, along with provider responses to these characteristics. Efforts to address these patient-level factors should happen in parallel with structural-level approaches to train and prepare providers to ensure attentive, respectful patient-centered care for all patients. Additionally, targeted use of ombudsmen and interventions may help reduce inequities.

"The one who doesn't take ART medication has no wealth at all and no purpose on Earth" - a qualitative assessment of how HIV-positive adults in Uganda understand the health and wealth-related benefits of ART.

BACKGROUND: Increases in life expectancy from antiretroviral therapy (ART) may influence future health and wealth among people living with HIV (PLWH). What remains unknown is how PLWH in care perceive the benefits of ART adherence, particularly in terms of improving health and wealth in the short and long-term at the individual, household, and structural levels. Understanding future-oriented attitudes towards ART may help policymakers tailor care and treatment programs with both short and long-term-term health benefits in mind, to improve HIV-related outcomes for PLWH. METHODS: In this qualitative study, we conducted semi-structured interviews among a subsample of 40 PLWH in care at a clinic in Uganda participating in a randomized clinical trial for treatment adherence in Uganda (clinicaltrials.gov: NCT03494777). Interviews were transcribed verbatim and translated from Luganda into English. Two co-authors independently reviewed transcripts, developed a detailed codebook, achieved 93% agreement on double-coded interviews, and analyzed data using inductive and deductive content analysis. Applying the social-ecological framework at the individual, household, and structural levels, we examined how PLWH perceived health and wealth-related benefits to ART. RESULTS: Our findings revealed several benefits of ART expressed by PLWH, going beyond the short-term health benefits to also include long-term economic benefits. Such benefits largely focused on the ability of PLWH to live longer and be physically and mentally healthy, while also fulfilling responsibilities at the individual level pertaining to themselves (especially in terms of positive long-term habits and motivation to work harder), at the household level pertaining to others (such as improved relations with family and friends), and at the structural level pertaining to society (in terms of reduced stigma, increased comfort in disclosure, and higher levels of civic responsibility). CONCLUSIONS: PLWH consider short and long-term health benefits of ART. Programming designed to shape ART uptake and increase adherence should emphasize the broader benefits of ART at various levels. Having such benefits directly integrated into the design of clinic-based HIV interventions can be useful especially for PLWH who face competing interests to increase medication adherence. These benefits can ultimately help providers and policymakers better understand PLWH's decision-making as it relates to improving ART-related outcomes.

Special considerations for evaluating psilocybin-facilitated psychotherapy in vulnerable populations.

Psilocybin-facilitated psychotherapy shows potential transdiagnostic efficacy for a range of mental health conditions. Though vulnerable populations bear disproportionate mental health burden, they have been largely neglected in the clinical psilocybin literature. However, if the field is to best respond to the diverse needs of individuals from vulnerable populations, care must be taken to ensure these individuals are represented in the empirical research. This report calls attention to this concern by detailing the challenges and opportunities associated with evaluating psilocybin-facilitated psychotherapy in vulnerable populations. First, we show how working with vulnerable populations must be considered in the context of an often-problematic past and differential exposure to and experience with classic psychedelics. We then provide actionable recommendations for future research testing psilocybin-facilitated psychotherapy in vulnerable populations, including an emphasis on recruitment strategies, the appropriate communication and assessment of subjective effects, building therapeutic alliance, multicultural competence, and flexible study designs. On these premises we call for future work in this area, underscoring that there is vast room for improvement and expansion in this rapidly advancing field of study.

Implementation of South Africa's Central Chronic Medicine Dispensing and Distribution Program for HIV Treatment: A Qualitative Evaluation.

We used the Practical, Robust Implementation and Sustainability Model to evaluate implementation of South Africa's Central Chronic Medicine Dispensing and Distribution (CCMDD) program, a differentiated service delivery program which allows clinically stable HIV-positive patients to receive antiretroviral therapy refills at clinic- or community-based pick-up points. Across ten clinics, we conducted 109 semi-structured interviews with stakeholders (pick-up point staff, CCMDD service providers and administrators) and 16 focus groups with 138 patients. Participants had highly favorable attitudes and said CCMDD decreased stigma concerns. Patient-level barriers included inadequate education about CCMDD and inability to get refills on designated dates. Organizational-level barriers included challenges with communication and transportation, errors in medication packaging and tracking, rigid CCMDD rules, and inadequate infrastructure. Recommendations included: (1) provide patient education and improve communication around refills (at the patient level); (2) provide dedicated space and staff, and ongoing training (at the organizational/clinic level); and (3) allow for prescription renewal at pick-up points and less frequent refills, and provide feedback to clinics (at the CCMDD program level).

Increased Depression during COVID-19 Lockdown Associated with Food Insecurity and Antiretroviral Non-Adherence among People Living with HIV in Uganda.

The health and economic threats posed by the COVID-19 pandemic can be sources of great distress among people living with HIV, which in turn can impact the management of their HIV disease. We examined change in depression from pre- to post-lockdown restrictions and correlates of elevated depressive symptoms, including antiretroviral therapy (ART) adherence. Participants enrolled in a randomized controlled trial of an ART adherence intervention in Uganda. The month-12 follow-up assessment was fully administered just prior to the start of the pandemic-related lockdown in March 2020; at the conclusion of the lockdown three months later, we administered a mixed-methods phone-based assessment. ART adherence was electronically monitored throughout the study period, including during and after the lockdown. Depression was assessed with the 8-item Patient health questionnaire (PHQ-8), on which scores > 9 signify a positive screen for elevated depressive symptoms. A sample of 280 participants completed both the month-12 and post-lockdown assessments. Rates of elevated depressive symptoms nearly tripled from month 12 (n = 17, 6.1%) to the post-lockdown assessment (n = 50, 17.9%; McNemar test < .001). Elevated depressive symptoms at post-lockdown were associated with being female, indicators of economic struggles at month 12 (unemployment, low income, high food insecurity), and lower ART adherence during the 3-month lockdown period [mean of 71.9% (SD = 27.9) vs. 80.8% (SD = 24.1) among those not depressed; p = .041] in bivariate analysis. In multiple regression analysis, higher food insecurity [adj. OR (95% CI) = 4.64 (2.16-9.96)] and perception that the pandemic negatively impacted ART adherence [adj. OR (95% CI) = 1.96 (1.22-3.16)] remained associated with a greater likelihood of elevated depressive symptoms, when other correlates were controlled for. Qualitative data suggested that economic stressors (lack of food, work, and money) were key contributors to elevated depressive symptoms, and these stressors led to missed ART doses because of lack of food and stress induced forgetfulness. Elevated depressive symptoms significantly increased during the COVID-19 lockdown and was associated with food insecurity and reduced ART adherence. Mechanisms for identifying and treating depression and food insecurity are needed to help PLHIV cope with and mitigate the harmful effects of unexpected crises that may impede disease management and access to food.

Sexual Minority Adults in England Have Greater Odds of Chronic Mental Health Problems: Variation by Sexual Orientation, Age, Ethnicity, and Socioeconomic Status.

Purpose: Sexual minority adults report worse mental health than heterosexual peers, although few empirical studies are large enough to measure variation in these disparities by sexual orientation, age, ethnicity, and socioeconomic status (SES). We investigate chronic mental health problems among sexual minority adults. Methods: Sex-disaggregated logistic regressions examined associations between self-reported chronic mental health problems and sexual orientation, age, ethnicity, and SES in a 2015-2017 dataset from the nationally representative English General Practice Patient Survey data (n = 1,341,339). Results: Bisexual adults, especially young bisexual females, reported the highest rates of chronic mental health problems. Sexual minority females 18-24 years of age had five times the odds of reporting chronic mental health problems of their heterosexual peers, with 32% of sexual minority females 18-24 years of age reporting the outcome. Sexual minority identity was also strongly associated with chronic mental health problems for adults who were White and lived in more affluent areas. Conclusion: The very high odds of chronic mental health problems among bisexual adults, especially younger bisexual females, may reflect simultaneous isolation from sexual minority and heterosexual communities. Elevated odds at younger ages may reflect disproportionate social media use and bullying. It is plausible that those who are subject to minority stress associated with SES and ethnicity may develop resilience strategies that they then apply to sexual minority stress. The results suggest that sexual minority identity is a source of minority stress, even for those who are affluent. Clinicians should be alert to the need to support the specific mental health concerns of their sexual minority patients.

Long-term conditions among sexual minority adults in England: evidence from a cross-sectional analysis of responses to the English GP Patient Survey.

BACKGROUND: Epidemiological evidence for specific long-term conditions is required to inform best practices regarding the substantial health inequalities experienced by sexual minority individuals compared with heterosexual peers. AIM: To describe inequalities in long-term conditions among sexual minority (lesbian, gay, and bisexual [LGB]) adults. DESIGN & SETTING: Cross-sectional analysis of 1 341 339 nationally representative survey responses from the English GP Patient Survey (GPPS). METHOD: Stratifying by sex, the weighted prevalence and covariate-adjusted association of 15 long-term conditions were calculated, comparing sexual minority and heterosexual adults, considering variation by sexual orientation and variation in sexual orientation inequalities by deprivation, ethnic group, region, and age. RESULTS: After adjusting for deprivation, ethnic group, region, and age, 13 long-term conditions (all except cancer and hypertension) were more prevalent among sexual minority women than their heterosexual peers, with the largest inequalities for mental health problems (odds ratio [OR] 2.8, 95% confidence interval [CI] = 2.7 to 3.0), neurological conditions (OR 1.7, 95% CI = 1.5 to 1.8), dementia (OR 1.6, 95% CI = 1.3 to 1.9), and back problems (OR 1.4, 95% CI = 1.3 to 1.5). It was found that nine long-term conditions were also more prevalent among sexual minority men including mental health problems (OR 2.3, 95% CI = 2.2 to 2.4), 'all other conditions' (OR 1.8, 95% CI = 1.7 to 1.8), neurological conditions (OR 1.5, 95% CI = 1.4 to 1.6), and kidney or liver disease (OR 1.4, 95% CI = 1.3 to 1.5); inequalities were often largest for bisexual adults. Inequalities did not vary significantly by deprivation, ethnic group, or region except for mental health problems. Inequalities in multimorbidity were highest at younger ages; for example, LGB women aged 18-24 years had multimorbidity at the same level (approximately 20%) as heterosexual women aged 45-54 years. CONCLUSION: Sexual minority adults, especially bisexual adults, are at elevated risk for many long-term conditions and multimorbidity; this risk spans socioeconomic status and ethnic group, representing a significant healthcare challenge.

Inter-Group and Intraminority-Group Discrimination Experiences and the Coping Responses of Latino Sexual Minority Men Living With HIV.

Discrimination negatively impacts the health of HIV-positive Latino sexual minority men (LSMM+). A growing literature on LSMM+ chronicles associations based on multiple devalued identities and mental health symptoms, HIV medication nonadherence, and sexual behaviors with the potential to transmit HIV. To gain additional insights on identity-based discrimination-as well as the associated coping responses-we conducted 30 qualitative interviews with LSMM+.Participantswereprobedregardingrecentdiscriminationevents(context,details,perpetrator, type) based on their intersecting identities (Latinx ethnicity, residency status, sexual minority orientation, HIV-positive serostatus) and their coping responses. We transcribed and translated the interviews and conducted a content analysis. Participants reported inter-group (i.e., between majority and minority group members) and intraminority-group (i.e., within minority group members) experiences as common. Participants described their intraminority-group experiences with discrimination based on being a Latinx sexual minority person in their families and home communities. Participants reported a range of coping responses to discrimination experiences. However, participants reported only functional (and no dysfunctional) coping strategies, and they endorsed using similar strategies in response to inter-group and intraminority-group discrimination. Coping strategies included strategic avoidance, social support, self-advocacy, and external attribution. Additional coping strategies (spirituality and positive reframing) emerged more strongly in response to inter-group experiences with discrimination. Our results underscore the need to address both inter-group and intraminority-group discrimination experiences. Future interventions can focus on strengthening the effective coping skills that LSMM+ currently employ as potential levers to address LSMM+ health disparities.

Culturally Competent Clinical Care for Older Sexual Minority Adults: A Scoping Review of the Literature.

STUDY OBJECTIVE: As recent efforts to improve culturally competent clinical care (CCCC) have largely overlooked older LGB adults, we conducted a scoping review of position statements, empirical, and non-empirical research and suggest action steps. METHODS: We followed PRISMA Extension for Scoping Reviews Guidelines and searched for articles 1/1/11-3/14/19 (n = 1210) and other resources (n = 52), deduplicating, dually screening abstracts (n = 1,156), reviewing full-text (n = 107), and conducted a content analysis to identify distinct and cross-cutting domains (n = 44). MAIN FINDINGS: Most research was based on simple pre/post-training differences in provider knowledge. A majority of sources were non-empirical. We identified three distinct domains (education & staffing, physical environment, and inclusive language & communication) and three cross-cutting domains (subgroup differences, research, and policy). PRINCIPAL CONCLUSIONS: Sparse empirical data that specify best approaches to improve CCCC exist; nevertheless, providers, in collaboration with researchers and policy makers, can initiate improved practices aimed at increasing CCCC for older LGB patients.