An evaluation of the impact of social and structural determinants of health on forgone care during the COVID-19 pandemic in Baltimore, Maryland.

Evidence suggests that reductions in healthcare utilization, including forgone care, during the COVID-19 pandemic may be contributing towards excess morbidity and mortality. The objective of this study was to describe individual and community-level correlates of forgone care during the COVID-19 pandemic. We conducted a cross-sectional, secondary data analysis of participants (n = 2,003) who reported needing healthcare in two population-representative surveys conducted in Baltimore, MD in 2021 and 2021-2022. Abstracted data included the experience of forgone care, socio-demographic data, comorbidities, financial strain, and community of residence. Participant's community of residence were linked with data acquired from the Baltimore Neighborhood Indicators Alliance relevant to healthcare access and utilization, including walkability and internet access, among others. The data were analyzed using weighted random effects logistic regression. Individual-level factors found to be associated with increased odds for forgone care included individuals age 35-49 (compared to 18-34), female sex, experiencing housing insecurity during the pandemic, and the presence of functional limitations and mental illness. Black/African American individuals were found to have reduced odds of forgone care, compared to any other race. No community-level factors were significant in the multilevel analyses. Moving forward, it will be critical that health systems identify ways to address any barriers to care that populations might be experiencing, such as the use of mobile health services or telemedicine platforms. Additionally, public health emergency preparedness planning efforts must account for the unique needs of communities during future crises, to ensure that their health needs can continue to be met. Finally, additional research is needed to better understand how healthcare access and utilization practices have changed during versus before the pandemic.

Social networks of people with serious mental illness who smoke: potential role in a smoking cessation intervention.

BACKGROUND: Smoking is a major contributor to morbidity and mortality among individuals with serious mental illness (SMI) and social networks may play an important role in smoking behaviors. AIMS: Our objectives were to (1) describe the network characteristics of adults with SMI who smoke tobacco (2) explore whether network attributes were associated with nicotine dependence. METHODS: We performed a secondary analysis of baseline data from a tobacco smoking cessation intervention trial among 192 participants with SMI. A subgroup (n = 75) completed questions on the characteristics of their social network members. The network characteristics included network composition (e.g. proportion who smoke) and network structure (e.g. density of connections between members). We used multilevel models to examine associations with nicotine dependence. RESULTS: Participant characteristics included: a mean age 50 years, 49% women, 48% Black, and 41% primary diagnosis of schizophrenia/schizoaffective disorder. The median personal network proportion of active smokers was 22%, active quitters 0%, and non-smokers 53%. The density of ties between actively smoking network members was greater than between non-smoking members (55% vs 43%, p = .02). Proportion of network smokers was not associated with nicotine dependence. CONCLUSIONS: We identified potential social network challenges and assets to smoking cessation and implications for network interventions among individuals with SMI.

Factors Associated with the Awareness of and Willingness to Use HIV Pre-exposure Prophylaxis Among Gay, Bisexual, and Other Men Who Have Sex with Men, Baltimore, MD, 2017-2019.

Pre-exposure prophylaxis (PrEP) is an effective tool in protecting persons from acquiring HIV infection through sex or injection drug use. However, awareness and willingness to use PrEP among Black gay, bisexual, and other men who have sex with men (BMSM) remain suboptimal compared to White MSM (WMSM) in the United States. Our aims were to (1) assess the factors associated with PrEP awareness and willingness to use PrEP among MSM and (2) compare the PrEP perceptions among BMSM versus non-Black MSM. Data were drawn from two cross-sectional behavioral surveys in Baltimore, MD: Behavioral Surveillance Research (BESURE) conducted in 2017, and Safe Spaces 4 Sexual Health (SS4SH), conducted in 2018 and 2019. Descriptive statistics were used to summarize the study population. We used Poisson regression models to identify variables associated with awareness of PrEP and willingness to use PrEP. PrEP perceptions were assessed via 13 items scored on a 5-point Likert scale. Finally, we conducted a post-hoc exploratory bivariate analysis of the relationship between PrEP perception and willingness to use PrEP, stratified by race/ethnicity. A total of 261 MSM participated in this study. Many of the participants were aware of PrEP (75.1%). Factors associated with greater PrEP awareness included having greater than a high school education (aRR 1.22, 95% CI 1.04, 1.43); and earning more than $25,000 annually (aRR 1.24, 95% CI 1.08, 1.42). Participants who had received money in exchange for sex one or more times were less likely to be aware of PrEP (aRR 0.59, 95% CI 0.36, 0.95). More than half of the participants were willing to use PrEP (55.3%). In bivariate and multivariable analyses, demographic or behavioral characteristics were not significantly associated with willingness to use PrEP. Higher agreement with the following statements was associated with lower willingness to use PrEP: "Having to take a pill every day is difficult" (RR 0.89, 95% CI 0.82-0.97) and, "I am concerned about the side effects of PrEP" (RR 0.89, 95% CI 0.82-0.96), and "PrEP is for people who have riskier sex lives than I do" (RR 0.86, 95% CI 0.78-0.95). Conversely, higher willingness to use PrEP was associated with comfortable having sex without a condom (RR 1.11, 95% CI 1.02-1.21), less anxious about sex (RR 1.12, 95% CI 1.02-1.24), and my friends think that I should take PrEP (RR 1.19, 95% CI 1.07-1.32). We found BMSM compared to non-Black MSM had higher mean scores related to taking a daily pill (p = 0.041), concerns about side effects (p = 0.012), concerns about people thinking they had HIV (p = 0.001), concerns about the financial costs of PrEP (p = 0.038) and caution when dealing with healthcare organizations/medical mistrust (p = 0.019). Perceptions with a statistically significant lower score among BMSM versus non-Black MSM included statements such as, comfortable having sex without a condom (p = 0.003) and less anxious about sex (p < 0.001). We conclude HIV prevention strategies, programs, and interventions should be cognizant of PrEP perceptions that facilitate or hinder PrEP uptake in Baltimore City, MD.

Moving Because of Unaffordable Housing and Disrupted Social Safety Net Access Among Children.

OBJECTIVES: To measure associations between residential moves because of unaffordable housing costs and disruptions in access to the Supplemental Nutrition Assistance Program; the Special Supplemental Nutrition Program for Women, Infants, and Children; and Medicaid in a health care-based sample of families with young children. METHODS: We used cross-sectional survey data on social safety net-eligible caregivers and children recruited into the Children's HealthWatch study from emergency departments and primary care clinics in Baltimore and Philadelphia (2011-2019). Children's HealthWatch measured residential moves (cost-driven and noncost-driven) in the past year and disruptions in safety net access. We used logistic regression to estimate associations between each type of move and disrupted access to social safety nets. RESULTS: Across 9344 children, cost-driven residential moves were associated with higher odds of disrupted access to at least 1 safety net program (Supplemental Nutrition Assistance Program; the Special Supplemental Nutrition Program for Women, Infants, and Children; or Medicaid; adjusted odds ratio 1.44; 95% confidence interval 1.16-1.80), as well as higher odds of disruption to each program separately. Noncost-driven moves were also associated with disruptions to at least 1 safety net program, but less strongly so (adjusted odds ratio 1.14; confidence interval 1.01-1.29; P value for comparison with cost-driven = .045). CONCLUSIONS: Residential moves, particularly cost-driven moves, are associated with social safety net benefit disruptions. The association between these events suggests a need for action to ensure consistent safety net access among children facing cost-driven moves and vice versa (ie, access to housing supports for children with disrupted safety net access).

Syphilis Diagnosis After a Chlamydia, Gonorrhea, or HIV Diagnosis Among Reproductive-Aged Women in Baltimore, MD.

BACKGROUND: Syphilis incidence is increasing among reproductive-aged women, and previous sexually transmitted infections (STIs) are a risk factor for subsequent STIs. This study aimed to determine syphilis incidence after a chlamydia, gonorrhea, or HIV diagnosis, and identify characteristics associated with higher syphilis incidence rates among reproductive-aged women in 1 mid-Atlantic city. METHODS: A retrospective cohort of 85,113 chlamydia, gonorrhea, and HIV diagnoses occurring between 2009 and 2021 and among women aged 13 to 50 years was constructed using public health surveillance data. Cumulative incidence curves were estimated to examine time to early syphilis (i.e., primary, secondary, or early latent) diagnosis, and multivariable analyses determined incidence rate ratios by age (<25 vs. ≥25 years) and number of prior STI diagnoses (0 vs. ≥1) during the study period, stratified by STI. RESULTS: There were 85,113 reportable STI diagnoses and 646 syphilis diagnoses in the cohort. Approximately 1 of 150 chlamydia, 1 of 100 gonorrhea, and 1 of 50 HIV diagnoses were followed by a syphilis diagnosis within 5 years. Cumulative incidence of syphilis differed significantly by STI diagnosis ( P < 0.001). In multivariable analysis, syphilis incidence rates were higher among women diagnosed with ≥1 (vs. 0) prior STI regardless of STI type ( P < 0.05) and among women ≥25 (vs. <25) years old diagnosed with gonorrhea ( P < 0.05). CONCLUSIONS: There were significant differences in syphilis incidence by prior STI type, number of STIs, and age. Our data support targeted screening for syphilis among women with a history of STIs, parwomen with ≥1 prior STI diagnosis, and older women diagnosed with gonorrhea.

HIV Prevention Services for Hispanic/Latino Persons in THRIVE, 2015-2020.

INTRODUCTION: Hispanic/Latino men who have sex with men (MSM) and transgender women (TGW) are disproportionately affected by HIV in the U.S. This study evaluated HIV prevention services and outcomes among Hispanic/Latino MSM and TGW in the Targeted Highly Effective Interventions to Reduce the HIV Epidemic (THRIVE) demonstration project and consider lessons learned. METHODS: The authors described the THRIVE demonstration project services provided to Hispanic/Latino MSM and TGW in 7 U.S. jurisdictions from 2015 to 2020. HIV prevention service outcomes were compared between 1 site with (2,147 total participants) and 6 sites without (1,129 total participants) Hispanic/Latino-oriented pre-exposure prophylaxis clinical services, and Poisson regression was used to estimate the adjusted RR between sites and pre-exposure prophylaxis outcomes. Analyses were conducted from 2021 to 2022. RESULTS: The THRIVE demonstration project served 2,898 and 378 Hispanic/Latino MSM and TGW, respectively, with 2,519 MSM (87%) and 320 TGW (85%) receiving ≥1 HIV screening test. Among 2,002 MSM and 178 TGW eligible for pre-exposure prophylaxis, 1,011 (50%) MSM and 98 (55%) TGW received pre-exposure prophylaxis prescriptions, respectively. MSM and TGW were each 2.0 times more likely to be linked to pre-exposure prophylaxis (95% CI=1.4, 2.9 and 95% CI=1.2, 3.6, respectively) and 1.6 and 2.1 times more likely to be prescribed pre-exposure prophylaxis (95% CI=1.1, 2.2 and 95% CI=1.1, 4.1), respectively, at the site providing Hispanic/Latino-oriented pre-exposure prophylaxis clinical services than at other sites and adjusted for age group. CONCLUSIONS: The THRIVE demonstration project delivered comprehensive HIV prevention services to Hispanic/Latino MSM and TGW. Hispanic/Latino-oriented clinical settings may improve HIV prevention service delivery to persons in Hispanic/Latino communities.

Correction: Desires for Individual- and Interpersonal-Level Patient Portal Use for HIV Prevention Among Urban Sexual Minority Men: Cross-sectional Study.

[This corrects the article DOI: 10.2196/43550.].

Desires for Individual- and Interpersonal-Level Patient Portal Use for HIV Prevention Among Urban Sexual Minority Men: Cross-sectional Study.

BACKGROUND: Gay, bisexual, and other sexual minority men have expressed the acceptability of patient portals as tools for supporting HIV prevention behaviors, including facilitating disclosure of HIV and other sexually transmitted infection (STI/HIV) laboratory test results to sex partners. However, these studies, in which Black or African American sexual minority men were undersampled, failed to determine the relationship of reported history of discussing HIV results with sex partners and anticipated willingness to disclose web-based STI/HIV test results using a patient portal. OBJECTIVE: Among a sample of predominantly Black sexual minority men, this study aimed to (1) determine preferences for patient portal use for HIV prevention and (2) test the associations between reported history of discussing HIV results and anticipated willingness to disclose web-based STI/HIV test results with most recent main and nonmain partners using patient portals. METHODS: Data come from audio-computer self-assisted interview survey data collected during the 3-month visit of a longitudinal cohort study. Univariate analysis assessed patient portal preferences by measuring the valuation rankings of several portal features. Multiple Poisson regression models with robust error variance determined the associations between history of discussing HIV results and willingness to disclose those results using web-based portals by partner type, and to examine criterion validity of the enhancing dyadic communication (EDC) scale to anticipated willingness. RESULTS: Of the 245 participants, 71% (n=174) were Black and 22% (n=53) were White. Most participants indicated a willingness to share web-based STI/HIV test results with their most recent main partner. Slightly fewer, nonetheless a majority, indicated a willingness to share web-based test results with their most recent nonmain partner. All but 2 patient portal features were valued as high or moderately high priority by >80% of participants. Specifically, tools to help manage HIV (n=183, 75%) and information about pre- and postexposure prophylaxis (both 71%, n=173 and n=175, respectively) were the top-valuated features to include in patient portals for HIV prevention. Discussing HIV test results was significantly associated with increased prevalence of willingness to disclose web-based test results with main (adjusted prevalence ratio [aPR] 1.46, 95% CI 1.21-1.75) and nonmain partners (aPR 1.54, 95% CI 1.23-1.93). CONCLUSIONS: Our findings indicate what features Black sexual minority men envision may be included in the patient portal's design to optimize HIV prevention, further supporting the criterion validity of the EDC scale. Efforts should be made to support Black sexual minority men's willingness to disclose STI/HIV testing history and status with partners overall as it is associated significantly with a willingness to disclose testing results digitally via patient portals. Future studies should consider discussion behaviors regarding past HIV test results with partners when tailoring interventions that leverage patient portals in disclosure events.

Enacted Sexual Minority Stigma, Psychological Distress, and Sexual and Drug Risk Behaviors Among Urban Men Who Have Sex with Men (MSM).

Urban Black men who have sex with men (MSM) bear a disproportionate burden of HIV and syphilis in the U.S. Experiences of enacted sexual minority stigma and psychological distress among these men may be associated with HIV/STI sexual and drug risk behaviors. The objective was to determine the associations between enacted sexual minority stigma, psychological distress, and sexual and drug risk behaviors. In an urban prospective cohort study, survey measures assessed past 3-month exposure to enacted sexual minority stigma, psychological distress, and sexual and drug risk behaviors. Multivariable logistic regression models were utilized for hypothesis testing. The Black MSM (N = 140) reported the following: 22.1% experiences of enacted sexual minority stigma, 39% high levels of psychological distress, 48.6% > 1 sex partner, 8.6% transactional sex, and 6% injection drug use (IDU). In models adjusted for age and education, enacted sexual minority stigma significantly increased the odds of reporting > 1 sex partner, transactional sex, and IDU. Adjusting additionally for homelessness, the association between enacted sexual minority stigma and transactional sex remained significant. Adding psychological distress to this model showed a significant association between psychological distress and transactional sex, while the association was no longer significant for transactional sex. These findings highlight some of the complex psycho-social relationships that may be associated with sexual and drug risk behaviors among Black MSM placing them at increased risk for HIV and syphilis.

RESUMEN: Hombres urbanos de raza Negra que tienen sexo con hombres (HSH) sobrellevan una carga desproporcionada de VIH y sífilis en los EE.UU. Experiencias de estigma efectivo de minoría sexual y angustia psicológica entre estos hombres pudiese ser asociado con conductas sexuales de riesgo VIH/ITS y drogas. El objetivo era determinar las asociaciones entre un estigma efectivo de minoría sexual, angustia psicológica, y comportamientos sexuales y de riesgo de drogas. En un estudio de cohortes prospectivo urbano, las medidas de la encuesta evaluada en los últimos tres meses de exposición al estigma efectivo, angustia psicológica, y sus conductas sexuales y comportamientos riesgoso de drogas. Modelos de regresión logística multivariante se utilizaron para la prueba de hipótesis. Los HSH de raza negra (N = 140) reportaron lo siguiente: 22.1% experiencias de estigma efectivo, 39% niveles altos de angustia psicológica, 48.6% y > 1 pareja sexual, 8.6% sexo transaccional, y 6% uso de drogas inyectables (UDI). En modelos ajustados a edad y educación, un estigma efectivo de minoría sexual aumentó de manera significante las probabilidades de reportar y > 1 pareja sexual, sexo transaccional, y UDI. Ajustando adicionalmente para personas sin vivienda, la asociación entre estigma efectivo de minoría sexual y sexo transaccional permaneció significante. La adición de angustia psicológica al modelo mostró una asociación significativa entre angustia psicológica y sexo transaccional, mientras que la asociación ya no era significativa para el sexo transaccional. Estos resultados destacan algunas de las complejas relaciones psicosociales que pudiesen estar asociadas con conductas sexuales y de riesgo de drogas entre HSH de raza negra, poniéndolos a mayor riesgo de contraer VIH y sífilis.

Improving Research Dissemination to Black Sexual Minority Men: Development of a Community-Led and Theory-Based Dissemination Plan.

Background. Although research dissemination to participants and community stakeholders is a fundamental component of translational research, it rarely occurs. The objective of this study was to create a community-led, theory-based dissemination plan to engage local Black sexual minority men in an active dissemination process throughout a sexual health research study. Method. Seven focus groups (N = 38) were conducted with Black, cisgender sexual minority men aged 18 to 45 years. Findings were analyzed through thematic content analysis guided by McGuire's persuasive communication theory. Findings were used to draft a dissemination plan, which was then reviewed and edited by the study's community advisory board (CAB). The plan continues to be updated in response to community needs through CAB discussions. Results. Participants preferred messages concerning syphilis and other health concerns as well as information on local resources. Preferred sources included researchers working with trusted community organizations and leaders. Preferred channels included community events and social media, implemented with consistency. CAB feedback included expanding the target audience of dissemination efforts as well as the development of ideas for channels (i.e., events) and sources (i.e., community organizations and leaders). Additional revisions occurred in response to the COVID-19 pandemic. Conclusion. Given the continued lack of research dissemination to participant and community stakeholders, the process of developing a community-led, theory-based dissemination plan may benefit and help guide researchers to adopt this practice. It is critical that participant and community stakeholder dissemination become more highly prioritized as we strive for public health improvements and the elimination of health disparities.

Factors Associated With Syphilis Transmission and Acquisition Among Men Who Have Sex With Men: Protocol for a Multisite Egocentric Network Study.

BACKGROUND: In the United States, the rates of primary and secondary syphilis have increased more rapidly among men who have sex with men (MSM) than among any other subpopulation. Rising syphilis rates among MSM reflect changes in both individual behaviors and the role of sexual networks (eg, persons linked directly or indirectly by sexual contact) in the spread of the infection. Decades of research examined how sexual networks influence sexually transmitted infections (STIs) among MSM; however, few longitudinal data sources focusing on syphilis have collected network characteristics. The Centers for Disease Control and Prevention, in collaboration with 3 sites, enrolled a prospective cohort of MSM in 3 US cities to longitudinally study sexual behaviors and STIs, including HIV, for up to 24 months. OBJECTIVE: The Network Epidemiology of Syphilis Transmission (NEST) study aimed to collect data on the factors related to syphilis transmission and acquisition among MSM. METHODS: The NEST study was a prospective cohort study that enrolled 748 MSM in Baltimore, Maryland; Chicago, Illinois; and Columbus, Ohio. NEST recruitment used a combination of convenience sampling, venue-based recruitment, and respondent-driven sampling approaches. At quarterly visits, participants completed a behavioral questionnaire and were tested for syphilis, HIV, gonorrhea, and chlamydia. The participants also provided a list of their sexual partners and described their 3 most recent partners in greater detail. RESULTS: The NEST participants were enrolled in the study from July 2018 to December 2021. At baseline, the mean age of the participants was 31.5 (SD 9.1) years. More than half (396/727. 54.5%) of the participants were non-Hispanic Black, 29.8% (217/727) were non-Hispanic White, and 8.8% (64/727) were Hispanic or Latino. Multiple recruitment strategies across the 3 study locations, including respondent-driven sampling, clinic referrals, flyers, and social media advertisements, strengthened NEST participation. Upon the completion of follow-up visits in March 2022, the mean number of visits per participant was 5.1 (SD 3.2; range 1-9) in Baltimore, 2.2 (SD 1.6; range 1-8) in Chicago, and 7.2 (SD 2.9; range 1-9) in Columbus. Using a community-based participatory research approach, site-specific staff were able to draw upon collaborations with local communities to address stigma concerning STIs, particularly syphilis, among potential NEST participants. Community-led efforts also provided a forum for staff to describe the NEST study objectives and plans for research dissemination to the target audience. Strategies to bolster data collection during the COVID-19 pandemic included telehealth visits (all sites) and adaptation to self-collection of STI specimens (Baltimore only). CONCLUSIONS: Data from NEST will be used to address important questions regarding individual and partnership-based sexual risk behaviors among MSM, with the goal of informing interventions to prevent syphilis in high-burden areas. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/40095.

Advancing Sexual Harassment Prevention and Elimination in the Sciences: "Every ... Health Organization Must Do Something Similar".

BACKGROUND: Sexual harassment is pervasive in science. A 2018 report found that the prevalence of sexual harassment in academia in the United States is 58%. An activity held at an international scientific congress was designed to advance sexual harassment prevention and elimination and empower binary and nonbinary persons at risk for harassment, discrimination, and violence. The objective is to describe the activity and outcomes to provide a promising model for other scientific communities. METHODS: A description of the plenary and key components as well as the data collection and analysis of selected outcomes are provided. RESULTS: Among 1338 congress participants from 61 countries, 526 (39%) attended the #MeToo plenary, and the majority engaged in some way during the plenary session. Engagement included standing for the pledge (~85%), participating in the question and answer session (n = 5), seeking counseling (n = 3), and/or providing written post-it comments (n = 96). Respondents to a postcongress survey (n = 388 [24% of all attendees]) ranked the plenary as number 1 among 14 congressional plenaries. In postanalysis, the written post-it comments were sorted into 14 themes within 6 domains, including: (1) emotional responses, (2) barriers to speaking out, (3) public health priorities, (4) reframing narratives about the issue, (5) allyship, and (6) moving the issue forward. CONCLUSIONS: Scientific organizations, agencies, and institutions have an important role to play in setting norms and changing enabling policies toward a zero-tolerance culture of sexual harassment. The activity presented offers a promising model for scientific communities with similar goals. The outcomes suggest that the plenary successfully engaged participants and had a measurable impact on the participants.

Psychological distress and adherence to anti-retroviral therapy or pre-exposure prophylaxis regimens among Urban Black gay and bisexual men (MSM).

BACKGROUND: Urban Black gay, and bisexual men (MSM) bear a disproportionate burden of HIV in the U.S. Mental health is a barrier to adherence to both antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP). The objective was to determine the association between psychological distress and ART or PrEP adherence among urban Black MSM. METHODS: Using data from a four-year prospective cohort study, adherence to ART was defined as > 95% and PrEP was defined as > 80% of doses taken in the past 30 days. Psychological distress measures included difficulty sleeping; feeling anxious; suicidality; feeling sad or depressed; feeling sick, ill, or not well in the past 3 months; high (vs. low) overall psychological distress was classified as above the median value. Associations were examined using Chi-square, Fisher's exact tests, and logistic regression. RESULTS: Among 165 Black MSM, 44.2% (73) reported high psychological distress. 65.3% (47/72) of participants living with HIV and 39.8% (37/93) of HIV negative participants were ART or PrEP adherent, respectively. Education was significantly associated with PrEP adherence (p = 0.038). Non-injection drug use in the past 3 months (p = 0.008), difficulty sleeping (p = 0.010), feeling anxious (p = 0.003), and feeling sad or depressed (p < 0.001), and overall psychological distress (p < 0.001) were significantly associated with ART adherence. High psychological distress was significantly associated with a reduced odds of ART adherence (aOR 0.23; 95% CI = 0.08-0.70) adjusting for age and non-injection drug use. CONCLUSIONS: Increased psychological distress was significantly associated with ART nonadherence and may represent an important barrier to viral suppression.

Safe Spaces 4 Sexual Health: A Status-Neutral, Mobile Van, HIV/STI Testing Intervention Using Online Outreach to Reach MSM at High Risk for HIV Acquisition or Transmission.

BACKGROUND: Black men who have sex with men (MSM) carry the greatest burden of new HIV diagnoses in the United States. Ending the HIV epidemic requires strategic, culturally specific approaches to target factors contributing to persistent HIV disparities. SETTING: Safe Spaces 4 Sexual Health (SS4SH), a community-informed HIV/sexually transmitted infection (STI) testing strategy combining mobile van testing with online outreach, was implemented over a 14-month period from 2018 to 2019 in Baltimore, MD. METHODS: We evaluated the reach of MSM at high risk with high acquisition or transmission risk by SS4SH mobile van combined with online outreach as compared with the Baltimore City Health Department's venue-based mobile van (with no online outreach) operating during the same period based on the following HIV/STI testing outcome measures: (1) number of MSM HIV or STI tested, (2) new HIV diagnosis rate, (3) percent with new syphilis diagnosis, (4) percent at high risk for HIV acquisition, and (5) percent people living with HIV at high risk for transmission. RESULTS: Over a 14-month period, SS4SH HIV/STI tested 151 MSM. Of these, 74% were Black and the mean age was 34 (SD = 10, range = 19-68). Seven percent (10/148) were new HIV diagnoses, and 10% (13/130) were diagnosed with syphilis. The Baltimore City Health Department's venue-based mobile van strategy yielded 53% (231) more MSM (71% Black, mean age 38, SD = 14, range = 15-74), but the HIV/syphilis positivity rate was significantly lower: 0.5% new HIV diagnosis rate (P < 0.001) and 0.5% with syphilis diagnosis (P < 0.001). CONCLUSIONS: Our findings suggest SS4SH combing online outreach with mobile van testing may be more effective at reaching high-risk Black MSM than venue-based mobile testing.

Factors Associated with SARS-CoV-2 Repeat Positivity - Beijing, China, June-September 2020.

INTRODUCTION: Repeat positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) following COVID-19 initial viral clearance (re-positivity) poses a public health management challenge. The objective was to determine factors associated with neutralizing antibody (Nab) level and re-positivity among patients infected with a single strain SARS-CoV-2. METHODS: During a single strain SARS-CoV-2 cluster in Beijing, China, longitudinal individual clinical, virological, and immunological data were collected from 368 infections from June 13 to September 22, 2020. Factors associated with Nab level and re-positivity were analyzed using generalized estimating equations. RESULTS: A total of 353 (96%) SARS-CoV-2 infections had demographic, clinical, and laboratory data available. Among the 353 infections, 55 (15.5%) were re-positive, and blood draws were taken from 346 individuals (98.0%) during hospitalization and/or during the follow-up period. Symptoms were milder for the second-time admission for the re-positives, although 36.4% of re-positives presented with radiographic appearance of pneumonia manifestation. Compared to non-re-positive patients, NAb titers were lower among re-positives; NAb was positively associated with clinical severity. Samples from the lower respiratory tract manifested higher viral load than that from the upper respiratory tract. Multivariable analysis showed re-positivity was positively associated with being female [odd ratio (OR)=1.7, 95% confidence interval (CI) 1.1-2.8] and being aged <18 years (OR=5.2, 95% CI 1.5-18.1); having initially asymptomatic infection (OR=13.7, 95% CI 1.6-116.3); and negatively associated with a higher NAb level (OR=0.9, 95% CI 0.5-1.7). CONCLUSIONS: NAb may be important for sustained viral clearance. Lower respiratory tract infection was associated with higher viral load among all infections when compared to upper respiratory tract infection. Continuous lower respiratory and intermittent upper respiratory viral shedding among COVID-19 infections may occur.

Sexually Transmitted Infection Transmission Dynamics During the Coronavirus Disease 2019 (COVID-19) Pandemic Among Urban Gay, Bisexual, and Other Men Who Have Sex With Men.

BACKGROUND: The impact of coronavirus disease 2019 (COVID-19) mitigation measures on sexually transmitted infection (STI) transmission and racial disparities remains unknown. Our objectives were to compare sex and drug risk behaviors, access to sexual health services, and STI positivity overall and by race during the COVID-19 pandemic compared with pre-pandemic among urban sexual minority men (MSM). METHODS: Sexually active MSM aged 18-45 years were administered a behavioral survey and STI testing every 3-months. Participants who completed at least 1 during-pandemic (April 2020-December 2020) and 1 pre-pandemic study visit (before 13 March 2020) that occurred less than 6 months apart were included. Regression models were used to compare during- and pre-pandemic visit outcomes. RESULTS: Overall, among 231 MSM, reports of more than 3 sex partners declined(pandemic-1: adjusted prevalence ratio 0.68; 95% confidence interval: .54-.86; pandemic-2: 0.65, .51-.84; pandemic-3: 0.57, .43-.75), substance use decreased (pandemic-1: 0.75, .61-.75; pandemic-2: 0.62, .50-.78; pandemic-3: 0.61, .47-.80), and human immunodeficiency virus/preexposure prophylaxis care engagement (pandemic-1: 1.20, 1.07-1.34; pandemic-2: 1.24, 1.11-1.39; pandemic-3: 1.30, 1.16-1.47) increased. STI testing decreased (pandemic-1: 0.68, .57-.81; pandemic-2: 0.78, .67-.92), then rebounded (pandemic-3: 1.01, .87-1.18). Nei-ther Chlamydia (pandemic-2: 1.62, .75-3.46; pandemic-3: 1.13, .24-1.27) nor gonorrhea (pandemic-2: 0.87, .46 1.62; pandemic-3: 0.56, .24-1.27) positivity significantly changed during vs pre-pandemic. Trends were mostly similar among Black vs. non-Black MSM. CONCLUSIONS: We observed sustained decreases in STI risk behaviors but minimal change in STI positivity during compared with pre-pandemic. Our findings underscore the need for novel STI prevention strategies that can be delivered without in-person interactions.

HIV Transmission Potential and Sex Partner Concurrency: Evidence for Racial Disparities in HIV Risk Among Gay and Bisexual Men (MSM).

We determined whether racial disparities in HIV infection among gay and bisexual men (MSM) may be partially explained by racial differences in the HIV transmission potential (i.e. mixing of people living with HIV and people not living with HIV or of unknown HIV serostatus) and density (i.e. sex partner concurrency) of sexual networks. Data included a behavioral survey, testing for HIV, and an egocentric sexual network survey. Mixed effects logistic regressions were used for hypothesis testing. Black (vs. non-Black) MSM were more likely to not know their partner's HIV serostatus (21.8% vs. 9.6%). Similar proportions reported sex partner concurrency (67.1% vs. 68.0%). In adjusted analyses, among Black MSM, sex partner concurrency significantly increased the odds of an HIV transmission potential partnership (TPP), and this association was not significant among non-Black indexes. The association between an HIV TPP and sex partner concurrency may help explain persistent racial disparities in HIV prevalence.

RESUMEN: Determinamos si las disparidades raciales en infecciones del VIH entre hombres homosexuales y bisexuales (hombres que tienen sexo con hombres) puede ser parcialmente explicado por diferencias raciales en el potencial de transmisión del VIH (es decir, mezcla de personas viviendo con VIH y personas que no viven con VIH o cuyo estado serológico del VIH es desconocido) y densidad (es decir, concurrencia de pareja sexual) de redes sexuales. Los datos incluyeron una encuesta de comportamiento, pruebas para el VIH y una encuesta de redes sexuales egocéntrica. Regresiones logísticas de efectos mixtos fueron usados para la prueba de hipótesis. HSH negros (vs. HSH no-negros) eran más propensos a no saber el estado serológico del VIH de su pareja (21.8% vs. 9.6%). Proporciones similares reportaron concurrencia de pareja sexual (67.1% vs. 68.0%). En análisis ajustados, entre HSH negros, la concurrencia de pareja sexual aumentó significativamente las probabilidades de una asociación potencial de transmisión del VIH (TPP por sus siglas en inglés), y esta asociación no fue significativa entre índices de no-negros. La asociación entre una TPP VIH y concurrencia de pareja sexual puede ayudar a explicar disparidades raciales persistentes en la prevalencia del VIH.

Storytelling to improve healthcare worker understanding, beliefs, and practices related to LGBTQ + patients: A program evaluation.

LGBTQ + persons experience significant health inequities and medical distrust resulting from anti-LGBTQ + bias or cultural incompetence from health care workers (HCW). This program evaluation examined whether storytelling events where LGBTQ + persons shared personal and patient experiences changed HCW understanding, beliefs, and practices related to LGBTQ + patients. Five storytelling events, held biannually in Baltimore, Maryland from 2016 to 2018, were evaluated using post-event surveys, written reflections/notes during the event, and a survey of HCW in a citywide care collaborative focused on HIV prevention and treatment for LGBTQ + persons that did and did not attend a storytelling event. We analyzed surveys to measure differences in understanding, beliefs and practices and used thematic qualitative analysis of written reflections/notes from the storytelling events. 416 persons attended storytelling events; 124(30 %) completed post-event surveys and 449 written reflections/notes were collected. 56 HCW completed post-event surveys; 49(87.5 %) strongly agreed/agreed they better understood LGBTQ + patients. Emergent themes from the 43 HCW written reflections/notes included improved understanding and new approaches for engaging LGBTQ + patients. Among HCW survey respondents (n = 111), attending an event was associated with significant differences in beliefs (p = 0.024) and practices (p = 0.000) related to LGBTQ + patients. Storytelling events may serve as effective tools for increasing HCW's understanding, beliefs and practices. This strategy may ultimately help decrease anti-LGBTQ + bias, reduce medical distrust and lower barriers to HIV prevention/treatment for LGBTQ + persons.

#ProjectPresence: Highlighting black LGBTQ persons and communities to reduce stigma: A program evaluation.

Etiologies of HIV disparities are multifaceted; anti-LGBTQ stigma and social marginalization are contributory factors. A city health department developed a program, #ProjectPresence, exhibiting professional photos of Black LGBTQ persons in public spaces. An academic partner explored the relationship of the program to visibility, anti-LGBTQ stigma and social marginalization of Black LGBTQ persons, i.e. models, directly involved in the program and their perceptions of these relationships more broadly for community members. Brief self-administered surveys and semi-structured, in-depth interviews with #ProjectPresence models (n = 15) were conducted after the program to gather their experiences before, during and after the program. Descriptive analyses of survey responses were conducted using Stata 15.1. Interviews were audio-recorded, transcribed and analyzed in NVivo10 using categorical analysis. Surveys indicated prevalent experiences of enacted stigma (73 %) and perceptions of poor local acceptance of LGBTQ people (53 %). Interviews suggested that the program may have influenced positive individual- and community-level changes by increasing visibility of LGBTQ communities and improving acceptance among non-LGBTQ persons, inspiring personal growth and self-acceptance among models, and providing opportunities to foster new connections among LGBTQ subpopulations. Our findings suggest similar programs may present promising approaches for the reduction of stigma and social marginalization affecting LGBTQ persons and communities.

Acceptability and Feasibility of Geographically Explicit Ecological Momentary Assessment Among Men Who Have Sex with Men.

Syphilis among men who have sex with men (MSM) has increased greatly in the past twenty years in the U.S. Geographically explicit ecological momentary assessment (GEMA), in which behaviors are geotagged and contextualized in time and space, may contribute to a greater understanding of transmission risk. The objective was to determine the acceptability and feasibility of GEMA for assessing HIV and syphilis transmission risk behaviors among a sample of MSM. Participants responded to a brief survey five times a day for two weeks. Feasibility was measured by participant recruitment, enrollment, prompts received and answered, geotagged prompts, and technical interference with data collection. Acceptability was measured by ratings of enjoyment and willingness for future participation. Summaries of five behavioral measures from the brief survey were calculated. Among the 83 participants contacted, 67.5% (56) expressed interest, 98% (55) were scheduled, and 81.8% (45) were enrolled. Participants answered 78.3% (2,277) of prompts received and 87.7% (1,998) of answered prompts were geotagged. Overall, 70.5% (31) enjoyed participating and 91.1% (41) were willing to participate in the future. Among prompts answered, missingness was low for five behavioral measures (range 0.2% (4) to 0.7% (16)). Feasibility and acceptability were high and missingness was low on behavioral measures in this MSM study population. Most participants reported that they would participate again. Future work should focus on whether GEMA improves our understanding of syphilis and HIV transmission risk.