Substance Use Stigma Among Clinical and Nonclinical Staff Who Provide Care for People With HIV in the Deep South: A Pilot Training Intervention.

ABSTRACT: Substance use stigma is a barrier to care among people with HIV (PWH), which is exacerbated in the Deep U.S. South. Nurses and nonclinical staff serve a central role in strengthening and expanding care coordination in clinics that serve PWH. We sought to implement and evaluate a pilot training intervention that aimed to reduce substance use stigma among clinical and nonclinical staff who provide care for PWH in the Deep South. In total, 32 clinical and nonclinical staff from five clinics participated in the training, of whom 22% were nurses and 38% were linkage coordinators. We evaluated the association between the intervention and stigma by asking respondents about their agreement with varying levels of stigmatized statements both before and after the training. Overall, we observed a slight reduction in stigma scores. This training has promise as one low-burden approach to substance use stigma reduction in HIV care settings.

Exploring Symptom Management Experiences Among College Students With Type 1 Diabetes Mellitus Using a Theoretical Framework: A Qualitative Study.

PURPOSE: The purpose of this study was to explore symptom management experiences among college students with type 1 diabetes mellitus (T1DM). Limited qualitative data using a theoretical framework exist that explore the self-care behavior processes for symptom management. METHODS: A qualitative approach was used for this study. The middle-range theory of self care of chronic illness served as a framework for data collection and analysis procedures. Data collection included distributing a survey to collect participants' demographic and sociodemographic data and utilizing a semi-structured interview guide to conduct one-on-one interviews with 31 participants. Interviews occurred via Zoom (n = 28) and in person (n = 3). Interview transcripts were uploaded in NVivo for data management. The research team created a codebook using theoretical constructs to assist with thematic analysis. Data are representative of a sample whose characteristics include undergraduate students ages 18 to 23 living with T1DM for 2 years or more who attended large, public, 4-year universities located in the southeastern United States. RESULTS: Three main themes were created using theoretical constructs: symptom detection experiences, symptom interpretation experiences, and symptom response experiences. Two subthemes were identified for each theme. Participants engaged in symptom management for blood glucose regulation through detecting changes in their blood glucose physiologically and via technology. Additionally, symptom interpretation involved analyzing blood glucose trends and determining common causes of blood glucose changes. Symptom response included immediately addressing hypoglycemia but delayed responses addressing hyperglycemia. CONCLUSIONS: Challenges were present responding to hypoglycemia; therefore, additional research is warranted to improve symptom response skills.

Barriers and Facilitators Impacting Disease and Symptom Management Among College Students With Type 1 Diabetes: A Qualitative Study.

PURPOSE: This study aimed to explore barriers and facilitators impacting disease and symptom management among college students living with Type 1 Diabetes (T1D). DESIGN: A qualitative, phenomenological approach using semi-structured, one-on-one interviews. SETTING: Interviews conducted on Zoom (n = 28) and in-person (n = 3). PARTICIPANTS: Purposive sample of 31 college students living with T1D for at least 2 years who attended large, 4-year public universities in the Southeastern United States. METHOD: This study was theoretically informed using the Middle-Range Theory of Self-Care of Chronic Illness Integration of Symptoms to develop interview questions. Interviews were transcribed verbatim and uploaded in NVivo. Data were analyzed thematically using a codebook developed by the research team using the theory as a framework. Trustworthiness was established using an audit trail, memos, and negative case analysis. RESULTS: Four themes described barriers: diabetes burnout, challenges adjusting to a college lifestyle, difficulty receiving medical supplies, and insurance limitations. Five themes explained facilitators: years of experience managing T1D, tangible support with medical supplies, informational support for disease management, and emotional/technological support for disease and symptom management. CONCLUSION: Barriers and facilitators in this study should be addressed in future T1D interventions for college students. Findings can also guide healthcare professionals, health promotion practitioners, family, friends, and significant others on how to better support college students as they manage T1D.

Lack of Informed and Affirming Healthcare for Sexual Minority Men: A Call for Patient-Centered Care.

BACKGROUND: Sexual minority men (SMM) face severe health inequities alongside negative experiences that drive avoidance of medical care. Understanding how SMM experience healthcare is paramount to improving this population's health. Patient-centered care, which emphasizes mutual respect and collaboration between patients and providers, may alleviate the disparaging effects of the homophobia that SMM face in healthcare settings. OBJECTIVE: To explore how SMM perceive their experiences with healthcare providers and how care can most effectively meet their needs. DESIGN: Semi-structured qualitative interviews focused on healthcare experiences, pre-exposure prophylaxis (PrEP), and HIV-related beliefs were conducted between July and November 2018. PARTICIPANTS: The study included a sample of 43 young adult SMM (ages 25-27), representing diverse socioeconomic, racial, and ethnic backgrounds, in New York City. APPROACH: Researchers utilized a multiphase, systematic coding method to identify salient themes in the interview transcripts. KEY RESULTS: Analyses revealed three main themes: (1) SMM perceived that their clinicians often lack adequate skills and knowledge required to provide care that considers participants' identities and behaviors; (2) SMM desired patient-centered care as a way to regain agency and actively participate in making decisions about their health; and (3) SMM felt that patient-centered care was more common with providers who were LGBTQ-affirming, including many who felt that this was especially true for LGBTQ-identified providers. CONCLUSIONS: SMM expressed a clear and strong desire for patient-centered approaches to care, often informed by experiences with healthcare providers who were unable to adequately meet their needs. However, widespread adoption of patient-centered care will require improving education and training for clinicians, with a focus on LGBTQ-specific clinical care and cultural humility. Through centering patients' preferences and experiences in the construction of care, patient-centered care can reduce health inequities among SMM and empower healthcare utilization in a population burdened by historic and ongoing stigmatization.

Opioid misuse among people with HIV: results from the National Survey on Drug Use and Health (NSDUH) 2015-2019.

Aim: Pain is a major challenge in the management of HIV/AIDS. This research analyzed the prevalence of substance use and opioid misuse among people with HIV (PWH) and those without (PWoH) in the USA. Methods: Using data from the 2015-2019 National Survey on Drug Use and Health, the study assessed misuse of pain relievers and opioids in 279,025 individuals. Results: PWH were about 1.88-times more likely to misuse pain relievers and 1.85-times to misuse opioids than PWoH, with a notable rise in hydrocodone and tramadol misuse. Conclusion: The data highlights an imperative for interventions targeting substance misuse among PWH, addressing the complex nexus of HIV, chronic pain and opioid use.

Coping among Black college women: A transformative study of gendered racism.

Black women in the United States are placed at higher risk for mental health challenges, including distress and depression, due to structural inequities. Black college women enrolled in predominantly White institutions may be particularly exposed to stressors related to gendered racism, but there is limited knowledge about this population's coping strategies. A cross-sectional survey and focus group were utilized to understand and disrupt participants' experiences of gendered racism. In phase one, a survey assessing coping strategies and mental health outcomes was conducted with 168 Black women enrolled at a predominantly White institution in the southeastern United States. Logistic regression results indicated that several coping strategies including behavioral disengagement, self-blame, self-distraction, denial, and positive reframing were significantly associated with depression and psychological distress, all p < 0.05. Phase two included a single focus group with a subset of the sample from phase one. The focus group findings supplemented the survey results, suggesting education (more accurately consciousness-raising) as a foundational theme that seemed to create space for humor and social support as coping subthemes and created a transformative space where participants spoke openly about gendered racism. Findings from this study highlight the societal underpinnings that shape Black college women's experiences of gendered racism. College settings should endeavor to provide formal and informal support for Black women to minimize the harms related to gendered racism.

Challenges to Providing Integrated HIV Prevention in Substance Use Treatment Settings: Frontline Staff Perspectives on HIV and Sex-Related, Education, Communication and Stigma.

INTRODUCTION: Substance use treatment settings can play a critical role in ending the HIV epidemic. Community-based methadone clinics are potentially useful sites to offer biomedical HIV prevention, but little is known about how clinicians and other clinic staff communicate with patients about sexual behavior and HIV-related topics. METHODS: Thirty semi-structured interviews were conducted at two methadone clinics in Northern New Jersey. Participants included medical providers (physicians, RNs, DNPs), methadone counselors, intake coordinators, lab technicians, and other auxiliary staff members. Results: Three major themes were identified: (1) HIV education is primarily provided by external organizations, (2) there is limited staff-patient communication around HIV and sexual behaviors, and (3) HIV stigma is prevalent among staff and patients. CONCLUSION: To implement PrEP in methadone treatment settings, clinic staff must be able to engage in non-judgmental communication about HIV and sex with patients. Additionally, federal and state funding for HIV prevention in substance use treatment settings must be prioritized to enable clinics to access the necessary training and resources.

Medical Mistrust Among a Racially and Ethnically Diverse Sample of Sexual Minority Men.

Purpose: Medical mistrust is a barrier to health care utilization and is associated with suboptimal health outcomes. Research on mistrust among sexual minority men (SMM) is limited and largely focuses on Black SMM and HIV, with few studies assessing mistrust among SMM of other race/ethnicities. The purpose of this study was to examine differences in medical mistrust among SMM by race. Methods: From February 2018 to February 2019, a mixed-methods study examined the health-related beliefs and experiences of young SMM in New York City. The Group-Based Medical Mistrust Scale (GBMMS) was used to measure medical mistrust related to race, and a modified version of the scale assessed mistrust related to one's "sexual/gender minority" status (Group-Based Medical Mistrust Scale-Sexual/Gender Minority [GBMMS-SGM]). With an analytic sample of 183 cisgender SMM, a one-way multivariate analysis of variance was used to examine differences in GBMMS and GBMMS-SGM scores by race/ethnicity [Black, Latinx, White, "Another Racial Group(s)"]. Results: There were significantly different GBMMS scores by race, with participants of color reporting higher levels of race-based medical mistrust than White participants. This finding is supported by effect sizes ranging from moderate to large. Differences in GBMMS-SGM scores by race were borderline; however, the effect size for Black and White participants' GBMMS-SGM scores was moderate, indicating that higher GBMMS-SGM scores among Black participants is meaningful. Conclusion: Multilevel strategies should be used to earn the trust of minoritized populations, such as addressing both historical and ongoing discrimination, moving beyond implicit bias trainings, and strengthening the recruitment and retention of minoritized health care professionals.

I Don't Believe a Person Has to Die When Trying to Get High: Overdose Prevention and Response Strategies in Rural Illinois.

BACKGROUND: Overdose is a leading cause of morbidity and mortality among people who inject drugs. Illicitly manufactured fentanyl is now a major driver of opioid overdose deaths. METHODS: Semi-structured interviews were conducted with 23 participants (19 persons who inject drugs and 4 service providers) from rural southern Illinois. Data were analyzed using constant comparison and theoretical sampling methods. RESULTS: Participants were concerned about the growing presence of fentanyl in both opioids and stimulants, and many disclosed overdose experiences. Strategies participants reported using to lower overdose risk included purchasing drugs from trusted sellers and modifying drug use practices by partially injecting and/or changing the route of transmission. Approximately half of persons who inject drugs sampled had heard of fentanyl test strips, however fentanyl test strip use was low. To reverse overdoses, participants reported using cold water baths. Use of naloxone to reverse overdose was low. Barriers to naloxone access and use included fear of arrest and opioid withdrawal. CONCLUSIONS: People who inject drugs understood fentanyl to be a potential contaminant in their drug supply and actively engaged in harm reduction techniques to try to prevent overdose. Interventions to increase harm reduction education and information about and access to fentanyl test strips and naloxone would be beneficial.

How the rural risk environment underpins hepatitis C risk: Qualitative findings from rural southern Illinois, United States.

BACKGROUND: Hepatitis C virus (HCV) infection has increased among persons who inject drugs (PWID) in the United States with disproportionate burden in rural areas. We use the Risk Environment framework to explore potential economic, physical, social, and political determinants of hepatitis C in rural southern Illinois. METHODS: Nineteen in-depth semi-structured interviews were conducted with PWID from August 2019 through February 2020 (i.e., pre-COVID-19 pandemic) and four with key informants who professionally worked with PWID. Interviews were recorded, professionally transcribed, and coded using qualitative software. We followed a grounded theory approach for coding and analyses. RESULTS: We identify economic, physical, policy, and social factors that may influence HCV transmission risk and serve as barriers to HCV care. Economic instability and lack of economic opportunities, a lack of physically available HCV prevention and treatment services, structural stigma such as policies that criminalize drug use, and social stigma emerged in interviews as potential risks for transmission and barriers to care. CONCLUSION: The rural risk environment framework acknowledges the importance of community and structural factors that influence HCV infection and other disease transmission and care. We find that larger structural factors produce vulnerabilities and reduce access to resources, which negatively impact hepatitis C disease outcomes.

An Examination of Condom Brand's Social Media Influence on Sexual Health Messages.

Social media is a primary source of sexual health information for young adults. Increased exposure to sexual health education on social media is associated with safer sexual behavior. Given the diversity of social media accounts, condom brands may be a trusted source of sexual health information. We quantified user interactions on the social media posts of the three most frequently used social media sites of condom brands from January 2020 to June 2021. We analyzed the reach each account had in terms of sexual health information separated into three categories: sexual health education, sexual health resources and social issues relating to sexual health. On Instagram, 48% of posts provide sexual health education, 5% mention resources, and 23% mention social issues. On YouTube 68% of posts provide sexual health education, 35% mention resources, and 31% mention social issues. Providing sexual health education had a positive association with likes on Instagram (n = 923, t = 4.09, p < .001). In terms of sexual health education topics, posts pertaining to reproductive health and sexual self-acceptance were a positive predictor of likes on Instagram (n = 56, t = 7.00, p < .001, n = 77, t = 2.37, p = .015 respectively). Posts pertaining to sex were a positive predictor of likes both on Instagram (n = 74, t = 2.79, p = .005) and YouTube (n = 57, t = 2.21, p = .029). These findings suggest that the sexual health education and resources provided by condom brands have significant reach and positive reception. To promote sexual health to a larger and more receptive audience, future research and education campaigns should recognize and utilize the social media influence of condom brands.

'Why aren't you on PrEP? You're a gay man': reification of HIV 'risk' influences perception and behaviour of young sexual minority men and medical providers.

Public health models and medical interventions have often failed to consider the impact of reductionist HIV 'risk' discourse on how sexual minority men interpret, enact and embody biomedical knowledge in the context of sexual encounters. The aim of this study was to use an anthropological lens to examine sexual minority men's perception of HIV risk and experience within the medical system in order to examine the influence of risk discourse on their health, behaviour and social norms. In-depth interviews (n = 43) were conducted with a racially, ethnically and socioeconomically diverse sample of young sexual minority men and explored HIV-related beliefs and experiences, as well as their interactions with healthcare providers. Findings suggest that the stigmatisation of behaviours associated with HIV appears to be shaped by three key forces: healthcare provider perceptions of sexual minority men as inherently 'risky', community slut-shaming, and perceptions of risk related to anal sex positioning. Stigmatising notions of risk appear to be embodied through sexual health practices and identities vis-à-vis preferred anal sex positions and appear to influence condom use and PrEP initiation.

Substance use treatment services for older adults in five states in the Southern United States: a state-by-state comparison of available treatment services.

Objectives: Substance use disorders (SUD) among older adults have become a serious public health concern. The purpose of this study was to assess which states in the Southern U.S. are more responsive to SUD treatment needs of older adults.Methods: This study is a secondary data analysis of the N-SSATS-2019 dataset.Results: There were 1,215 substance treatment facilities in the five states. Kentucky had the highest number of substance use treatment facilities (n = 449, 37%), followed by Georgia (357, 29%), Alabama (153, 13%), Louisiana (146, 12%) and then Mississippi (110, 9%). Out of the 1,215 facilities, only 20% (n = 244) indicated that they had programs specifically tailored for older adults. Kentucky had the largest number of facilities per 1 million older adults while Mississippi had the highest number of facilities per 1 million older adults offering detoxification services. Alabama had the lowest number of services per 1 million adults in all categories examined.Conclusion: Across the U.S., most adults with SUD do not have access to substance use treatment; in the southeastern region of the country, higher rates of poverty, rural geography and stigma, and lack of treatment availability may further complicate individuals' ability to access substance use-related medical care.

The Role of Nursing in Loosening the Pervasive Grip of Intersectional Stigma.

Stigma is a key driver of inequity and affects myriad health behaviors and outcomes, especially those related to substance use disorder, HIV, and mental illness. Intersectionality, theorized by Black feminist scholars, emphasizes the intersecting, structural processes that place people at risk for harm. As people's multiple identities are inseparable and non-additive, their experiences of stigma are complex and multifaceted. Nurse educators, scholars, and clinicians form the foundation of patient care and scientific advancements to improve the health and well-being of diverse patient populations. The nursing profession must contend with the underlying drivers of intersectional stigma, including systemic racism and White supremacy, classism, and gender inequality. Centering equity, strengthening recruitment/retention of minoritized nursing students, implementing stigma training in curricula, improving the nursing leadership pipeline, moving beyond implicit bias training and deficit models, and incorporating intersectional and implementation science approaches in research can help advance equity for clinicians and patient populations. [Journal of Psychosocial Nursing and Mental Health Services, 60(12), 9-15.].

Gendered racial microaggressions and black college women: A cross-sectional study of depression and psychological distress.

Objective: We assessed the association between gendered racism, the simultaneous experience of sexism and racism, depression, and psychological distress in Black college women using an intersectional instrument, the gendered racial microaggression scale. Participants: Black college women enrolled at a predominantly white institution (PWI) in the southeastern U.S. (N = 164, response rate = 77%, mean age 21.67). Methods: We used a cross-sectional survey to explore the impact of stress appraisal and frequency of gendered racial microaggressions on depression and psychological distress using validated scales. Results: 30% reported depression and 54% reported severe psychological distress. Correlations indicate significant relationships between gendered racism, depression and psychological distress, with the strongest relation reported between the frequency of gendered racism to depression. Regression analyses suggest significant relationships between gendered racism, depression and psychological distress. Conclusion: Gendered racism has significant bearing on the mental health of Black college women attending a PWI. Implications for interventions are discussed.

Feasibility and Acceptability of a Group Counseling Intervention for Opioid Use Disorder: An Exploratory Study.

The goal of the current exploratory study was to examine the feasibility and acceptability of an evidence-based group counseling intervention for individuals with opioid use disorders (OUD) reporting mental health issues and using medications for OUD. The intervention combines motivational interviewing and cognitive-behavioral therapy. Qualitative research methodology, specifically focus group interviewing, with seven individuals was used to examine the feasibility and acceptability of the intervention. Qualitative analysis of the focus group yielded four themes: Intervention Format, Group Counseling Factors, Comorbid Mental Health Issues, and Counselor Factors. The intervention proposed was found to be acceptable and feasible for addressing OUD and co-occurring mental health conditions, specifically depression, anxiety, and stress. [Journal of Psychosocial Nursing and Mental Health Services, 60(6), 7-10.].

Sex in the Time of COVID-19: Patterns of Sexual Behavior Among LGBTQ+ Individuals in the U.S.

The SARS-CoV-2 virus, the pathogen which causes COVID-19, has left an indelible impact on the daily lives of individuals in the USA. This study sought to explore the sexual behaviors among people in the LGBTQ+ population at the onset of the pandemic. Behaviors were explored across sub-groups of the population. The study employed data from an internet survey about the impact of COVID-19 on LGBTQ+ identified individuals conducted between May and July 2020. The final sample was comprised of 1090 participants from across the USA. Overall, sexual activity and the number of sexual partners decreased after March 13, 2020 (as compared to before this date) across all sexual orientation groups; however, living situation and partnership status supported sexual activity. Gay and bisexual men living with a partner or a spouse (AOR = 2.20, p = .023) and those living with a non-romantic roommate or friend (AOR = 2.88, p = .004) reported more sexual activity. For both cisgender lesbian and bisexual women and transgender and non-binary individuals, those who were married or in a domestic partnership (AOR = 4.54, p < .001; AOR = 9.97, p < .001, respectively) and those in a committed relationship (AOR = 3.54, p = .001; AOR = 8.46, p < .001, respectively) reported more sexual activity. Additionally, cisgender lesbian and bisexual women living with their partner or spouse (AOR = 2.14, p = .044) reported more sexual activity. When examining the number of sexual partners, cisgender lesbian and bisexual women and transgender and non-binary individuals in a committed relationship (AOR = 0.31, p < 0.001; AOR = 0.26, p = .004, respectively) and those living with a partner or spouse (AOR = 0.30, p = .002; AOR = 0.25, p = .028, respectively) were less likely to report two or more sexual partners. Examining the changes in sexual activity and number of sexual partners helps us better identify the effects of COVID-19 on intimate relationships and sexual behaviors. Furthermore, this study may help develop clinical best practices to facilitate risk-reduction strategies for LGBTQ+ populations when engaging in sexual activity within a communicable disease framework. Current guidance on sexual activity within a pandemic has created a unique opportunity for sex-positive public health messaging that protects individual health while also offering a framework for conversations about risk mitigation that is applicable for both COVID-19 and STI/HIV prevention.

Logistical Facilitators and Barriers to PrEP Implementation in Methadone Clinic Settings: Provider and Staff Perspectives.

OBJECTIVES: The purpose of this study was to examine the feasibility of implementing pre-exposure prophylaxis (PrEP), a daily oral medication for human immunodeficiency virus (HIV) prevention, in methadone clinics. METHODS: Medical and nonmedical staff (n = 30) at 2 methadone clinics in Northern New Jersey were qualitatively interviewed about various aspects of substance use treatment, clinical operations, and HIV risk and prevention among their patient populations. Audio-recorded interviews were professionally transcribed, then coded and analyzed by the research team. RESULTS: Themes surrounding the viability of PrEP implementation emerged for both logistical facilitators and barriers. Facilitators included availability of prescribing clinicians, ability to conduct lab testing on-site, and availability of existing hepatitis C programs as a blueprint for PrEP management. Barriers included increased provider burden, financial concerns, and perceptions that PrEP provision is outside the clinic's treatment scope. CONCLUSIONS: Although staff expressed willingness and potential ability to provide PrEP, they identified barriers regarding insurance reimbursement, limited funding, and concerns that PrEP would extend the clinic's treatment scope. However, given the enabling factors such as availability of providers and existing clinical infrastructure, providing PrEP could increase clinic revenue through insurance reimbursement and federal funding for PrEP-related services. Clinic-level education is needed for clinical and nonclinical staff to better understand the logistics of implementing PrEP, particularly regarding prescribing practices, billing and insurance concerns, and the essential nature of HIV prevention as a critical component of substance use treatment.

PrEP Care Continuum Engagement Among Persons Who Inject Drugs: Rural and Urban Differences in Stigma and Social Infrastructure.

Pre-exposure prophylaxis (PrEP) is a medication that prevents HIV acquisition, yet PrEP uptake has been low among people who inject drugs. Stigma has been identified as a fundamental driver of population health and may be a significant barrier to PrEP care engagement among PWID. However, there has been limited research on how stigma operates in rural and urban settings in relation to PrEP. Using in-depth semi-structured qualitative interviews (n = 57) we explore PrEP continuum engagement among people actively injecting drugs in rural and urban settings. Urban participants had more awareness and knowledge. Willingness to use PrEP was similar in both settings. However, no participant was currently using PrEP. Stigmas against drug use, HIV, and sexualities were identified as barriers to PrEP uptake, particularly in the rural setting. Syringe service programs in the urban setting were highlighted as a welcoming space where PWID could socialize and therefore mitigate stigma and foster information sharing.

SARS-CoV-2 Vaccination Hesitancy and Behaviors in a National Sample of People Living with HIV.

As COVID-19 vaccinations became available in early 2021, we collected data from a US national sample of 496 people living with HIV (PLWH) to assess COVID-19 vaccination uptake and attitudes. The study was cross-sectional, and data were collected using an online survey between March and May 2021. At the time, 64% of the participants received at least one dose of a COVID-19 vaccine. Vaccine uptake was associated with older age and more years living with HIV, higher educational attainment, less vaccine hesitancy, and higher perceived COVID-19 vulnerability. Rates of vaccination uptake were highest among sexual and gender minority (SGM) cisgender men and transgender participants as well as those more likely to report undetectable viral load. Among the 166 unvaccinated, intention to receive the vaccine was related to older age and years living with HIV as well as lower vaccine hesitancy. Among the unvaccinated, SGM individuals demonstrated higher intent than non-SGM individuals. Findings indicate relatively high levels of vaccination in PLWH, although uptake and intent are not monolithic in the population. Patterns of vaccination are consistent with the health behavior literature in so much as those with higher levels of perceived heath vulnerability due to age as well as higher levels of proactivity about their HIV health are more likely to be vaccinated or intend to be vaccinated. Ongoing vigilance is required to vaccinate the US population, particularly those with underlying conditions such as HIV, as is the need to tailor health messaging to the highly diverse population of PLWH, with particular emphasis on the intersection of HIV and SGM status.