Intersectional Stigma and Prevention Among Gay, Bisexual, and Same Gender-Loving Men in New York City, 2020: System Dynamics Models.

Objectives. To create causal loop diagrams that characterize intersectional stigma experiences among Black, gay, bisexual, same gender-loving, and other men who have sex with men and to identify intervention targets to reduce stigma and increase testing and prevention access. Methods. Between January and July 2020, we conducted focus groups and in-depth interviews with 80 expert informants in New York City, which were transcribed, coded, and analyzed. These qualitative insights were developed iteratively, visualized, and validated in a causal loop diagram (CLD) using Vensim software. Results. The CLD revealed 3 key feedback loops-medical mistrust and HIV transmission, serosorting and marginalization of Black and gay individuals, and family support and internalized homophobia-that contribute to intersectional HIV and related stigmas, homophobia, and systemic racism. On the basis of these results, we designed 2 novel intervention components to integrate into an existing community-level anti-HIV stigma and homophobia intervention. Conclusions. HIV stigma, systemic racism, and homophobia work via feedback loops to reduce access to and uptake of HIV testing, prevention, and treatment. Public Health Implications. The CLD method yielded unique insights into reciprocal feedback structures that, if broken, could interrupt stigmatization and discrimination cycles that impede testing and prevention uptake. (Am J Public Health. 2022;112(S4):S444-S451. https://doi.org/10.2105/AJPH.2022.306725).

The Role of Social Support in HIV Testing and PrEP Awareness among Young Black Men and Transgender Women Who Have Sex with Men or Transgender Women.

Young black men and transgender women (transwomen) who have sex with men or transwomen are most vulnerable in terms of risk for HIV infection, also reflected in their extremely high incidence rates. As testing rates and pre-exposure prophylaxis (PrEP) uptake remain suboptimal among these groups, primarily due to unique structural barriers, the present analyses draw on data from an online survey, administered October 2014 to August 2015, to explore social support-related predictors of knowledge and behavior around HIV prevention.Participants were 169 biological men who identified as black, with a mean age of 24 (SD = 2.97, range 17-29); 8% identified as transwomen. Logistic regression models assessed whether HIV-related social support predicted HIV testing patterns, PrEP awareness, and use. Those with higher HIV-related social support reported having been more likely to have ever tested (adjusted odds ratio (aOR) = 1.48; p < 0.001) and tested in the past 6 months (aOR = 1.22; p < 0.01). They were also more likely to intend to test in the next 6 months (aOR = 1.16; p < 0.001), including at a medical office or community-based organization (aOR = 1.20; p < 0.001), yet less likely to intend to self-test (aOR = 0.81; p < 0.001). Lastly, higher social support was significantly associated with prior knowledge of self-testing (aOR = 1.19; p < 0.05), couples testing (aOR = 1.26; p < 0.001), and PrEP (aOR = 1.22; p < 0.01), as well as prevention self-efficacy (aOR = 1.30; p < 0.001), but inversely associated with prior self-testing (aOR = 0.80; p < 0.05). For young black men and transwomen who have sex with men or transwomen, HIV-related social support, which likely has a strong peer component, appears to be a facilitator of optimal testing and intentions to test, as well as awareness of novel prevention strategies (like self-testing or PrEP). However, community resourcefulness needs to be bolstered by other mechanisms, such as changes within healthcare settings, to increase actual use of novel prevention modalities.

Post-exposure Prophylaxis Awareness, Knowledge, Access and Use Among Three Populations in New York City, 2016-17.

Post-exposure prophylaxis (PEP) is a cost-effective, but underused HIV prevention strategy. PEP awareness, knowledge, access, and usage was assessed among young men of color who have sex with men (YMSMOC; n = 177), transgender women (TW; n = 182), and cisgender women of color (CWOC; n = 170) in New York City. 59% were aware of PEP: 80% among YMSMOC, 63% among TW and 34% among CWOC (p < 0.001). 13% had ever used PEP. PEP awareness was higher among YMSMOC with a recent HIV test and lower among those with ≥ 4 partners. PEP awareness was lower among TW who anticipated stigma and reported barriers to taking PEP, and higher among TW who exchanged sex for resources. Among CWOC, more barriers to taking PEP reduced the odds of PEP awareness. PEP education and outreach needs to be deliberate about population-specific campaigns, with a need to focus on reducing PEP stigma and other barriers which impede PEP access.

Popular Culture and Shaping HIV Perception.

The Gilead COMPASS Initiative® used celebrity partnerships to highlight HIV prevalence in the Southern U.S. and support Southern HIV and Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ) organizations. Using various media platforms, HIV organizations engaged with popular culture in collaboration with national media advocacy and public relations organizations to campaign against stigmatization and raise awareness about HIV.

Changing Narratives and Provoking Dialogue: An Analysis of the HIV Stigma and Faith Summit.

GLAAD in partnership with the Gilead COMPASS Initiative® Coordinating Centers conducted a three-day summit to address the HIV epidemic in the Southern region of the United States. The summit featured virtual panel discussions with HIV experts, faith leaders, community advocates, and entertainers to bring about conversation and change around HIV stigma.

Brief Report: Randomized Controlled Trial of an Intervention to Match Young Black Men and Transwomen Who Have Sex With Men or Transwomen to HIV Testing Options in New York City (All About Me).

BACKGROUND: HIV testing is critical to HIV prevention and care. Infrequent HIV testing and late HIV diagnosis have been observed among young Black men who have sex with men and transwomen. Novel interventions to increase HIV testing rates among young Black men who have sex with men and transwomen are needed. METHODS: A randomized controlled trial among 236 young Black men and transwomen who have sex with men or transwomen evaluated the efficacy of an intervention that included completion of a brief survey and receipt of a personalized recommendation of an optimal HIV testing approach. Participants completed a computerized baseline assessment and were randomized to electronically receive either a personalized recommendation or standard HIV testing information. Follow-up surveys were conducted online at 3 and 6 months. RESULTS: Retention was 92% and 93% at 3-month and 6-month follow-up, respectively. At baseline, 41% of participants reported that they tested for HIV in the past 3 months and another 25% between 4 and 6 months ago. Intent-to-treat analyses found that participants randomized to the experimental arm (personalized recommendation) were not significantly more likely to test for HIV compared with participants in the standard HIV testing information control arm at 3 months (76% vs. 71%; P = 0.40) and 6 months (73% vs. 72%; P = 0.81), respectively. CONCLUSIONS: This study evaluated an innovative intervention to increase HIV testing by matching individuals to optimal HIV testing approaches. Participants in both arms increased past 3-month HIV testing, suggesting that providing information on options and/or raising risk awareness is sufficient to significantly increase HIV testing. TRIAL REGISTRATION: ClinicalTrial.gov NCT02834572 https://clinicaltrials.gov/ct2/show/NCT02834572.

Assessing Knowledge of HIV Vaccines and Biomedical Prevention Methods Among Transgender Women in the New York City Tri-State Area.

Purpose: To lower the HIV risk of transgender women, it is imperative to understand their unique HIV prevention needs and design biomedical prevention interventions that are responsive to the psychosocial, behavioral, and clinical needs of these communities. Preventive HIV vaccines are an important modality under investigation in diverse study participants. We sought to assess the knowledge of HIV vaccine research and the most common barriers and facilitators to participation in HIV vaccine studies among HIV-negative transgender women living in New York City. Methods: Six focus groups were conducted among 29 participants recruited in the New York City tri-state area from December 2014 to July 2015. Prefocus group quantitative questionnaire assessed demographic, behavioral information, knowledge of preventive vaccine research, and reasons for potential participation in prevention studies. Results: Median age of participants was 29 years and 41.4% identified as white. Over half of participants have heard of preventive vaccine research and majority indicated that an important factor in participating in HIV prevention research is to help the community collective effort. Key barriers that emerged were fear of side effects, feelings of exclusion from biomedical research. Facilitators to participation in prevention studies included trusting relationships with providers. Conclusions: These barriers and facilitators are important to consider in the design of studies inclusive of trans communities and transgender-specific prevention strategies. Barriers may be overcome by disseminating accurate information via social media or health providers.

Impact of a Community-level Intervention on HIV Stigma, Homophobia and HIV Testing in New York City: Results from Project CHHANGE.

Background: HIV stigma and homophobia are barriers to access to HIV prevention and treatment services. Project CHHANGE, Challenge HIV Stigma and Homophobia and Gain Empowerment, was a multicomponent intervention designed to reduce community-level HIV stigma and homophobia via workshops, space-based events and bus shelter ads delivered to community-based organizations and neighborhood residents in a high HIV prevalence, primarily African-American, Black and/or Afro-Caribbean, neighborhood in New York City (NYC). Methods: Serial cross-sectional, street intercept surveys among residents of the invention neighborhood and matched control neighborhood were conducted before and after the intervention. Propensity score matching and generalized estimating equation regression models assessed the impact of CHHANGE on HIV stigma and homophobia. HIV testing service utilization data were assessed and multivariable models of self-reported HIV testing among post-intervention street survey respondents were built. Results: We did not find a significant treatment effect on HIV stigma and homophobia among residents of the intervention neighborhood as compared with control community residents. However, HIV testing increased by 350% at the testing site in the intervention community after the intervention implementation. Further, lower HIV stigma, attending an HIV stigma workshop and having friends or family living with HIV were independently associated with past six-month HIV testing among post-intervention respondents in both neighborhoods. Conclusions: CHHANGE was feasible and acceptable to community residents. Evaluating community-level interventions is challenging. Our triangulated approach yielded somewhat conflicting results, which may be due to design limitations. Further research is needed to understand whether and how CHHANGE affected HIV testing.

Preferences for HIV test characteristics among young, Black Men Who Have Sex With Men (MSM) and transgender women: Implications for consistent HIV testing.

BACKGROUND: Promoting consistent HIV testing is critical among young, Black Men Who Have Sex With Men (MSM) and transgender women who are overrepresented among new HIV cases in the United States. New HIV test options are available, including mobile unit testing, one-minute testing, at home or self-testing and couples HIV testing and counseling (CHTC). In the context of these newer options, the objective of this study was to explore whether and how preferences for specific characteristics of the tests acted as barriers to and/or facilitators of testing in general and consistent testing specifically among young Black MSM and transgender women aged 16 to 29. METHODS: We conducted 30 qualitative, semi-structured, in-depth interviews with young, Black, gay, bisexual or MSM and transgender women in the New York City metropolitan area to identify preferences for specific HIV tests and aspects of HIV testing options. Participants were primarily recruited from online and mobile sites, followed by community-based, face-to-face recruitment strategies to specifically reach younger participants. Thematic coding was utilized to analyze the qualitative data based on a grounded theoretical approach. RESULTS: We identified how past experiences, perceived test characteristics (e.g., accuracy, cost, etc.) and beliefs about the "fit" between the individual, and the test relate to preferred testing methods and consistent testing. Three major themes emerged as important to preferences for HIV testing methods: the perceived accuracy of the test method, venue characteristics, and lack of knowledge or experience with the newer testing options, including self-testing and CHTC. CONCLUSIONS: These findings suggest that increasing awareness of and access to newer HIV testing options (e.g., free or reduced price on home or self-tests or CHTC available at all testing venues) is critical if these new options are to facilitate increased levels of consistent testing among young, Black MSM and transgender women. Addressing perceptions of test accuracy and supporting front line staff in creating welcoming and safe testing environments may be key intervention targets. Connecting young Black MSM and transgender women to the best test option, given preferences for specific characteristics, may support more and more consistent HIV testing.

Intervention to Match Young Black Men and Transwomen Who Have Sex With Men or Transwomen to HIV Testing Options (All About Me): Protocol for a Randomized Controlled Trial.

BACKGROUND: HIV testing is a critical component of HIV prevention and care. Interventions to increase HIV testing rates among young black men who have sex with men (MSM) and black transgender women (transwomen) are needed. Personalized recommendations for an individual's optimal HIV testing approach may increase testing. OBJECTIVE: This randomized trial tests the hypothesis that a personalized recommendation of an optimal HIV testing approach will increase HIV testing more than standard HIV testing information. METHODS: A randomized trial among 236 young black men and transwomen who have sex with men or transwomen is being conducted. Participants complete a computerized baseline assessment and are randomized to electronically receive a personalized HIV testing recommendation or standard HIV testing information. Follow-up surveys are conducted online at 3 and 6 months after baseline. RESULTS: The All About Me randomized trial was launched in June 2016. Enrollment is completed and 3-month retention is 92.4% (218/236) and has exceeded study target goals. CONCLUSIONS: The All About Me intervention is an innovative approach to increase HIV testing by providing a personalized recommendation of a person's optimal HIV testing approach. If successful, optimizing this intervention for mobile devices will widen access to large numbers of individuals. TRIAL REGISTRATION: ClinicalTrial.gov NCT02834572; https://clinicaltrials.gov/ct2/show/NCT02834572 (Archived by WebCite at http://www.webcitation.org/6vLJWOS1B).

Informing the Development of a Mobile Phone HIV Testing Intervention: Intentions to Use Specific HIV Testing Approaches Among Young Black Transgender Women and Men Who Have Sex With Men.

BACKGROUND: Regular human immunodeficiency virus (HIV) testing of persons at risk is critical to HIV prevention. Infrequent HIV testing and late diagnosis of HIV infection have been observed among young black men who have sex with men (MSM) and transwomen (transgender women)-two groups overrepresented in the HIV epidemic. OBJECTIVE: The objective of this study was to inform the development of a brief mobile phone intervention to increase HIV testing among young black MSM and transwomen by providing a tailored recommendation of an optimal HIV testing approach. We identified demographic, behavioral, psychosocial, and sociostructural factors associated with intentions to use three specific HIV testing approaches: self-testing, testing at a clinic or other provider, and couples HIV testing and counseling (CHTC). METHODS: Individuals were eligible for a Web-based survey if they were male at birth; were between the ages of 16 and 29 years; self-identified as black, African American, Caribbean black, African black, or multiethnic black; were not known to be HIV-infected; and reported insertive or receptive anal intercourse with a man or transwoman in the last 12 months. Recruitment occurred via banner advertisements placed on a range of social and sexual networking websites and apps in New York City and nationally, and via events attended by young black MSM and transwomen in New York City. Intention to test by each testing method was analyzed using logistic regression with best subset models and stepwise variable selection. RESULTS: Among 169 participants, intention to use a self-test was positively associated with comfort in testing by a friend or a partner at home (Adjusted odds ratio, AOR, 2.40; 95% CI 1.09-5.30), and stigma or fear as a reason not to test (AOR 8.61; 95% CI 2.50-29.68) and negatively associated with higher social support (AOR 0.48; 95% CI 0.33-0.72) and having health insurance (AOR 0.21; 95% CI 0.09-0.54). Intention to test at a clinic or other provider was positively associated with self-efficacy for HIV testing (AOR 2.87; 95% CI 1.48-5.59) and social support (AOR 1.98; 95% CI 1.34-2.92), and negatively associated with a lifetime history of incarceration (AOR 0.37; 95% CI 0.16-0.89). Intention to test by CHTC was negatively associated with higher educational level (Some college or Associate's degree vs high school graduate or less [AOR 0.81; 95% CI 0.39-1.70]; Bachelor's degree or more vs high school graduate or less [AOR 0.28; 95% CI 0.11-0.70]). CONCLUSIONS: Unique factors were associated with intention to test using specific testing approaches. These data will be critical for the development of a tailored intervention that shows promise to increase comfort and experiences with a variety of testing approaches among young black MSM and transwomen.

"Just Because It's Out There, People Aren't Going to Use It." HIV Self-Testing Among Young, Black MSM, and Transgender Women.

HIV disproportionately affects young black MSM and transgender women in the US. Increasing HIV testing rates among these populations is a critical public health goal. Although HIV self-tests are commercially available, there is a need to better understand access to and uptake of HIV self-testing among this population. Here, we report results of a qualitative study of 30 young black MSM and transgender women residing in the New York City area to understand facilitators of and barriers to a range of HIV testing approaches, including self-testing. Mean age was 23.7 years (SD = 3.4). Over half (54%) had some college or an associate's degree, yet 37% had an annual personal income of less than $10,000 per year. Most (64%) participants had tested in the past 6 months; venues included community health/free clinics, medical offices, mobile testing units, hospitals, emergency departments, and research sites. Just one participant reported ever using a commercially available HIV self-test. Facilitators of self-testing included convenience, control, and privacy, particularly as compared to venue-based testing. Barriers to self-testing included the cost of the test, anxiety regarding accessing the test, concerns around correct test operation, and lack of support if a test result is positive. Participants indicated that instruction in correct test operation and social support in the event of a positive test result may increase the likelihood that they would use the self-test. Alongside developing new approaches to HIV prevention, developing ways to increase HIV self-testing is a public health priority for young, black MSM, and transgender women.