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.

The role of social support networks in a sample of older adults living with HIV: the GOLD studies.

As the epidemiological landscape of HIV/AIDS changed over the last 40 years, more people are now living with HIV/AIDS deeper into senior adulthood. People over age 50 living with HIV face myriad challenges including medical, psychological, and social comorbidities. In this analysis, we consider the social realities and social networks of older adults living with HIV and assess how relationships and communities have been affected by stigma and other challenges of aging with HIV. A total of 40 participants, ages 51-69 years, living with HIV in the Newark metropolitan area were interviewed. A thematic analysis was conducted, and four main themes were identified: (1) friends and relationships; (2) support groups; (3) stigma and discrimination; (4) family. The role of social support within this community is discussed within these key themes. This study helps us to better understand how support networks affect older adults living with HIV and how stigma and fragmented relationships can ultimately contribute to negative health outcomes.

ARRIVE Together: A Qualitative Process Evaluation of the New Jersey State Police Co-responding Pilot Program.

Law enforcement personnel are often first to respond to calls involving behavioral health emergencies. However, encounters with law enforcement are more dangerous and lethal for people with behavioral health conditions. Co-responding models, wherein law enforcement and behavioral health professionals respond to calls together, are among the top programs developed to improve responding to behavioral health crises. The current study describes a qualitative process evaluation of a co-responding pilot program in New Jersey: "Alternative Responses to Reduce Instances of Violence & Escalation" (ARRIVE Together). The evaluation centered on the experience of the co-responding team as to their perceptions of specific deployments and of the program implementation overall. Semi-structured interviews were conducted following 10 consecutive encounters (three interviews per encounter; February-March 2022). Transcripts were transcribed and thematically analyzed by two trained researchers independently. Once thematically analyzed, researchers determined a consensus and developed a SWOT analysis report. Thematic analysis produced six major themes: communication, staffing, training, resources, community outreach, and deployments with minors. Overall, participants were enthusiastic about the program, but they shared numerous observations about ways in which the program could be improved. Sample size, the brief follow-up window, and lack of generalizability to other contexts were among the most limiting factors. Further research should include an effectiveness evaluation and extend to urban and suburban communities and communities of color. Future research should also explore after-response affects including accessibility to follow-up care. The current study gives insight into piloting a co-responding model for approaching behavioral health crisis calls.

Assessing the Factor Structure and Psychometric Properties of the HIV-Related Resilience Screener: The GOLD Studies.

People who are 50 and older constitute the majority of those living with HIV/AIDS (PLWHA) in the US. Aging PLWHA face myriad biopsychosocial health challenges related to HIV/AIDS and the aging process. Resilience may act as a buffer to the negative impact of these challenges however measuring it among PLWHA has been inconsistent, so the HIV-Related Resilience Screener (HIV-RRS) was developed. Data for the present study are drawn from 250 sociodemographically diverse HIV-positive gay men ages 50-69 in NYC. Tests of reliability and validity were conducted, and an Exploratory Factor Analysis indicated a three-factor model was the most parsimonious solution. Items were examined for their underlying relationships and labeled: adaptive coping, optimism, and effective coping. The total HIV-RRS yielded a Cronbach's α of 0.84. Convergent and face validity were established using psychosocial and physical outcomes. The HIV-RRS is a psychometrically sound instrument to assess resilience among older HIV-positive gay men.

'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.

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.

Discrimination is associated with C-reactive protein among young sexual minority men.

This report examines associations between everyday discrimination, microaggressions, and CRP to gain insight on potential mechanisms that may underlie increased CVD risk among sexual minority male young adults. The sample consisted of 60 participants taken from the P18 cohort between the ages of 24 and 28 years. Multinomial logistic regression models were used to examine the association between perceived everyday discrimination and LGBQ microaggressions with C-reactive protein cardiovascular risk categories of low-, average-, and high-risk, as defined by the American Heart Association and Centers for Disease Control. Adjustments were made for BMI. Individuals who experienced more everyday discrimination had a higher risk of being classified in the high-risk CRP group compared to the low-risk CRP group (RRR = 3.35, p = 0.02). Interpersonal LGBQ microaggressions were not associated with CRP risk category. Everyday discrimination, but not specific microaggressions based on sexual orientation, were associated with elevated levels of CRP among young sexual minority men (YSMM). Thus, to implement culturally and age-appropriate interventions, further researcher is needed to critically examine the specific types of discrimination and the resultant impact on YSMM's health.

Evidence for the Confluence of Cigarette Smoking, Other Substance Use, and Psychosocial and Mental Health in a Sample of Urban Sexual Minority Young Adults: The P18 Cohort Study.

BACKGROUND: Sexual minority men (SMM) and transgender women (TW) are more likely to smoke cigarettes than heterosexual and cisgender peers, which may exacerbate existing disparities in mental and psychosocial health and substance use. PURPOSE: As few existing studies have examined the confluence of these factors, we sought to examine tobacco use in a diverse sample of SMM and TW and describe its relationship with other substance use and health. METHODS: Data were drawn from a study of syndemic conditions among SMM and TW, which included measures assessing tobacco use, substance use, and mental, psychosocial, and general health. RESULTS: A majority of the racially/ethnically and socioeconomically diverse sample (n = 665) reported ever smoking a cigarette, and more than half of them were current smokers. Current smoking was associated with more frequent recent substance use and poorer mental, psychosocial, and general health. In multivariable analyses, current smoking was predicted by more frequent substance use and more severe anxiety, when adjusting for demographic, substance use, and health factors. CONCLUSIONS: A syndemic approach to health conditions such as substance use, mental health, and psychosocial burden dictates a framework of interrelation and mutual exacerbation. In doing so, we found that current cigarette use was associated with more frequent alcohol and marijuana use and more severe anxiety, suggesting a confluence of cigarette smoking, other substance use, and mental health burden. We recommend a holistic approach to treating tobacco use in sexual and gender minority populations that addresses both substance use and the myriad psychosocial burdens that sexual and gender minority communities experience.

The Burden of COVID-19 in People Living with HIV: A Syndemic Perspective.

The emergence of the novel coronavirus disease known as COVID-19 creates another health burden for people living with HIV (PLWH) who face multiple morbidities and may be at heightened risk for severe physical health illness from COVID-19. Our abilities to address these morbidities in PLWH must be considered alongside the socially-produced burdens that both place this population at risk for COVID-19 and heighten the likelihood of adverse outcomes. These burdens can affect the physical, emotional, and social well-being of PLWH and interfere with the delivery of effective healthcare and access to HIV treatment. We posit that a syndemic framework can be used to conceptualize the potential impact of COVID-19 among PLWH to inform the development of health programming services.

Misinformation, Gendered Perceptions, and Low Healthcare Provider Communication Around HPV and the HPV Vaccine Among Young Sexual Minority Men in New York City: The P18 Cohort Study.

Human papillomavirus (HPV) is the most common sexually transmitted infection among adults in the United States, and can cause several types of cancer. This is of particular concern for sexual minority men, as their increased risk of HIV acquisition increases risk for HPV and HPV-associated cancers, particularly when coupled with low rates of HPV vaccination. As part of a larger study of the syndemic of HIV, substance use, and mental health among young sexual minority men in New York City, we sought to explore what sexual minority men know about HPV and the HPV vaccine, along with their experiences have been communicating about the virus and vaccine. We interviewed 38 young sexual minority men with diverse sociodemographic characteristics and identified three main themes: low knowledge about HPV infection and vaccination, highly gendered misconceptions about HPV only affecting women, and lack of communication from healthcare providers about HPV. The prevalence of incorrect HPV knowledge, coupled with inadequate education and vaccination in healthcare settings, indicates a missed opportunity for HPV prevention in a high-risk and high-need population.

Towards a More Inclusive and Dynamic Understanding of Medical Mistrust Informed by Science.

Mistrust of medical advances and the medical professions continues to persist, and is perhaps increasing. The popular press has documented the growing number of parents globally whose concerns around childhood vaccination, albeit based on faulty scientific information, has led to the anti-vax movement which has already resulted in outbreaks of measles in various parts of the U.S. In recent years, the AIDS Healthcare Foundation has increased speculation and mistrust with regard to the denialism of the effectiveness of pre-exposure prophylaxis (PrEP) to avert HIV infections, again based on misinformation. However, in other cases, medical mistrust reflects the very real historical and ongoing injustices experienced by socially and economically marginalized groups. Whether the genesis of the mistrust is based on fact or fallacy, the results may be similar. There are myriad negative consequences associated with medical mistrust, including lower utilization of healthcare and poorer management of health conditions. Mistrust is thought to provide a partial explanation for staggering health disparities, particularly among Black and African American people, and much of the public health and medical literature cites the infamous Tuskegee Study as a main catalyst for this persistent health-related mistrust among people of color and other groups who experience social and economic vulnerability. While mistrust is often referred to as a phenomenon existing within an individual or community, we must rethink this conceptualization and instead locate mistrust as a phenomenon created by and existing within a system that creates, sustains and reinforces racism, classism, homophobia and transphobia, and stigma. The purpose of this article is to briefly address the state of the medical mistrust literature, and to provide a summary of the articles included in this special issue on medical mistrust. Although the scholarship in this issue addresses diverse methodologies, outcomes and populations, they share a message: social inequality drives mistrust.

Beliefs About the End of AIDS, Concerns About PrEP Functionality, and Perceptions of HIV Risk as Drivers of PrEP Use in Urban Sexual Minority Men: The P18 Cohort Study.

Using cross-sectional data from an ongoing cohort study of young gay, bisexual, and other men who have sex with men (N = 492), we examined the extent to which cognitive factors such as beliefs about the end of AIDS, concerns about the manner in which PrEP works, and perceptions about risk of contracting HIV, are related to PrEP uptake and use. While almost all participants indicted awareness of PrEP, a mere 14% had ever used PrEP. Those with lower concerns about the side effects of PrEP and greater belief that treatment and PrEP would eliminate AIDS were also more likely to have ever used PrEP. Our findings support the ongoing challenges of PrEP uptake as means of curtailing HIV in young sexual minority men, and suggest that beyond the structural factors, consideration must be given to further educating the population as a means of adjusting potentially faulty beliefs, concerns, and perceptions which may influence PrEP utilization.

Collecting Mobility Data with GPS Methods to Understand the HIV Environmental Riskscape Among Young Black Men Who Have Sex with Men: A Multi-city Feasibility Study in the Deep South.

While research increasingly studies how neighborhood contexts influence HIV among gay, bisexual and other men who have sex with men (MSM) populations, to date, no research has used global positioning system (GPS) devices, an innovative method to study spatial mobility through neighborhood contexts, i.e., the environmental riskscape, among a sample of Black MSM. The purpose of this study was to examine the feasibility of collecting two-week GPS data (as measured by a pre- and post-surveys as well as objectively measured adherence to GPS protocol) among a geographically-diverse sample of Black MSM in the Deep South: Gulfport, MS, Jackson, MS, and New Orleans LA (n = 75). GPS feasibility was demonstrated including from survey items, e.g. Black MSM reported high ratings of pre-protocol acceptability, ease of use, and low levels of wear-related concerns. Findings from this study demonstrate that using GPS methods is acceptable and feasible among Black MSM in the Deep South.

Latent Growth Curve Modeling of Non-Injection Drug Use and Condomless Sexual Behavior from Ages 18 to 21 in Gay, Bisexual, and Other YMSM: The P18 Cohort Study.

BACKGROUND: HIV/AIDS continues to be a health disparity faced by sexual minority men, and is exacerbated by non-injection drug use. OBJECTIVES: We sought to delineate growth in non-injection drug use and condomless sex in a sample of racially and economically diverse of gay, bisexual, and other young men who have sex with men (YMSM) as they emerged into adulthood between the ages of 18 and 21 and who came of age in the post-HAART era. METHODS: Behavioral data on drug use and condomless sex, collected via a calendar based technique over 7 waves of a cohort study of 600 YMSM, were analyzed using latent growth curve modeling to document patterns of growth in these behaviors, their associations, and the extent to which patterns and associations are moderated by race/ethnicity and socioeconomic status. RESULTS: Significant growth was noted in the frequencies of condomless oral and anal intercourse, alcohol to intoxication, marijuana use, and inhalant nitrate use. High levels of association were noted between all behaviors across time but associations did not differ by either race/ethnicity or socioeconomic status. The link between drug use and risky sexual behavior continue to be evident in YMSM with significant increases in these behaviors demonstrated as YMSM transition between adolescence and young adulthood. Conclusions/Importance: Healthcare for a new generation of sexual minority males must address the synergy of these behaviors and also nest HIV prevention and care within a larger context of sexual minority health that acknowledges the advances made in the last three decades.

Post-exposure prophylaxis awareness and use among men who have sex with men in London who use geosocial-networking smartphone applications.

The number of new HIV infections continues to be on the rise in many high-income countries, most notably among men who have sex with men (MSM). Despite recent attention to the use of antiretroviral medications as pre-exposure prophylaxis (PrEP) among MSM, considerably less research has been devoted to examining the awareness and use of post-exposure prophylaxis (PEP). Based on a convenience sample of 179 self-reported HIV-uninfected MSM using a geosocial-networking smartphone application, this study is among the first to examine the awareness and use of PEP and their demographic and behavioral correlates among MSM in London. Most respondents (88.3%) had heard of PEP, where 27.4% reported having used it. In multivariable models, the disclosure of one's sexual orientation to their general practitioner (Prevalence ratio [PR]: 3.49; 95% confidence interval (CI): 1.14, 10.70; p = .029) and reporting one's HIV status as negative (rather than unknown) (PR: 11.49; 95% CI: 1.68, 76.92; p = .013) were associated with having heard of PEP; while the recent use of club drugs (PR: 3.02; 95% CI: 1.42, 6.43; p = .004) was associated with having ever used PEP. High awareness and use in this sample suggest that PEP is a valuable risk-reduction strategy that should be capitalized on, be it in addition to or in the absence of PrEP.

Personality and its Relation to Mental and Psychosocial Health in Emerging Adult Sexual Minority Men: The P18 Cohort Study.

Personality disorder and personality pathology encompass a dimension of psychological dysfunction known to severely impact multiple domains of functioning. However, there is a notable dearth of research regarding both the pervasiveness and correlates of personality pathology among young sexual minority males who themselves experience heightened mental health burdens. Using the self-report version of the Standardized Assessment of Personality-Abbreviated Scale we tested associations between distinct personality characteristics with sociodemographic and psychosocial factors as well as mental health states in a sample of 528 young (aged 21-25 years) sexual minority men. In multivariate analysis, personality traits varied significantly by race/ethnicity. Personality traits were also positively associated with psychosocial states, specifically, internalized anti-homosexual bias, level of connection with the gay community, and male body dissatisfaction, as well as mental health in the form of recent depressive and anxious symptomatology. These findings support the complex synergy which exists between personality characteristics, psychosocial conditions, and mental health burdens present among sexual minority men and support the need for an all-encompassing approach to both the study and care of this population that addresses the influences of both internal and external factors on well-being.

Correlates of Awareness of and Willingness to Use Pre-exposure Prophylaxis (PrEP) in Gay, Bisexual, and Other Men Who Have Sex with Men Who Use Geosocial-Networking Smartphone Applications in New York City.

Geosocial-networking smartphone applications are commonly used by gay, bisexual, and other men who have sex with men (MSM) to meet sexual partners. The purpose of the current study was to evaluate awareness of and willingness to use pre-exposure prophylaxis (PrEP) among MSM who use geosocial-networking smartphone applications residing in New York City. Recruitment utilizing broadcast advertisements on a popular smartphone application for MSM yielded a sample of 152 HIV-uninfected MSM. Multivariable models were used to assess demographic and behavioral correlates of awareness of and willingness to use PrEP. Most participants (85.5 %) had heard about PrEP but few (9.2 %) reported current use. Unwillingness to use PrEP was associated with concerns about side effects (PR = 0.303; 95 % CI 0.130, 0.708; p = 0.006). Given that more than half (57.6 %) of participants were willing to use PrEP, future research is needed to elucidate both individual and structural barriers to PrEP use among MSM.

Drug use among HIV+ adults aged 50 and older: findings from the GOLD II study.

Understanding the nexus of aging, HIV, and substance use is key to providing appropriate services and support for their aging, HIV seropositive patients. The proportion of PLWHA aged 50 and older is growing due to a variety of factors like decreases in mortality due to highly active retroviral therapy and non-negligible HIV incidence. We describe prevalence of alcohol, tobacco, and other drug use and participation in substance use treatment and 12-step programs among 95 HIV-positive patients aged 50 and older engaged in care. Most (73.7%) smoked cigarettes in their lifetime and 46.3% were current smokers. Most were at medium (81.1%) or high risk (13.7%) for an alcohol use disorder. With respect to illicit drug use, 48.4% had used marijuana, cocaine, crack, methamphetamines, heroin, and/or prescription opiates without a prescription in the last 12 months; 23.2% met criteria for drug dependence. Marijuana was the most commonly reported illicit drug (32.6%) followed by cocaine and crack (10.5% each), heroin and prescription opiates (7.4% each), and methamphetamines (6.3%). Among those who had not used drugs in the past 12 months, 36.7% had been in a substance use treatment program and 26.5% had participated in a 12-step program in their lifetime; 8.2% were currently in treatment and 16.3% were currently participating in a 12-step program. Among those who had used an illicit drug in the past 12 months, 37.0% had never been in treatment, 34.8% had been in treatment in their lifetime, and 28.3% were currently in treatment. With respect to 12-step programs, 27.3% of those meeting dependence criteria had never participated, 45.5% had participated in their lifetimes, and 27.3% were currently participating. Our findings suggest that older adults in HIV care settings could benefit from Screening, Brief Intervention, and Referral to Treatment interventions and/or integrated services for substance abuse and medical treatment.

Early Life Psychosocial Stressors and Housing Instability among Young Sexual Minority Men: the P18 Cohort Study.

Homelessness and housing instability is a significant public health problem among young sexual minority men. While there is a growing body of literature on correlates of homelessness among sexual minority men, there is a lack of literature parsing the different facets of housing instability. The present study examines factors associated with both living and sleeping in unstable housing among n = 600 sexual minority men (ages 18-19). Multivariate models were constructed to examine the extent to which sociodemographic, interpersonal, and behavioral factors as well as adverse childhood experiences explain housing instability. Overall, 13 % of participants reported sleeping in unstable housing and 18 % had lived in unstable housing at some point in the 6 months preceding the assessment. The odds of currently sleeping in unstable housing were greater among those who experienced more frequent lack of basic needs (food, proper hygiene, clothing) during their childhoods. More frequent experiences of childhood physical abuse and a history of arrest were associated with currently living in unstable housing. Current enrollment in school was a protective factor with both living and sleeping in unstable housing. These findings indicate that being unstably housed can be rooted in early life experiences and suggest a point of intervention that may prevent unstable housing among sexual minority men.