State-level structural sexual stigma and HIV prevention in a national online sample of HIV-uninfected MSM in the United States

The impact of socio-environmental factors on doxycycline post-exposure prophylaxis awareness in the US: a cross-sectional study

Background We investigated awareness and use of doxycycline post-exposure prophylaxis (doxyPEP) in the US. DoxyPEP has preventative benefits for bacterial STIs among people assigned male at birth. We considered how individual, interpersonal and social determinants of health, such as state-level LGBTQ equality, impact doxyPEP awareness. Methods We conducted an online snapshot cross-sectional survey in June 2023. Survey questions included demographics, sexual and substance use behaviours, and socio-environmental factors, and provided a short explanation of doxyPEP, with questions regarding prior awareness and use. Results Among a racially diverse sample of 196 participants (median age 33 years), 94% identified as cisgender men, 26% were aware of doxyPEP, whereas only 14 (7%) had ever used it. Factors significantly associated with awareness included being college educated (OR 2.50, 95% CI 1.09-5.74), a past year bacterial STI (OR 4.20, 95% CI 1.97-8.89), having discussed HIV pre-exposure prophylaxis with a health care provider (OR 3.88, 95% CI 1.99-7.57) and having taken HIV pre-exposure prophylaxis (OR 2.29, 95% CI 1.11-4.70). Socio-environmental factors associated with doxyPEP awareness included living in a large urban city (OR 2.14, 95% CI 1.12-4.10) and living in a state with higher levels of LGBTQ policy equality (OR 2.18, 95% CI 1.07-4.44). Conclusions Considering the disproportionate impact of bacterial STIs on men who have sex with men, especially those living in lower LGBTQ equality regions, such as the Southern US, our study emphasises how socio-environmental factors may limit awareness and uptake of novel biomedical approaches that have the potential to prevent morbidity and enhance sexual health.

Access to Federally Qualified Health Centers and HIV Outcomes in the U.S. South

INTRODUCTION

Federally Qualified Health Centers may increase access to HIV prevention, care, and treatment for at-risk populations.

METHODS

A pooled cross section of ZIP Code Tabulation Areas from cites in the U.S. South with high HIV diagnoses were used to examine Federally Qualified Health Center density and indicators of HIV epidemic control. The explanatory variable was Federally Qualified Health Center density-number of Federally Qualified Health Centers in a ZIP Code Tabulation Areas' Primary Care Service Area per low-income population-high versus medium/low (2019). Outcomes were 5-year (2015-2019 or 2014-2018) (1) number of new HIV diagnoses, (2) percentage late diagnosis, (3) percentage linked to care, and (4) percentage virally suppressed, which was assessed over 1 year (2018 or 2019). Multiple linear regression was used to examine the relationship, including ZIP Code Tabulation Area-level sociodemographic and city-level HIV funding variables, with state-fixed effects, and data analysis was completed in 2022-2023. Sensitivity analyses included (1) examining ZIP Code Tabulation Areas with fewer non-Federally Qualified Health Center primary care providers, (2) controlling for county-level primary care provider density, (3) excluding the highest HIV prevalence ZIP Code Tabulation Areas, and (4) excluding Florida ZIP Code Tabulation Areas.

RESULTS

High-density ZIP Code Tabulation Areas had a lower percentage of late diagnosis and virally suppressed, a higher percentage linked to care, and no differences in new HIV diagnoses (p<0.05). In adjusted analysis, high density was associated with a greater number of new diagnoses (number or percentage=5.65; 95% CI=2.81, 8.49), lower percentage of late diagnosis (-3.71%; 95% CI= -5.99, -1.42), higher percentage linked to care (2.13%; 95% CI=0.20, 4.06), and higher percentage virally suppressed (1.87%; 95% CI=0.53, 2.74) than medium/low density.

CONCLUSIONS

Results suggest that access to Federally Qualified Health Centers may benefit community-level HIV epidemic indicators.

Experiences of oral pre-exposure prophylaxis use among heterosexual men accessing sexual and reproductive health services in South Africa: a qualitative study

INTRODUCTION

South African men face a substantial burden of HIV and are less likely to test for HIV and initiate antiretroviral therapy if tested positive and more likely to die from AIDS-related causes than women. In addition to condoms and circumcision, guidelines provide for the use of daily oral pre-exposure prophylaxis (PrEP) as an HIV prevention intervention for any men who recognize their need and request PrEP. However, heterosexual men have not been a focus of PrEP programmes, and since its introduction, there is limited literature on PrEP use among men in South Africa. This study explores the experiences, motivators and barriers to oral PrEP use among heterosexual men accessing primary healthcare services in South Africa.

METHODS

This study forms part of a mixed-methods implementation science study aimed at generating evidence for oral PrEP introduction and conducted in primary healthcare clinics in South Africa since 2018. Men aged ≥15 years who initiated oral PrEP and enrolled in a parent cohort study were purposefully invited to participate in an in-depth interview (IDI). Between March 2020 and May 2022, 30 men participated in IDIs exploring their motivators for PrEP use, and experiences with accessing health services. Interviews were audio recorded, transcribed and analysed thematically.

RESULTS

The final analysis included 28 heterosexual men (18-56 years old). Motivations to initiate PrEP included fear of acquiring HIV, self-perceived vulnerability to HIV and mistrust in relationships; health systems factors which motivated PrEP use included the influence of healthcare providers, educational materials and mobile services. Perceived reduction in HIV vulnerability and changing proximity to partners were reasons for PrEP discontinuation. Side effects, daily-pill burden and stigma were noted as challenges to PrEP use. Health system barriers to PrEP use included limited PrEP availability, school and work demands, and inconsistent mobile clinic schedules.

CONCLUSIONS

Our study reports on the experiences of heterosexual men accessing oral PrEP in real-world settings and contributes to the limited literature among this population. We highlight multiple levels which could be strengthened to improve men's PrEP use, including individual support, education among partners and communities, and addressing health system barriers to access.

"Make it more than a pill, make it an experience of health:" results from an open pilot intervention to retain young African American men who have sex with men in PrEP care

Uptake and retention in clinical care for pre-exposure prophylaxis (PrEP) is suboptimal, particularly among young African American men who have sex with men (MSM) in the Deep South. We conducted a two-phase study to develop and implement an intervention to increase PrEP persistence. In Phase I, we conducted focus groups with 27 young African American MSM taking PrEP at a community health center in Jackson, Mississippi to elicit recommendations for the PrEP persistence intervention. We developed an intervention based on recommendations in Phase I, and in Phase II, ten participants were enrolled in an open pilot. Eight participants completed Phase II study activities, including a single intervention session, phone call check-ins, and four assessments (Months 0, 1, 3, and 6). Exit interviews demonstrated a high level of acceptability and satisfaction with the intervention. These formative data demonstrate the initial promise of a novel intervention to improve PrEP persistence among young African American MSM.

Willingness to Use Long-Acting Injectable PrEP Among PrEP Naïve Black and Hispanic Sexual Gender Minority Persons

In December 2021, long-acting injectable pre-exposure prophylaxis (LAI-PrEP) was approved for the prevention of HIV in at-risk adults and adolescents. LAI-PrEP may address adherence issues of daily oral daily PrEP and PrEP stigma. However, studies assessing LAI-PrEP willingness among PrEP naive Black and Hispanic sexual and gender minority (SGM) persons- a group disproportionately impacted by the HIV epidemic in the United States - is rare. To assess the extent of and characteristics of willingness to use LAI-PrEP in a national sample of Black and Hispanic SGM who are self-reported that they have never used PrEP. We analyzed data from a national sample of Black and Hispanic SGM collected between March and August 2020. We used log-binomial regression models to assess characteristics associated with willingness to use LAI-PrEP. Of the overall sample (N = 380), the mean age was 24 (SD = 2.8) and the majority of the sample (54%, n = 205) reported willingness to use LAI-PrEP. In multivariable log-binomial regression models, PrEP stigma was independently associated with less [prevalence ratio (PR) = 0.7, 95% confidence interval (CI) = 0.6, 0.9], while number of sexual partners in the past 12 months was associated with a more willingness to use LAI-PrEP (PR = 1.1, 95% CI = 1.0, 1.2). Our findings highlight the persistence of PrEP stigma as a potential barrier to willingness to use LAI-PrEP in this sample of Black and Hispanic SGM who have never used PrEP. Additional work needs to be done to reduce PrEP stigma more broadly.

Marital status, State policy environment and Foregone healthcare of same-sex families during the COVID-19 period

Sexual minorities in the United States have often reported a higher likelihood of forgoing healthcare than heterosexuals, but whether this occurred during the COVID-19 pandemic remains underexplored. This study applies and extends the Andersen model to examine different-sex and same-sex families' likelihood of forgoing healthcare during the pandemic using nationally representative data from the 2020 (May-October) Current Population Survey (N = 139,636). Results are that during the early stage of the pandemic (1) same-sex families overall are more likely than different-sex families to forgo medical care, (2) cohabitating same-sex families were less likely to forgo healthcare than their married counterparts, and (3) state policy environments will moderate only some of the differences in healthcare utilization by family types. Findings provide partial support for hypotheses and suggest a more careful consideration of the role of partnership and state policy in the Andersen model. Policy implications are also discussed.

Structural stigma and LGBTQ+ health: a narrative review of quantitative studies

Health disparities related to sexual orientation and gender identity exist across multiple outcomes. Scholarship has begun to evaluate whether structural stigma-ie, societal-level conditions, cultural norms, and institutional policies that constrain opportunities, resources, and wellbeing-contributes to health burdens among LGBTQ+ individuals. We conducted a comprehensive review of quantitative studies examining this hypothesis. We found 98 articles that linked objective (ie, non-self-reported) measures of structural stigma to mental (n=57), behavioural (ie, substance use; n=27; HIV/AIDS or sexually transmitted infection; n=20), and physical (n=20) health outcomes. There was generally consistent evidence that structural stigma increases risk of poor health among LGBTQ+ individuals. Several methodological strengths were identified, including the use of multiple measures (eg, laws or policies [59%, 58 of 98]), designs (eg, quasi-experiments [21%, 21 of 98]), and samples (eg, probability-based [56%, 55 of 98]). However, important gaps exist. Just over half of studies included area-level covariates or non-LGBTQ+ comparison groups, which are necessary to address alternative explanations for the observed associations. Additionally, while studies (n=90) have begun to identify candidate mechanisms, only nine (10%) formally tested mediation. We offer suggestions for future research to advance this literature, which has implications not only for the identification of structural determinants of LGBTQ+ health but also for the development of public health interventions that reduce LGBTQ+ health disparities.

Examining HIV Knowledge and Sexually Risky Behaviors among Female Sex Workers in Kampala, Uganda

HIV incidence remains alarmingly high among female sex workers (FSWs) in Uganda, necessitating targeted interventions. This study aimed to identify individual and provider-level barriers and facilitators to primary HIV prevention among FSWs in an urban setting. Focus groups involving FSWs and healthcare providers (HCPs) were conducted to inform the development of tailored prevention interventions. Results revealed that all participants had mobile phones, recent sexual activity, and a history of HIV testing, with high rates of sexually transmitted infections and varying HIV test results. FSWs displayed a well-informed awareness of HIV transmission risks, emphasizing the threat for those not testing positive. They unanimously recognized the crucial role of HIV testing in informing, mitigating risks, promoting ART use, and endorsing consistent condom usage. Despite heightened awareness, HCPs noted potential underestimation of vulnerability. Various challenges, including inadequate condom usage, substance abuse, and client dynamics, underscored the complexity of safeguarding against HIV transmission among FSWs. Widespread alcohol and drug use, including marijuana, kuber, and khat, served as coping mechanisms and social facilitators. Some FSWs successfully reduced alcohol intake, highlighting challenges in addressing substance use. FSWs preferred group discussions in health education programs, emphasizing peer interactions and the effectiveness of visual aids in HIV prevention education. This study provides comprehensive insights to guide the development of targeted interventions addressing the multi-faceted challenges FSWs face in HIV prevention.

Same-Sex Marriage Laws, Provider-Patient Communication, and PrEP Awareness and Use Among Gay, Bisexual, and Other Men Who have Sex with Men in the United States

State-level structural stigma and its consequences in healthcare settings shape access to pre-exposure prophylaxis (PrEP) for HIV prevention among gay, bisexual, and other men who have sex with men (GBMSM). Our objective was to assess the relationships between same-sex marriage laws, a measure of structural stigma at the state level, provider-patient communication about sex, and GBMSM awareness and use of PrEP. Using data from the Fenway Institute's MSM Internet Survey collected in 2013 (N = 3296), we conducted modified Poisson regression analyses to evaluate associations between same-sex marriage legality, measures of provider-patient communication, and PrEP awareness and use. Living in a state where same-sex marriage was legal was associated with PrEP awareness (aPR 1.27; 95% CI 1.14, 1.41), as were feeling comfortable discussing with primary care providers that they have had sex with a man (aPR 1.63; 95% CI 1.46, 1.82), discussing with their primary care provider having had condomless sex with a man (aPR 1.65; 95% CI 1.49, 1.82), and discussing with their primary care provider ways to prevent sexual transmission of HIV (aPR 1.39; 95% CI 1.26, 1.54). Each of these three measures of provider-patient communication were additionally associated with PrEP awareness and use. In sum, structural stigma was associated with reduced PrEP awareness and use. Policies that reduce stigma against GBMSM may help to promote PrEP and prevent HIV transmission.

Branched sexuality and sexual health among Black cisgender sexual minority men in Baltimore, Maryland: an exploratory study

Branched sexuality - in form of combinations of sexual identity, behaviour and attraction (e.g. heterosexual identity, sex with men, attraction to women) that differ from coincident combinations (e.g. gay/homosexual/same-gender-loving identity, sex with men, attraction to men) - has been observed among Black sexual minority men and may correlate with sexual health. Using baseline survey data from Black sexual minority men (N = 323) enrolled in a sexual health intervention trial, we examined sexual identity, behaviour and attraction to determine the prevalence of branched sexuality and used modified Poisson regression with robust variance estimation to test associations with sexual health. Black sexual minority men reporting branched sexuality (n = 50, 15.5%) were marginally more likely to endorse negative condom-use attitudes compared to those reporting coincident sexuality (n = 273, 84.5%; adjusted prevalence ratio [aPR] = 1.48, 95% confidence interval [CI] = 0.94, 2.32) and significantly more likely to endorse negative condom-use attitudes compared to those reporting gay/homosexual/same-gender-loving-coincident sexuality (aPR = 1.85, 95% CI = 01.07, 3.22). Those reporting branched sexuality were significantly less likely to report past-year testing for sexually transmitted infections compared to those reporting coincident (PR = 0.52, 95% CI = 0.28, 0.94) or gay/homosexual/same-gender-loving-coincident sexuality (PR = 0.46, 95% CI = 0.25, 0.84) in bivariate analyses only. Increased understanding of Black sexual minority men's sexuality and improved sexuality data collection efforts are needed.

Structural racism and homophobia evaluated through social media sentiment combined with activity spaces and associations with mental health among young sexual minority men

BACKGROUND

Research suggests that structural racism and homophobia are associated with mental well-being. However, structural discrimination measures which are relevant to lived experiences and that evade self-report biases are needed. Social media and global-positioning systems (GPS) offer opportunity to measure place-based negative racial sentiment linked to relevant locations via precise geo-coding of activity spaces. This is vital for young sexual minority men (YSMM) of color who may experience both racial and sexual minority discrimination and subsequently poorer mental well-being.

METHODS

P18 Neighborhood Study (n = 147) data were used. Measures of place-based negative racial and sexual-orientation sentiment were created using geo-located social media as a proxy for racial climate via socially-meaningfully-defined places. Exposure to place-based negative sentiment was computed as an average of discrimination by places frequented using activity space measures per person. Outcomes were number of days of reported poor mental health in last 30 days. Zero-inflated Poisson regression analyses were used to assess influence of and type of relationship between place-based negative racial or sexual-orientation sentiment exposure and mental well-being, including the moderating effect of race/ethnicity.

RESULTS

We found evidence for a non-linear relationship between place-based negative racial sentiment and mental well-being among our racially and ethnically diverse sample of YSMM (p < .05), and significant differences in the relationship for different race/ethnicity groups (p < .05). The most pronounced differences were detected between Black and White non-Hispanic vs. Hispanic sexual minority men. At two standard deviations above the overall mean of negative racial sentiment exposure based on activity spaces, Black and White YSMM reported significantly more poor mental health days in comparison to Hispanic YSMM.

CONCLUSIONS

Effects of discrimination can vary by race/ethnicity and discrimination type. Experiencing place-based negative racial sentiment may have implications for mental well-being among YSMM regardless of race/ethnicity, which should be explored in future research including with larger samples sizes.

Temporal and Geographic Patterns of Documentation of Sexual Orientation and Gender Identity Keywords in Clinical Notes

OBJECTIVE

Disclosure of sexual orientation and gender identity correlates with better outcomes, yet data may not be available in structured fields in electronic health record data. To gain greater insight into the care of sexual and gender-diverse patients in the Veterans Health Administration (VHA), we examined the documentation patterns of sexual orientation and gender identity through extraction and analyses of data contained in unstructured electronic health record clinical notes.

METHODS

Salient terms were identified through authoritative vocabularies, the research team's expertise, and frequencies, and the use of consistency in VHA clinical notes. Term frequencies were extracted from VHA clinical notes recorded from 2000 to 2018. Temporal analyses assessed usage changes in normalized frequencies as compared with nonclinical use, relative growth rates, and geographic variations.

RESULTS

Over time most terms increased in use, similar to Google ngram data, especially after the repeal of the "Don't Ask Don't Tell" military policy in 2010. For most terms, the usage adoption consistency also increased by the study's end. Aggregated use of all terms increased throughout the United States.

CONCLUSION

Term usage trends may provide a view of evolving care in a temporal continuum of changing policy. These findings may be useful for policies and interventions geared toward sexual and gender-diverse individuals. Despite the lack of structured data, the documentation of sexual orientation and gender identity terms is increasing in clinical notes.

Sexually Transmitted Infections in Women of Reproductive Age by Disability Type

INTRODUCTION

The objectives of this study were to estimate the prevalence of sexually transmitted infections in women of reproductive age by disability type and examine the association between disability types, participant characteristics, and the prevalence of sexually transmitted infections (STIs).

METHODS

Pooled data from 2015 to 2019 National Survey on Drug Use and Health were analyzed in 2022. The analytic sample included 90,233 women of reproductive age (18-49 years). Disability was defined as having any sensory, cognitive, physical, or ≥2 disabilities.. A total of 15% of women reported having a disability. Descriptive analyses were used to estimate the prevalence of STI, and logistic regression analyses were conducted to examine the association of disability type and other participant characteristics with the odds of having STIs.

RESULTS

The prevalence of STIs was more than twice as high for women of reproductive age with cognitive disabilities (6.8%) or ≥2 disabilities (6.7%) as for those without disabilities (2.7%). Women with sensory disabilities (AOR=1.47; 95% CI=1.17, 1.85), cognitive disabilities (AOR=1.89; 95% CI=1.65, 2.17), or ≥2 disabilities (AOR=1.78; 95% CI=1.49, 2.14) had greater odds of STIs than those without disabilities. Bisexual women had higher odds (AOR=1.31; 95% CI=1.14, 1.50) of STIs than straight women, whereas lesbian/gay women had lower odds (AOR=0.41; 95% CI=0.27, 0.63). The odds of STIs were higher among non-Hispanic Blacks (AOR=1.42; 95% CI=1.24, 1.63) and lower among Asian women (AOR=0.62; 95% CI=0.43, 0.90) than among non-Hispanic Whites. The odds of STIs were also greater among participants having any alcohol, cannabis, or illicit drug use.

CONCLUSIONS

Women of reproductive age with disabilities have a higher prevalence of sexually transmitted infections. In addition to disability type, the odds of sexually transmitted infections varied by race/ethnicity, sexual orientation, and substance use.

Awareness and use of HIV pre-exposure prophylaxis and factors associated with awareness among MSM in Beijing, China

Human immunodeficiency virus (HIV) sexual transmission among men who have sex with men (MSM) has increased markedly in Beijing, China in the past decade. Pre-exposure prophylaxis (PrEP) is a highly efficacious biomedical prevention strategy that remarkably reduces HIV-transmission risk. This study examined PrEP awareness among MSM and the factors influencing it. From April to July 2021, respondent-driven sampling was used to conduct a cross-sectional survey among MSM in Beijing, China. Demographic, behavior, and awareness data regarding PrEP were collected. The factors influencing PrEP awareness were assessed using univariate and multivariable logistic regression. In total, 608 eligible responders were included in the study. Among the respondents, 27.9% had PrEP awareness, 3.3% had taken PrEP, and 57.9% expressed interest in receiving PrEP, if required. Greater odds of PrEP awareness were associated with higher education level (adjusted odds ratio [aOR] 3.525, 95% confidence interval [CI] 2.013-6.173, P < 0.0001), greater HIV-related knowledge (aOR 3.605, 95% CI 2.229-5.829, P < 0.0001), HIV testing (aOR 2.647, 95% CI 1.463-4.788, P = 0.0013), and sexually transmitted infections (aOR 2.064, 95% CI 1.189-3.584, P = 0.0101). Lower odds of PrEP awareness were associated with higher stigma score (aOR 0.729, 95% CI 0.591-0.897, P = 0.0029). The findings indicate sub-optimal awareness and low utilization of PrEP in Beijing and highlight PrEP inequities among MSM with stigma. Strengthening the training of peer educators in disseminating PrEP knowledge and reducing stigma are critical for improving PrEP awareness.

Significant Others and Not Family or Friend Support Mediate Between Stigma and Discrimination Among People Living With HIV in Lagos State, Nigeria: A Cross-sectional Study

ABSTRACT

Approximately 70% of the 37.7 million people living with HIV (PLWH) globally reside in sub-Saharan Africa and 10% of the global HIV burden is in Nigeria. PLWH encounter stigma and discrimination. Limited support from family, friends, and significant others increases stigma and discrimination among PLWH. This study sought to understand how support from family, friends, and significant others mediates stigma and discrimination in the Nigerian context. This descriptive cross-sectional study enrolled 396 PLWH from six health facilities between June and July 2021 in Lagos State, Nigeria. Stigma, discrimination, and social support were assessed. On average, participants were 32 years of age and female. Increased social support was associated with reduced stigma and discrimination. Support from participants' significant others was found to mediate the relationship between stigma and discrimination.

Intersectional Discrimination and PrEP uSe Among Young Black Sexual Minority Individuals: The Importance of Black LGBTQ Communities and Social Support

Intersectional stigma and discrimination have increasingly been recognized as impediments to the health and well-being of young Black sexual minority men (YBSMM) and transgender women (TW). However, little research has examined the relationship between intersectional discrimination and HIV pre-exposure prophylaxis (PrEP) outcomes. This study with 283 YBSMM and TW examines the relationship between intersectional discrimination and current PrEP use and likelihood of future PrEP use. Path models were used to test associations between intersectional discrimination, resilience and social support, and PrEP use and intentions. Individuals with higher levels of anticipated discrimination were less likely to be current PrEP users (OR = 0.59, p = .013), and higher levels of daily discrimination were associated with increased likelihood of using PrEP in the future (B = 0.48 (0.16), p = .002). Greater discrimination was associated with higher levels of resilience, social support, and connection to the Black LGBTQ community. Social support mediated the effect of day-to-day discrimination on likelihood of future PrEP use. Additionally, there was a significant and negative indirect effect of PrEP social concerns on current PrEP use via Black LGBTQ community connectedness. The results of this study highlight the complexity of the relationships between discrimination, resilience, and health outcomes.

An integrated online-to-offline model for HIV post-exposure prophylaxis (O2O-PEP) scale-up among men who have sex with men (MSM): Protocol for developing a pilot randomized controlled trial

Background

HIV post-exposure prophylaxis (PEP) is an evidence-based biomedical HIV prevention strategy consisting of a 28-day course of highly active antiretroviral therapy after recent potential exposure to HIV. However, awareness and uptake of PEP among men who have sex with men (MSM) are very low. Innovative and effective methods are needed to support PEP implementation among MSM. This work reports a protocol to design and evaluate an online-to-offline-based delivery model for HIV PEP uptake (O2O-PEP) in Chinese MSM.

Methods and analysis

This will be a two-phase study. In phase 1, we will develop an O2O-PEP model delivered through the WeChat mini-app (an app built into the WeChat platform). The O2O-PEP model initially includes four core components: a gamification-based education package for PEP, an online HIV risk assessment tool, a free online booking system for PEP initiation, and offline PEP prescription in the study hospitals. In phase 2, a two-arm pilot stratified randomized controlled trial comparing the O2O-PEP group with the standard care group will be designed to assess the feasibility, usability, and preliminary evidence of the efficacy of the O2O-PEP model in increasing PEP uptake among Chinese MSM. Model feasibility and usability will be further explored for broader model implementation.

Discussion

The O2O-PEP model is one of the first interventions in China aiming to promote PEP initiation in Chinese MSM. Components in the O2O-PEP model could assist MSM in better understanding their HIV infection risk and increasing accessibility of PEP. Moreover, coupled with online and offline recruitment, the O2O-PEP model has great potential to reach and engage MSM who are not involved in care by traditional methods.

Clinical trial registration

No. ChiCTR2200062538.

Use of HIV Post-Exposure Prophylaxis Among Men Who Have Sex With Men in Shenzhen, China: A Serial Cross-Sectional Study

HIV postexposure prophylaxis (PEP) has been prescribed to non-occupational people in recent years, but the implementation of PEP in China is still unclear. This study sought to examine the PEP use rate and factors associated with PEP in Men who have sex with men (MSM). We recruited HIV-negative MSM through offline methods from 2018 to 2020 in Shenzhen, China. Overall, PEP use increased from 3.92% to 2018, 5.73% in 2019, and 10.29% in 2020. Among 2833 participants who reported their most recent questionnaire, factors associated with PEP use included residence in Shenzhen less than 1 year, sexual intercourse with women, preferred way of finding sexual partners in MSM venues, multiple sexual partners (≥ 2), condom use, lubricant use, viagra use, less use of rush popper, HIV-related services and interest in initiating Pre-exposure prophylaxis (PrEP). The implementation of the PEP plan should focus on the groups that may be at risk of HIV infection and their continued risky behaviours. For the inappropriate use of PEP, PEP publicity should guide MSM to choose regular hospitals and strengthen HIV testing before and after PEP.

Health Care Consumption, Psychiatric Diagnoses, and Pharmacotherapy 1 and 2 Years Before and After Newly Diagnosed HIV: A Case-Control Study Nested in The Greater Stockholm HIV Cohort Study

OBJECTIVE

We compare individuals with newly diagnosed HIV with sex-, age-, and socioeconomic status-matched HIV-negative controls, with the aim of studying the frequency of health care visits, the types of clinics visited, registered diagnoses, and psychopharmacotherapy.

METHODS

The data were collected through the Stockholm Region administrative database (Stockholm Regional Health Care Data Warehouse) for men and women (people) living with newly diagnosed HIV (PLWH) in their medical records (930 men, 450 women) and controls. The odds ratios (ORs) with 99% confidence intervals (CIs) for psychiatric comorbidities and relevant pharmacotherapies were calculated during the 2011-2018 period.

RESULTS

Substance use disorder was higher in PLWH than in controls, before and after newly diagnosed HIV in men (OR = 1 year before 4.36 [99% CI = 2.00-9.5] and OR = 1 year after 5.16 [99% CI = 2.65-10.08]) and women (OR = 1 year before 6.05 [99% CI = 1.89-19.40] and OR = 1 year after 5.24 [99% CI = 1.69-16.32]). Health care contacts and psychiatric disorders were more common in cases than controls 1 and 2 years after diagnosis, particularly for depression in men 1 year after HIV (OR = 3.14, 99% CI = 2.11-4.67), which was not found in women (1 year OR = 0.94, 99% CI = 0.50-1.77).

CONCLUSIONS

Before newly diagnosed HIV, PLWH have the same level of psychiatric diagnoses as their controls, except for substance use disorder. Psychiatric problems are more common in PLWH than in their controls after newly diagnosed HIV.

Socio-behavioral correlates of pre-exposure prophylaxis use and correct adherence in men who have sex with men in West Africa

BACKGROUND

Multiple barriers compromise pre-exposure prophylaxis (PrEP) engagement (i.e., use and adherence) in men who have sex with men (MSM). In low/middle-income countries, little is known about PrEP engagement in this population. In West Africa, the CohMSM-PrEP study was one of the rare interventions providing PrEP to MSM. We estimated PrEP use and correct adherence rates in CohMSM-PrEP, together with associated factors over time.  METHODS: CohMSM-PrEP recruited MSM in four community-based clinics in Mali, Côte d'Ivoire, Burkina Faso, and Togo. Quarterly follow-up included collecting socio-behavioral data, and providing a comprehensive HIV prevention package, PrEP (daily or event-driven), and peer educator (PE)-led counselling. Using repeated measures, multivariate generalized estimating equations models were used to identify factors associated with self-reported i) PrEP use and ii) correct PrEP adherence during participants' most recent anal intercourse (defined as four pills/week for daily users and 2 + 1 + 1 for event-driven users).

RESULTS

Five hundred twenty participants were included with a median follow-up time of 12 months (IQR 6-21). Of the 2839 intercourses declared over the follow-up period, PrEP use was self-reported for 1996 (70%), and correct PrEP adherence for 1461 (73%) of the latter. PrEP use was higher in participants who also attended participating clinics outside of scheduled visits (adjusted odds ratio (aOR) [95% Confidence Interval, CI], p-value; 1.32[1.01-1.71], 0.040), and in those who practiced condomless anal sex (1.86[1.54-2.24], < 0.001). Correct adherence was higher in those who often contacted PE outside of scheduled visits (2.16[1.01-4.64], 0.047) and in participants who adopted receptive/versatile sexual positions with stable partners (1.36[1.03-1.81], 0.030). Instead, after an interaction effect between financial situation and regimen was tested, it was lower in event-driven users with a difficult/very difficult financial situation (comfortable/just making ends meet & daily, 4.19[2.56-6.86], < 0.001; difficult/very difficult & daily, 6.47[4.05-10.30], < 0.001; comfortable/just making ends meet & event-driven, 1.63[1.22-2.17], 0.001), and in participants who felt alone (0.76[0.58-0.99], 0.042).

CONCLUSIONS

Community-based clinic attendance and PE contact outside of scheduled visits were both associated with higher PrEP engagement, but some socially and economically marginalized participants struggled with adherence. As scale-up continues in West Africa, we recommend implementing community-based interventions and providing extra support for vulnerable users to ensure adequate PrEP engagement.

Associations between HIV testing and multilevel stigmas among gay men and other men who have sex with men in nine urban centers across the United States

Background

Complex manifestation of stigma across personal, community, and structural levels and their effect on HIV outcomes are less understood than effects in isolation. Yet, multilevel approaches that jointly assesses HIV criminalization and personal sexual behavior stigma in relation to HIV testing have not been widely employed or have only focused on specific subpopulations. The current study assesses the association of three types of MSM-related sexual behavior-related stigma (family, healthcare, general social stigma) measured at both individual and site levels and the presence/absence of laws criminalizing HIV transmission with HIV testing behaviors to inform HIV surveillance and prevention efforts among HIV-negative MSM in a holistic and integrated way.

Methods

We included nine National HIV Behavioral Surveillance (NHBS) 2017 sites: Baltimore, MD; Denver, CO; Detroit, MI; Houston, TX; Long Island/Nassau-Suffolk, NY; Los Angeles, CA; Portland, OR; San Diego, CA; and Virginia Beach and Norfolk, VA. Multivariable generalized hierarchical linear modeling was used to examine how sexual behavior stigmas (stigma from family, anticipated healthcare stigma, general social stigma) measured at the individual and site levels and state HIV criminalization legislation (no, HIV-specific, or sentence-enhancement laws) were associated with past-year HIV testing behaviors across sites (n = 3,278).

Results

The majority of MSM across sites were tested for HIV in the past two years (n = 2,909, 95.4%) with the average number of times tested ranging from 1.79 (SD = 3.11) in Portland, OR to 4.95 (SD = 4.35) in Los Angeles, CA. In unadjusted models, there was a significant positive relationship between stigma from family and being tested for HIV in the past two years. Site-level HIV-specific criminalization laws were associated with an approximate 5% reduction in the prevalence of receiving any HIV test in the past two years after individual level stigma and sociodemographic covariate adjustments (PR = 0.94, 95% CI, 0.90–0.99).

Conclusions

Structural barriers faced by MSM persist and ending the HIV epidemic in the US requires a supportive legal environment to ensure effective engagement in HIV services among MSM. Home-based solutions, such as self-testing, used to deliver HIV testing may be particularly important in punitive settings while legal change is advocated for on the community and state levels.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08572-4.

Racial disparity in ART adherence is closed in states with high social trust: Results from the Medical Monitoring Project (MMP), 2015

Racial/ethnic disparities persist in antiretroviral therapy (ART) adherence and viral suppression. We examined associations between state-level social trust and individual-level ART adherence and viral suppression and assessed whether these relationships varied by race/ethnicity. The Medical Monitoring Project (MMP) annually reports nationally representative estimates of the behavioral and clinical characteristics of HIV-positive adults in primary care. A total of 3298 adults diagnosed with HIV between 2015 and 2016 from 16 US states were included. We used weighted logistic regression to model the association between state-level social trust, race/ethnicity (Non-Hispanic Black, White, and Hispanic/Latino), and cross-product interactions with ART adherence (a binary measure derived from three self-reported questions), and viral suppression (a binary measure corresponding to plasma HIV RNA < 200 copies/ml). Social trust was the percentage of people in each state who agreed that most people in their neighborhood could be trusted. A high level of social trust was associated with a higher likelihood of ART adherence (PR [prevalence ratio] = 1.17; 95% confidence interval [CI]: 1.05-1.30). In covariate-adjusted analyses, the association between state-level social trust and individual-level ART adherence significantly varied by race/ethnicity (Wald χ2  F = 9.8 [df = 4], p = 0.044). Social trust was positively associated with ART, but the effect was smaller for Blacks than for Whites (PR = 0.66; 95% CI: 0.57-0.82) in states with the lowest social trust. Black-White differences were closed and no longer significant above mean social trust (PP [predicted probability] = 0.50 vs. 0.53, at two standard deviations). Racial/ethnic disparities in ART adherence were closed among individuals living in states with high social trust. Understanding the mechanisms that promote social trust among neighbors may have downstream impacts on reducing disparities in ART adherence among people with HIV (PWH).

Metrics of sexual behavior stigma among cisgender men who have sex with men in Mexico: exploratory and confirmatory factor analyses

Cisgender gay, bisexual, and other men who have sex with men (MSM) in Mexico experience disparities in sexual health outcomes, perhaps most notably in HIV prevalence, HIV testing and status awareness, and condom use. Sexual behavior stigma, underpinned by socio-structural factors specific to Mexico (e.g., machismo), uniquely shapes these sexual health disparities. However, few reliable, valid measures are available to document, track, and ultimately mitigate sexual behavior stigma in this context. Exploratory and confirmatory factor analyses were performed on responses to a 13-item sexual behavior stigma scale from 15,681 MSM recruited online across Mexico. Associations with extracted factors were tested to assess construct validity. Three subscales were identified in exploratory factor analysis and validated in confirmatory factor analysis: "stigma from family and friends" (α = 0.65), "anticipated healthcare stigma" (α = 0.84), and "general social stigma" (α = 0.70). External construct validity was indicated through each subscale's strong association (all p < 0.001) with perceived community intolerance of MSM and perceived community discrimination toward people living with HIV. These subscales show promise as reliable, valid measures for assessing sexual behavior stigma among MSM in Mexico, and as tools for documenting and tracking sexual behavior stigma trends, comparing regional burdens of sexual behavior stigma, and tracking the progress of stigma-mitigation interventions among MSM in Mexico. Future research is needed to understand the extent to which each subscale is differentially associated with sexual (and other) health outcomes, which can inform the development and implementation of uniquely tailored stigma-mitigation, HIV-prevention, HIV-care, and other needed interventions for MSM in Mexico.

Exposure to interpersonal stigma enhances the effectiveness of a culturally adapted personalized normative feedback alcohol intervention for sexual minority women

Stigma-related stress and inflated perceptions of substance use norms are positioned in the literature as theoretically distinct explanations for disproportionate substance use among sexual minorities. As research has yet to examine how these variables may interact in an intervention context, this study examined the impact of recent experiences with violence and harassment due to sexual minority status (i.e., interpersonal stigma exposure) on the effectiveness of a culturally adapted personalized normative feedback intervention for lesbian, bisexual, and queer (LBQ) women. A sub-sample of 499 moderate-to-heavy drinking LBQ women were randomized to receive personalized normative feedback (PNF) on alcohol use or control topics within a broader digital competition designed to challenge negative LBQ stereotypes. At baseline, recent interpersonal stigma exposure strengthened the relationship between perceived LBQ alcohol-related norms and participants' own alcohol-related behaviors (i.e., consumption and consequences). At follow-up, 3 months later, recent interpersonal stigma exposure moderated the effectiveness of alcohol PNF with substantially less drinking and consequences among participants in the treatment condition reporting recent violence or harassment due to sexual minority status, relative to those reporting no such experiences. Underscoring the utility of PNF for LBQ women and potentially other heavy drinking stigmatized populations, findings suggest that a greater tendency to conform to over-estimated ingroup drinking norms may be another way in which minority status-based violence and harassment contributes to alcohol consumption in stigmatized populations.

Factors Associated with Unprotected Anal Sex among Men Who Have Sex with Men in Mexico

The global prevalence of HIV is notably higher in men who have sex with men (MSM) compared with other male populations. Unprotected anal intercourse is the riskiest sexual behavior for HIV acquisition and/or transmission among this minority population. The purpose of the study was to identify if the syndemic of psychosocial stressors and experienced stigma are predictors of unprotected anal sex in Mexican MSM. A cross-sectional analytic study was carried out. It included adults residing in Manzanillo, Mexico, with oral/anal sex practices within the last year. Informed consent was given by 142 participants selected using snowball sampling. Collected data included sociodemographic characteristics, psychosocial stressors, experienced stigma, HIV knowledge, knowing a friend/acquaintance living with HIV/AIDS, and sexual risk behaviors. Adjusted logistic regression was used to identify predictors of unprotected anal sex within the last six months. Presence of syndemic of psychosocial stressors, drug use during sex, having friends/acquaintances with HIV/AIDS, and experiencing high stigma were positively associated; high level of HIV knowledge was negatively linked. Reducing psychosocial stressors and integrating stigma-mitigation strategies are key elements to reduce HIV transmission.

Perceived Stigma and Stigma Management Strategies Among Online Male Sex Workers

Technological advances like the Internet and Internet-enabled devices, such as smartphones, and the dating and hookup websites and apps available to the users of them, have transformed the nature, organization, and practice of sex work in fundamental ways. Some scholars have argued that these changes have contributed to a normalization of male exchange sex (i.e., providing sex in exchange for money, drugs, shelter, or goods), and in so doing, have diminished the stigma historically associated with it. However, little empirical research has focused on how male sex workers (MSWs), including those engaged in what might be called informal or incidental or casual sex work and primarily use dating/hookup websites and apps not designed for commercial to meet clients experience and manage stigma. To help fill this gap, we analyzed interview data from 180 MSWs who engaged in exchange sex and met their client on dating/hookup websites and apps. Most participants felt that sex work was still highly stigmatized in society at large, but many also felt it was generally accepted-if not completely normalized-within the gay community. Nevertheless, many struggled with the emotional impact of engaging in a stigmatized practice and most employed one or more of the following stigma management strategies: information management, distancing, discrediting the discreditors, asserting no other option existed, and challenging or reframing stereotypes and narratives. These findings indicate that MSWs, even those engaged in informal or incidental sex work, who meet clients on dating/hookup websites and apps are still strongly affected by sex work-related stigma and seek to manage it in various ways. Future research should investigate the sources of internalized stigma among this under-studied population of sex workers.

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).

Consumer-Based STI Screening among Young Adult Women: The Negative Influence of the Social System

BACKGROUND

Young adults (ages 18-24) are disproportionately burdened by sexually transmitted infections (STIs), but STI screening rates are low among this age group. Negative social factors, such as stigma, influence STI screening behavior, but it is unknown if alternative methods such as consumer-based screening can reduce these barriers. This study examined how stigma impacts consumer-based STI testing among young adult women.

METHODS

Qualitative data were collected via in-depth interviews with sexually active women, age 18-24, enrolled at a large public university in the South (n = 24). Interviews were audio recorded, transcribed, and analyzed thematically with a priori and emergent codes by two coders (Kappa = .83).

RESULTS

Participants from this study perceived sexual activity was viewed positively for men, but negatively stigmatized for women. Further, lack of sexuality education in schools was another contributor to stigma since abstinence-only education is commonly provided in this region. Participants felt offering information on consumer-based STI screening methods may be beneficial to address these barriers.

CONCLUSIONS

Stigma and social influences must be accounted for in future research and interventions to meet the STI screening needs of young adult women. Findings from this research can inform the development of targeted interventions for women who may perceive heightened stigma to STI screening.

Patterns of sexual and HIV-related stigma among men who have sex with men and women living with HIV in Haiti

Vulnerability to contracting HIV among Men who have Sex with Men and Women (MSMW) was recognized early in the epidemic. However, while global HIV efforts have made tremendous progress for the heterosexually-identified population, the specific needs of MSMW were not directly addressed with tailored and context-adapted interventions. The purpose of this study was to inform this area of research by exploring patterns of stigma through sexual identity developmental history as well as coping mechanisms among MSMW living with HIV in Haiti. A qualitative descriptive study comprised of in-depth interviews with 32 MSMW living with HIV was carried out. Participants were recruited using snowball techniques. An inductive thematic analysis was conducted in NVivo, contextualized by the socio-ecological context of Haiti. MSMW reported struggling with their sexuality since their adolescence, often because of enacted stigma from family members, the community, and cultural conflicts. Most participants described experiencing anxiety, psychological distress, depression, social isolation, suicidal ideation and suicide attempts. Mechanisms for coping with stigma included self-acceptance, social support, hiding their sexual orientation, and tolerance of the voodoo religion. To combat stigma, and improve HIV treatment adherence and retention among MSMW, culturally-tailored multilevel initiatives should be implemented.

Preferences for Long-Acting and Alternative Modalities for PrEP among Military Men Who Have Sex with Men: Segmentation Results of an Adaptive Choice-Based Conjoint Analysis Study

The use of pre-exposure prophylaxis (PrEP) for HIV prevention within the U.S. military is low. Implementing preference-based alternative modalities of PrEP delivery, however, can be an innovative strategy to address the specific barriers to PrEP uptake among military MSM. We sought to identify population-based, segment-specific preferences for longer-acting and alternative PrEP delivery modalities to guide patient-centered strategies to optimize uptake within military-serving healthcare systems. HIV-negative military men who have sex with men (MSM) completed an anonymous, adaptive choice-based conjoint (ACBC) analysis survey consisting of five key attributes of interest (dosing method, provider type, visit location, lab work evaluation location, and dispensing venue). Relative importance and part-worth utility scores were generated using Hierarchical Bayes (HB) estimation, and cluster ensemble analysis grouped participants into "phenotype" segments by preference similarity. The randomized first-choice model was then used to examine changes in program interest rates among segments through market simulation. The 429 participants were segmented into five preference groups. The dosing method attribute was found to be the most important to nearly all segments. Simulations revealed that PrEP program interest among two segments with low interest levels increased when smartphone, civilian-based, and long-acting injectable PrEP options were involved. Findings also suggested a need for clinics to be responsive and sensitive to sexual practices, risk perception, and functional PrEP knowledge. Responsiveness to segment-specific preferences in the design of military PrEP programs and acting on the importance of clinical relationships within the context of PrEP engagement within a military setting may contribute to increasing PrEP uptake.

Structural Stigma and Sexual Health Disparities Among Gay, Bisexual, and Other Men Who Have Sex With Men in Australia

BACKGROUND

Discrimination and stigmatization at the institutional and sociocultural level (conceptualized as "structural stigma") has been associated with adverse health outcomes among sexual and gender minorities. However, few studies explore whether structural stigma is associated with sexual health outcomes. Addressing this gap, here, we explore this relationship among Australian gay, bisexual, and other men who have sex with men (GBM)-a population disproportionately affected by HIV.

SETTING AND METHODS

Using responses from the 2017 Australian Marriage Law Postal Survey, we operationalized structural stigma related to sexual minority status as the regional percentage of votes against legalizing same-sex marriage. These responses were then linked to national HIV behavioral surveillance data from Australian GBM (43,811 responses between 2015 and 2019). Controlling for a rich set of individual and regional level confounders, regression analyses were used to estimate the extent to which structural stigma was associated with testing for, and diagnoses of, HIV and sexually transmitted infections (STIs), and awareness and use of HIV prevention and treatment interventions (pre-exposure and postexposure prophylaxis, combination therapy, and HIV-related clinical care).

RESULTS

Australian GBM living in regions with higher levels of structural stigma were less likely to undergo HIV/STI testing, receive HIV/STI diagnoses, and be taking, or aware of, biomedical prevention strategies. Among GBM living with HIV, structural stigma was associated with a reduced likelihood of being on combination therapy and fewer HIV-related clinical visits.

CONCLUSIONS

Altogether, these results suggest that structural stigma may undermine HIV prevention strategies as well as adequate management of HIV infection among GBM.

Metrics of Sexual Behavior Stigma Among Cisgender Men Who Have Sex With Men in 9 Cities Across the United States

Men who have sex with men (MSM) in the United States are stigmatized for their same-sex practices, which can lead to risky sexual behavior, potentiating risk for human immunodeficiency virus (HIV) infection. Improved measurement is necessary for accurately reporting and mitigating sexual behavior stigma. We added 13 sexual behavior stigma items to local surveys administered in 2017 at 9 sites in the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance system, which uses venue-based, time-sampling procedures to survey cisgender MSM in US Census Metropolitan Statistical Areas. We performed exploratory factor analytical procedures on site-specific (Baltimore, Maryland; Denver, Colorado; Detroit, Michigan; Houston, Texas; Nassau-Suffolk, New York; Portland, Oregon; Los Angeles, California; San Diego, California; and Virginia Beach-Norfolk, Virginia) and pooled responses to the survey items. A 3-factor solution-"stigma from family" (α = 0.70), "anticipated health-care stigma" (α = 0.75), and "general social stigma" (α = 0.66)-best fitted the pooled data and was the best-fitting solution across sites. Findings demonstrate that MSM across the United States experience sexual behavior stigma similarly. The results reflect the programmatic utility of enhanced stigma measurement, including tracking trends in stigma over time, making regional comparisons of stigma burden, and supporting evaluation of stigma-mitigation interventions among MSM across the United States.

Programs and interventions promoting health equity in LGBTQ2+ populations in Canada through action on social determinants of health

Sexual and gender minorities (SGM) experience a number of health inequities. That social determinants of health drive these inequities is well-documented, but there is little evidence on the number and types of interventions across Canada that address these determinants for these populations. We conducted an environmental scan of programs in Canada that target SGM, and classified the programs based on their level of intervention (individual/interpersonal, institutional and structural). We found that few programs target women, mid-life adults, Indigenous people or ethnoracial minorities, recent immigrants and refugees, and minority language speakers, and few interventions operate at a structural level.

Pre-Exposure Prophylaxis (PrEP) Dissemination: Adapting Diffusion Theory to Examine PrEP Adoption

PrEP adoption among African-American men-who-have-sex-with-men (AAMSM) remains low. We applied Diffusion-of-Innovations (DOI) theory to understand PrEP adoption processes among young HIV-negative/status unknown AAMSM (AAYMSM; N = 181; 17-24 years). Quantitative and qualitative analyses were used to examine predictors of PrEP diffusion stages. Most AAYMSM were in the persuasion stage (PrEP-aware, hadn't adopted; 72.4%). Our results suggest that model antecedents are DOI stage-specific. PrEP awareness (knowledge stage) was associated with lower levels of social stigma (p < .03) and greater health literacy (p < .05), while sexual risk (p < .03) and education (p < .03) predicted PrEP adoption (12.2%). PrEP efficacy and side effects were primary innovation characteristics influencing adoption receptivity in the persuasion stage. Interventions to improve PrEP diffusion should be tailored to stage-specific antecedents depending on how a community is stratified across the DOI stages.

Awareness and use of nonoccupational HIV post-exposure prophylaxis and factors associated with awareness among MSM in Beijing, China

Background

Human immunodeficiency virus (HIV) sexual transmission among men who have sex with men (MSM) has increased markedly in Beijing, China, during the past decade. Nonoccupational HIV post-exposure prophylaxis (nPEP) is a highly efficacious biomedical prevention strategy that significantly reduces HIV-transmission risk. This study examined nPEP awareness among MSM and the factors influencing it.

Methods

Consecutive, cross-sectional MSM surveys were conducted from April to August of 2018 and 2019. Demographic data as well as that on behavior and awareness regarding nPEP was collected. Factors influencing nPEP awareness were assessed using univariate and multivariable logistic regression.

Results

There were 1,202 eligible responders recruited. Of the responders, 42.5% had nPEP awareness, and 59.9% expressed interest in receiving nPEP in the future, if required. Greater odds of nPEP awareness were associated with younger age, higher education level (adjusted odds ratio [aOR]: 4.011, 95% confidence interval [CI]: 2.834–5.678, P<0.001), higher income, use of the Internet to meet sexual partners (aOR: 2.016, 95% CI: 1.481–2.744, P<0.001), greater HIV-related knowledge (aOR: 3.817, 95% CI: 1.845–7.899, p<0.001), HIV testing (aOR: 2.584, 95% CI: 1.874–3.563, p<0.001), and sexually transmitted infections (aOR: 1.736, 95% CI: 1.174–2.569, P = 0.006). Lower odds of nPEP awareness were associated with greater stigma score (aOR: 0.804, 95% CI: 0.713–0.906, P<0.001).

Conclusions

The findings indicate suboptimal awareness and low utilization of nPEP in Beijing and highlight nPEP inequities among MSM with stigma. Strengthening the training of health service providers and peer educators in reducing stigma and disseminating nPEP knowledge is imperative.

Risk From Within: Intraminority Gay Community Stress and Sexual Risk-Taking Among Sexual Minority Men

BACKGROUND

Sexual minority men remain highly impacted by the human immunodeficiency virus (HIV) with social stress being a clear predictor of their risk for infection. The past several decades of stress research regarding sexual minority men's HIV-risk behaviors has almost exclusively focused on the influence of stress emanating from outside the gay community (e.g., stigma-related stress, or minority stress, such as heterosexist discrimination). However, recent evidence suggests that sexual minority men also face stress from within their own communities.

PURPOSE

We sought to examine whether stress from within the gay community, or intraminority gay community stress, might influence sexual minority men's risk behaviors, including HIV-risk behaviors, over-and-above more commonly examined stressors affecting this risk.

METHODS

We tested whether intraminority gay community stress was associated with sexual minority men's HIV-risk behaviors in a large national survey of sexual minority men (Study 1), and experimentally tested intraminority gay community stress's impact on behavioral risk-taking and attitudes toward condom use (Study 2).

RESULTS

Self-reported exposure to intraminority gay community stress was positively associated with HIV-risk behaviors when accounting for the effects of several commonly examined minority stressors and general life stress (Study 1). Participants who were rejected from an online group of other sexual minority men evidenced greater risk-taking in a subsequent task and reported fewer benefits of condom use than participants who were accepted by the online group, when accounting for state affect (Study 2).

CONCLUSIONS

Sexual minority men's experiences of stress and rejection stemming from their own community may be an important and overlooked predictor of HIV infection and transmission.

Characterization of HIV Preexposure Prophylaxis Use Behaviors and HIV Incidence Among US Adults in an Integrated Health Care System

IMPORTANCE

Long-term follow-up is needed to evaluate gaps in HIV preexposure prophylaxis (PrEP) care delivery and to identify individuals at risk for falling out of care.

OBJECTIVE

To characterize the PrEP continuum of care, including prescription, initiation, discontinuation, and reinitiation, and evaluate incident HIV infections.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used data from the electronic health records (EHR) at Kaiser Permanente Northern California to identify individuals aged 18 years and older who received PrEP care between July 2012 and March 2019. Individuals were followed up from date of linkage (defined as a PrEP referral or PrEP-coded encounter) until March 2019, HIV diagnosis, discontinuation of health plan membership, or death. Data were analyzed from December 2019 to January 2021.

EXPOSURES

Sociodemographic factors included age, sex, race and ethnicity, and neighborhood deprivation index, and clinical characteristics were extracted from the EHR.

MAIN OUTCOMES AND MEASURES

The primary outcomes were attrition at each step of the PrEP continuum of care and incident HIV infections.

RESULTS

Among 13 906 individuals linked to PrEP care, the median (interquartile range [IQR]) age was 33 (27-43) years, 6771 individuals (48.7%) were White, and 13 227 (95.1%) were men. Total follow-up was 26 210 person-years (median [IQR], 1.6 [0.7-2.8] years). Of individuals linked to PrEP care, 88.1% (95% CI, 86.1%-89.9%) were prescribed PrEP and of these, 98.2% (95% CI, 97.2%-98.8%) initiated PrEP. After PrEP initiation, 52.2% (95% CI, 48.9%-55.7%) discontinued PrEP at least once during the study period, and 60.2% (95% CI, 52.2%-68.3%) of these individuals subsequently reinitiated. Compared with individuals aged 18 to 25 years, older individuals were more likely to receive a PrEP prescription (eg, age >45 years: hazard ratio [HR], 1.21 [95% CI, 1.14-1.29]) and initiate PrEP (eg, age >45 years: HR, 1.09 [95% CI, 1.02-1.16]) and less likely to discontinue (eg, age >45 years: HR, 0.46 [95% CI, 0.42-0.52]). Compared with White patients, African American and Latinx individuals were less likely to receive a PrEP prescription (African American: HR, 0.74 [95% CI, 0.69-0.81]; Latinx: HR, 0.88 [95% CI, 0.84-0.93]) and initiate PrEP (African American: HR, 0.87 [95% CI, 0.80-0.95]; Latinx: HR, 0.90 [95% CI, 0.86-0.95]) and more likely to discontinue (African American: HR, 1.36 [95% CI, 1.17-1.57]; Latinx: 1.33 [95% CI, 1.22-1.46]). Similarly, women, individuals with lower neighborhood-level socioeconomic status (SES), and persons with a substance use disorder (SUD) were less likely to be prescribed (women: HR, 0.56 [95% CI, 0.50-0.62]; lowest SES: HR, 0.72 [95% CI, 0.68-0.76]; SUD: HR, 0.88 [95% CI, 0.82-0.94]) and initiate PrEP (women: HR, 0.71 [95% CI, 0.64-0.80]; lower SES: HR, 0.93 [95% CI, 0.87-.0.99]; SUD: HR, 0.88 [95% CI, 0.81-0.95]) and more likely to discontinue (women: HR, 1.99 [95% CI, 1.67-2.38]); lower SES: HR, 1.40 [95% CI, 1.26-1.57]; SUD: HR, 1.23 [95% CI, 1.09-1.39]). HIV incidence was highest among individuals who discontinued PrEP and did not reinitiate PrEP (1.28 [95% CI, 0.93-1.76] infections per 100 person-years).

CONCLUSIONS AND RELEVANCE

These findings suggest that gaps in the PrEP care continuum were concentrated in populations disproportionately impacted by HIV, including African American individuals, Latinx individuals, young adults (aged 18-25 years), and individuals with SUD. Comprehensive strategies to improve PrEP continuum outcomes are needed to maximize PrEP impact and equity.

Biomedical HIV Prevention among Gay Male Couples: A Qualitative Study of Motivations and Concerns

Pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) are highly efficacious biomedical prevention strategies, which significantly reduce the risk of HIV transmission. Yet, partnered sexual minority men (SMM) continue to exhibit poorer uptake rates especially those in a non-monogamous or serodiscordant relationship for whom PrEP is recommended. The purpose of the study was to identify factors that may facilitate or impede the uptake of PrEP or PEP among partnered SMM. This qualitative study conducted semi-structured interviews with 10 sexual minority male couples recruited from the New York City metropolitan area. Thematic analysis identified relationship-specific and structural-level factors, which influence motivation and willingness for biomedical prevention uptake. Specifically, results highlighted the tension between relationship functioning and HIV prevention. In addition, stigma and access to knowledgeable health care providers diminished interest in biomedical prevention. Findings suggest a need for interventions that frame biomedical prevention in ways that minimize social perceptions of mistrust between partners and improve access.

Pre-Exposure Prophylaxis Care Continuum, Barriers, and Facilitators among Black Men Who Have Sex with Men in the United States: A Systematic Review and Meta-Analysis

Pre-exposure prophylaxis (PrEP) represents a viable HIV prevention tool for black men who have sex with men (BMSM). However, aggregated evidence regarding the presentations and determinants of the PrEP continuum (e.g., awareness, willingness, intention, uptake and adherence) remains absent to empirically inform future intervention efforts. We meta-analytically summarized the prevalence and qualitatively synthesized key barriers/facilitators of the stages of the PrEP continuum among a pooled sample of 42,870 BMSM aggregated from 56 published studies. Our random-effect models indicated a pooled prevalence of PrEP awareness (50.8%, 95% CI: 43.6-58.0%, willingness/intention (58.2%, 95% CI: 52.0-68.1%) and uptake (15.5%, 95% CI: 12.8-18.2%). Qualitative summary revealed that perception of HIV risk, intersectional/PrEP-related stigma and medical mistrust were among the most quoted factors that influence PrEP use. BMSM remain underrepresented in key stages of the PrEP continuum. Futures interventions are continuously needed to target multilevel barriers/facilitators to enhance the PrEP continuum among BMSM.

A Scoping Review of HIV Pre-exposure Prophylaxis Stigma and Implications for Stigma-Reduction Interventions for Men and Transwomen Who Have Sex with Men

HIV remains a public health concern in the United States. Although pre-exposure prophylaxis (PrEP) can be expected to reduce HIV incidence, its uptake, adherence, and persistence remain limited, particularly among highest priority groups such as men who have sex with men and transwomen (MSMTW). Using a socioecological framework, we conducted a scoping review to examine PrEP-related stigma to inform future research, policy, and programmatic planning. Using the PRISMA extension for scoping reviews, we conducted database searches from August 2018 to April 2020 for articles addressing PrEP stigma. Studies were independently screened and coded by three authors, resulting in thematic categorization of several types of PrEP stigma on four socioecological levels. Of 557 references, a final sample of 23 studies was coded, 61% qualitative, and 87% focusing exclusively on MSMTW. Most instances of PrEP-related stigma occurred on the interpersonal level and included associations of PrEP with risk promotion, HIV-related stigma, and promiscuity. Other frequent themes across socioecological levels included provider distrust and discrimination, government and pharmaceutical industry distrust, internalized homonegativity, PrEP efficacy distrust, and anticipated homonegativity. Notably, PrEP was also framed positively as having physical and psychological benefits, and assuming responsibility for protecting one's community via PrEP awareness-raising. PrEP-related stigma persists, demanding interventions to modify its impact. Leveraging PrEP-positive discourses to challenge PrEP stigma is an emerging avenue, alongside efforts to increase provider willingness to promote PrEP routinely by reducing provider bias, aligning with the national strategy to End the HIV Epidemic.

Intersecting Structural Oppression and Black Sexual Minority Men's Health

INTRODUCTION

Although evidence indicates that Black gay, bisexual, and other sexual minority men experience vast psychological and behavioral health inequities, most research has focused on individual rather than structural drivers of these inequities. This study examines the associations between structural racism and anti-lesbian, gay, bisexual, transgender, and queer policies and the psychological and behavioral health of Black and White sexual minority men.

METHODS

Participants were an Internet-based U.S. national sample of 1,379 Black and 5,537 White sexual minority men during 2017-2018. Analysis occurred in 2019-2020. Structural equation modeling tested the associations from indicators of structural racism, anti‒lesbian, gay, bisexual, transgender, and queer policies, and their interaction to anxiety symptoms, depressive symptoms, perceived burdensomeness, heavy drinking, and HIV testing frequency. Separate models for Black and White sexual minority men adjusted for contextual and individual covariates.

RESULTS

For Black participants, structural racism was positively associated with anxiety symptoms (β=0.20, SE=0.10, p=0.04), perceived burdensomeness (β=0.42, SE=0.09, p<0.001), and heavy drinking (β=0.23, SE=0.10, p=0.01). Anti‒lesbian, gay, bisexual, transgender, and queer policies were positively associated with anxiety symptoms (β=0.08, SE=0.04, p=0.03), perceived burdensomeness (β=0.20, SE=0.04, p<0.001), and heavy drinking (β=0.10, SE=0.04, p=0.01) and were negatively associated with HIV testing frequency (β= -0.14, SE=0.07, p=0.04). Results showed significant interaction effects, such that the positive associations between structural racism and both perceived burdensomeness (β=0.38, SE=0.08, p≤0.001) and heavy drinking (β=0.22, SE=0.07, p=0.003) were stronger for individuals living in states with high levels of anti‒lesbian, gay, bisexual, transgender, and queer policies. Neither of the oppression variables nor their interaction was significantly associated with outcomes for White sexual minority men.

CONCLUSIONS

Results highlight the intersectional nature of structural oppression and suggest that racist and anti-lesbian, gay, bisexual, transgender, and queer policies must be repealed to rectify health inequities facing Black sexual minority men.

State-Level Discrimination Policies And HIV Pre-Exposure Prophylaxis Adoption Efforts In The US

Pre-exposure prophylaxis (PrEP) is a drug regimen recommended for anyone at high risk of getting HIV to prevent them from being infected. Little research exists on how state-level policies might be related to differential PrEP uptake across the United States. To better understand the associations between state-level policies and PrEP uptake, we examined HIV criminalization, nondiscrimination laws for sexual and gender minorities, Medicaid expansion, Ryan White funding, and sociodemographic characteristics in relation to the PrEP-to-need ratio, a measure of PrEP uptake. Using a cross-sectional design, we analyzed data from all fifty states; Washington, D.C.; and Puerto Rico (all of which we categorize as states here) regarding policy, socioeconomic factors, and PrEP-to-need ratio in 2018. States with HIV criminalization laws had lower PrEP-to-need ratio, and states with more nondiscrimination laws for sexual and gender minorities had higher PrEP-to-need ratio. We found no association between Medicaid expansion, Ryan White funding, percentage Hispanic, percentage uninsured, median household income, percentage with high school education, or state population and PrEP uptake. Legislators should consider how laws concerning HIV and sexual and gender minorities might protect against discrimination and subvert fear and stigma, given the potential impact of these policies on HIV prevention.

A Review of the State of the Science of HIV and Stigma: Context, Conceptualization, Measurement, Interventions, Gaps, and Future Priorities

ABSTRACT

Stigma is a fundamental cause of health inequities. As such, stigma is a major barrier to HIV prevention, care, and treatment. This review will examine the concept of stigma, explicating the mechanisms of action of HIV-related stigma while also examining intersectional stigma and structural stigma. Instruments to measure HIV-related stigma and its mechanisms of action, as well as stigma enacted and experienced by HIV health care providers, will also be reviewed. This article will conclude with a review of stigma interventions, gaps in the literature, and priorities for future HIV, intersectional, and structural stigma research.

A Review of Recent HIV Prevention Interventions and Future Considerations for Nursing Science

ABSTRACT

As our knowledge of HIV evolved over the decades, so have the approaches taken to prevent its transmission. Public health scholars and practitioners have engaged in four key strategies for HIV prevention: behavioral-, technological-, biomedical-, and structural/community-level interventions. We reviewed recent literature in these areas to provide an overview of current advances in HIV prevention science in the United States. Building on classical approaches, current HIV prevention models leverage intimate partners, families, social media, emerging technologies, medication therapy, and policy modifications to effect change. Although much progress has been made, additional work is needed to achieve the national goal of ending the HIV epidemic by 2030. Nurses are in a prime position to advance HIV prevention science in partnership with transdisciplinary experts from other fields (e.g., psychology, informatics, and social work). Future considerations for nursing science include leveraging transdisciplinary collaborations and consider social and structural challenges for individual-level interventions.

mHealth to reduce HIV-related stigma among youth in the United States: a scoping review

Multiple intersecting stigmas and discrimination related to sex, gender, HIV, and race/ethnicity may challenge HIV prevention and treatment service utilization, particularly among youth. This scoping review describes recent and ongoing innovative mobile health (mHealth) interventions among youth in the United States that aim to reduce stigma as an outcome or as part of the intervention model. To identify examples of stigma-mitigation via mHealth, we searched peer-reviewed published literature using keyword strategies related to mHealth, HIV, stigma, and youth (ages 10 to 29). We identified eleven articles that met our inclusion criteria, including three describing data from two randomized controlled trials (RCTs), five describing pilot studies, one describing the process evaluation of an ongoing intervention, one describing formative work for intervention development, and one published study protocol for an ongoing intervention. We review these articles, grouped by HIV prevention and care continuum stages, and describe the mHealth approach used, including telehealth, simulation video games, motion comics, smartphone applications (apps), social media forums, online video campaigns, video vignettes, and a computerized behavioral learning module. Four studies focused on preventing primary acquisition through individual-level behavior change (e.g., reducing condomless anal intercourse), three focused on increasing HIV testing, three focused on linking to prevention services [e.g., pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP)] and one focused on promoting adherence to antiretroviral therapy (ART). Our review did not identify any published studies using mHealth with a primary aim to reduce stigma as a way to improve care engagement and increase viral suppression among youth in the United States. Additional RCTs and implementation studies examining the effectiveness of mHealth stigma-reduction interventions on HIV-related outcomes are needed to end the HIV epidemic among youth. mHealth offers unique advantages to address the complex intersecting stigma barriers along the HIV continuum to improve HIV-related outcomes for youth.

Structural Issues Associated with Pre-exposure Prophylaxis Use in Men Who Have Sex with Men

BACKGROUND

Limited access to healthcare has been associated with limited uptake of pre-exposure prophylaxis (PrEP) for HIV among men who have sex with men (MSM). This descriptive analysis examined, in a near universal healthcare setting, differences between MSM reporting using versus not using PrEP in the past 12 months.

METHOD

Data come from the 2017 Boston sample of the National HIV Behavioral Surveillance (NHBS) system, containing a venue-based and time-spaced sample of 530 MSM. The analysis used descriptive frequencies and tests of bivariate associations by PrEP use using Fisher's exact test.

RESULTS

Five hundred four respondents had data necessary to determine if PrEP was indicated, and 233 (43.9%) had an indication for PrEP. Of these 233 participants, 117 (50.2%) reported using PrEP in the past 12 months. Not being out, in terms of disclosing one's sexual orientation to a healthcare provider, lack of health insurance, limited access to healthcare, and history of incarceration were all significantly associated with not using PrEP in the past 12 months. Race/ethnicity was not significantly associated with PrEP use in the past 12 months.

CONCLUSIONS

In the setting of Massachusetts healthcare expansion and reform, and in a sample somewhat uncharacteristic of the population of individuals experiencing difficulties accessing PrEP, structural and demographic factors remain potent barriers to PrEP uptake. Targeted PrEP expansion efforts in Massachusetts may focus on identifying vulnerable subgroups of MSM (e.g., underinsured or criminal justice system-involved MSM) and delivering evidence-based interventions to reduce stigma and promote disclosure of same-sex behavior in healthcare settings.

Exploration of the Complex Relationships Among Multilevel Predictors of PrEP Use Among Men Who Have Sex with Men in the United States

To explore the relationships among individual-, social-, and contextual- (state-level characteristics, including LBGTQ + and racial inequality) level factors and PrEP use. A cross-sectional survey was conducted in 2015-2016 among a geographically diverse group of men who have sex with men (MSM). Survey data was linked to publicly available state-level data based on participant zip code. Multivariable multilevel logistic regression was used to explore the association between multilevel variables and PrEP use. Of 4165 HIV-negative MSM, 13.4% were taking PrEP. In the regression analysis, several demographic and behavioral factors were associated with higher odds of PrEP use. Importantly, after adjusting for individual- and social-level factors, residents of states with high LGBTQ + equality had significantly higher odds of taking PrEP (OR 1.57; 95% CI 1.119, 2.023) compared to low equality states. LGBTQ + inequality between states may hinder PrEP use. States may need to take proactive measures to reduce LGBTQ + inequality as this may negatively impact the ability to reach the federal administration's stated goal to end the HIV epidemic in the US.