Leveraging Technology to Blend Large-Scale Epidemiologic Surveillance With Social and Behavioral Science Methods: Successes, Challenges, and Lessons Learned Implementing the UNITE Longitudinal Cohort Study of HIV Risk Factors Among Sexual Minority Men in the United States

The use of digital technologies to conduct large-scale research with limited interaction (i.e., no in-person contact) and objective endpoints (i.e., biological testing) has significant potential for the field of epidemiology, but limited research to date has been published on the successes and challenges of such approaches. We analyzed data from a cohort study of sexual minority men across the United States, collected using digital strategies during a 10-month period from 2017 to 2018. Overall, 113,874 individuals were screened, of whom 26,000 were invited to the study, 10,691 joined the study, and 7,957 completed all enrollment steps, including return of a human immunodeficiency virus-negative sample. We examined group differences in completion of the steps towards enrollment to inform future research and found significant differences according to several factors, including age and race. This study adds to prior work to provide further proof-of-concept for this limited-interaction, technology-mediated methodology, highlighting some of its strengths and challenges, including rapid access to more diverse populations but also potential for bias due to differential enrollment. This method has strong promise, and future implementation research is needed to better understand the roles of burden, privacy, access, and compensation, to enhance representativeness and generalizability of the data generated.

Chronic High Risk Prescription Opioid Use Among Persons With HIV

Persons with HIV (PWH) are a population at risk for adverse sequelae of opioid use. Yet, few studies have examined correlates of chronic high risk opioid use and its impact on HIV outcomes. Trends in prescribing patterns and identification of factors that impact the use of opioid prescriptions among PWH are crucial to determine prevention and treatment interventions. This study examined electronic medical records (EMR) of patients receiving HIV care to characterize prescribing patterns and identify risk factors for chronic high risk prescription opioid use and the impact on HIV outcomes among PWH in primary care from July 1, 2016-December 31, 2017. EMR were analyzed from 8,882 patients who were predominantly male and ethnically and racially diverse with half being 50 years of age or older. The majority of the 8,744 prescriptions (98% oral and 2% transdermal preparations) given to 1,040 (12%) patients were oxycodone (71%), 8% were morphine, 7% tramadol, 4% hydrocodone, 4% codeine, 2% fentanyl, and 4% were other opioids. The number of monthly prescriptions decreased about 14% during the study period. Bivariate analyses indicated that most demographic and clinical variables were associated with receipt of any opioid prescription. After controlling for patient socio-demographic characteristics and clinical factors, the odds of receipt of any prescription were higher among patients with pain diagnoses and opioid use and mental health disorders. In addition, the odds of receipt of high average daily morphine equivalent dose (MED) prescriptions were higher for patients with pain diagnoses. Lastly, patients with substance use disorders (SUD) had an increased likelihood of detectable viral load compared to patients with no SUD, after adjusting for known covariates. Our findings show that despite opioid prescribing guidelines and monitoring systems, additional efforts are needed to prevent chronic high risk prescriptions in patients with comorbid conditions, including pain-related, mental health and substance use disorders. Evidence about the risk for chronic high risk use based on prescribing patterns could better inform pain management and opioid prescribing practices for patients receiving HIV care.

A systematic review of stigma in sexual and gender minority health interventions

Stigma against sexual and gender minorities is a major driver of health disparities. Psychological and behavioral interventions that do not address the stigma experienced by sexual and gender minorities may be less efficacious. We conducted a systematic review of existing psychological and behavioral health interventions for sexual and gender minorities to investigate how interventions target sexual and gender minority stigma and consider how stigma could affect intervention efficacy. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were followed. Eligible studies were peer reviewed and published in English between January 2003 and July 2019 and reported empirical results of behavioral or psychological interventions implemented among sexual and gender minorities. All interventions addressed stigma. We identified 37 eligible interventions. Most interventions targeted sexual minority men. Interventions were frequently developed or adapted for implementation among sexual and gender minorities and addressed multiple levels and types of stigma. Interventions most frequently targeted proximal stressors, including internalized and anticipated stigma. HIV and mental health were the most commonly targeted health outcomes. A limited number of studies investigated the moderating or mediating effects of stigma on intervention efficacy. The application of an intersectional framework was frequently absent and rarely amounted to addressing sources of stigma beyond sexual and gender minority identities. A growing number of interventions address sexual and gender minority stigma in an effort to prevent deleterious health effects. Future research is needed to assess whether stigma modifies the effectiveness of existing psychological and behavioral interventions among sexual and gender minorities. Further, the application of intersectional frameworks is needed to more comprehensively intervene on multiple, intersecting sources of stigma faced by the diverse sexual and gender minority community.

Treatment Is More Than Prevention: Perceived Personal and Social Benefits of Undetectable = Untransmittable Messaging Among Sexual Minority Men Living with HIV

Research suggests that the science of undetectable viral load (VL) status and HIV transmission-conveyed with the slogan "Undetectable = Untransmittable" or "U = U"-has gaps in acceptance despite robust scientific evidence. Nonetheless, growing acceptance of U = U creates conditions for a shift in the sociopolitical and personal implications of viral suppression. We conducted an online survey over a 23-month period in 2018 and 2019 among 30,361 adolescent and adult (aged 13-99) sexual minority men living with HIV (SMM-LHIV) across the United States. We examined the impact of U = U on self-image, potential for changing societal HIV stigma, whether SMM-LHIV had ever spoken with a provider about viral suppression and HIV transmission, and primary sources of hearing about U = U. Approximately 80% of SMM-LHIV reported that U = U was beneficial for their self-image and societal HIV stigma, 58.6% reported it made them feel "much better" about their own HIV status, and 40.6% reporting it had the potential to make HIV stigma "much better." The most consistent factors associated with these beliefs centered around care engagement, particularly self-reported viral suppression and excellent antiretroviral therapy adherence. Two-thirds reported ever talking to a provider about VL and HIV transmission, although the primary sources for having heard about U = U were HIV and lesbian, gay, bisexual, transgender, and queer (LGBTQ) news media and personal profiles on networking apps. These findings demonstrate the significant personal and social importance of U = U for SMM-LHIV that go above-and-beyond the well-documented health benefits of viral suppression, suggesting that providers should consider routinely initiating conversations with patients around the multifaceted benefits (personal health, sexual safety and intimacy, increased self-image, and reduced social stigma) of viral suppression.

Evaluation of a Stepped-Care eHealth HIV Prevention Program for Diverse Adolescent Men Who Have Sex With Men: Protocol for a Hybrid Type 1 Effectiveness Implementation Trial of SMART

BACKGROUND

Adolescent men who have sex with men (AMSM), aged 13 to 18 years, account for more than 80% of teen HIV occurrences. Despite this disproportionate burden, there is a conspicuous lack of evidence-based HIV prevention programs. Implementation issues are critical as traditional HIV prevention delivery channels (eg, community-based organizations, schools) have significant access limitations for AMSM. As such, eHealth interventions, such as our proposed SMART program, represent an excellent modality for delivering AMSM-specific intervention material where youth are.

OBJECTIVE

This randomized trial aimed to test the effectiveness of the SMART program in reducing condom-less anal sex and increasing condom self-efficacy, condom use intentions, and HIV testing for AMSM. We also plan to test whether SMART has differential effectiveness across important subgroups of AMSM based on race and ethnicity, urban versus rural residence, age, socioeconomic status, and participation in an English versus a Spanish version of SMART.

METHODS

Using a sequential multiple assignment randomized trial design, we will evaluate the impact of a stepped-care package of increasingly intensive eHealth interventions (ie, the universal, information-based SMART Sex Ed; the more intensive, selective SMART Squad; and a higher cost, indicated SMART Sessions). All intervention content is available in English and Spanish. Participants are recruited primarily from social media sources using paid and unpaid advertisements.

RESULTS

The trial has enrolled 1285 AMSM aged 13 to 18 years, with a target enrollment of 1878. Recruitment concluded in June 2020. Participants were recruited from 49 US states as well as Puerto Rico and the District of Columbia. Assessments of intervention outcomes at 3, 6, 9, and 12 months are ongoing.

CONCLUSIONS

SMART is the first web-based program for AMSM to take a stepped-care approach to sexual education and HIV prevention. This design indicates that SMART delivers resources to all adolescents, but more costly treatments (eg, video chat counseling in SMART Sessions) are conserved for individuals who need them the most. SMART has the potential to reach AMSM to provide them with a sex-positive curriculum that empowers them with the information, motivation, and skills to make better health choices.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT03511131; https://clinicaltrials.gov/ct2/show/NCT03511131.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/19701.

Intersectional social control: The roles of incarceration and police discrimination in psychological and HIV-related outcomes for Black sexual minority men

RATIONALE

Although Black gay, bisexual, and other sexual minority men face disproportionately high levels of incarceration and police discrimination, little research examines how these stressors may drive HIV and psychological health inequities among these men.

OBJECTIVE

In this study we examined associations between incarceration history, police and law enforcement discrimination, and recent arrest with sexual HIV risk, Pre-Exposure Prophylaxis (PrEP) willingness, and psychological distress among Black sexual minority men.

METHOD

Participants were a U.S. national sample of 1172 Black sexual minority men who responded in 2017-2018 to self-report measures of incarceration history, past year police and law enforcement discrimination, recent arrests, sexual HIV risk, PrEP willingness, and psychological distress. We used structural equation modeling to examine direct and indirect pathways from incarceration, police and law enforcement discrimination, and arrests to sexual HIV risk, PrEP willingness, and psychological distress.

RESULTS

Past-year police and law enforcement discrimination prevalence was 43%. Incarceration history was positively associated with later police and law enforcement discrimination, which, in turn, was positively associated with recent arrest. Incarceration and recent arrest and were associated with greater sexual HIV risk; incarceration and police and law enforcement discrimination were associated with lower PrEP willingness; and police and law enforcement discrimination was associated with higher psychological distress. Mediation analyses showed that the effects of incarceration were partially mediated by police and law enforcement discrimination.

CONCLUSION

Findings suggest police discrimination may be a mechanism of mass incarceration and fundamental driver of health inequities among Black sexual minority men.

Willingness to Distribute HIV Self-Testing Kits to Recent Sex Partners Among HIV-Negative Gay and Bisexual Men and an Examination of Free-Response Data from Young Men Participating in the Nationwide Cohort

Sexual minority men (SMM)-and young SMM in particular-are disproportionately affected by HIV. Secondary distribution of HIV self-testing (HIVST) kits-wherein patients deliver kits to partners-is a novel strategy to increase HIV testing access. Using quantitative data, we assessed willingness to distribute HIVST kits to recent sex partners among a U.S. national sample of HIV-negative SMM (n = 786). A thematic analysis was then conducted to identify barriers and facilitators of kit distribution to partners among young SMM (M age = 25.75 years; range: 20-29; n = 165). Overall, 93.5% of SMM (and 97.0% of young SMM) were willing to deliver HIVST kits to recent sex partners. Among young SMM, main barriers and facilitators included concerns about their partners' reaction, availability and cost, protection beliefs for others, HIV stigma and perceived infidelity, packaging and support, communication skill needs, inability to contact partners, requests for anonymity, and dyadic self-testing with their partners. The findings highlight the need for supportive intervention strategies such as informational content for HIVST, using motivational interviewing when providing the testing kits to index clients and providing skills-based training through role-playing exercises. Secondary distribution of HIVST kits through index patients is a potentially acceptable approach that could be used to expand access to HIV testing and aid in efforts to end the HIV epidemic in the U.S.

Psychosocial Well-Being and HIV-Related Immune Health Outcomes among HIV-Positive Older Adults: Support for a Biopsychosocial Model of HIV Stigma and Health

Evidence suggests that psychosocial stress negatively impacts immunological health in HIV-positive individuals. However, few studies have explored this association in substance-using older adults living with HIV (OALWH). We evaluated the effect of depression, loneliness, substance use problems, and HIV stigma on primary markers of immune function in a sample of 120 OALWH with substance-related issues. HIV stigma correlated with the greatest number of factors, including depression, loneliness, and substance use problems. Older age and antiretroviral adherence were associated with viral suppression, which was in turn associated with higher percentage of CD4 count. Multivariate path analyses demonstrated that lower HIV stigma and viral suppression were the only factors independently associated with higher percentage of CD4 count, with a significant indirect effect of adherence on CD4 through viral suppression. HIV stigma emerged as the most salient factor associated with both psychosocial well-being and immune health in the current study, suggesting that it is a critical factor to consider in future interventions for the rapidly growing population of OALWH.

The Mediating Role of Psychological Distress in the Association between Harassment and Alcohol Use among Lesbian, Gay, and Bisexual Military Personnel

BACKGROUND

The purpose of this study was to examine the mediating role of psychological distress on the associations between two forms of harassment, military sexual trauma (MST) and sexual orientation-based discrimination (SOBD), and alcohol use in a sample of lesbian, gay, and bisexual (LGB) military personnel. Methods: Data were analyzed from 254 LGB military service members in the United States. Bivariate associations were examined between MST, SOBD, anxiety and depression, distress in response to stressful military events, and alcohol use. A latent psychological distress factor was estimated using anxiety and depression, and distress in response to stressful military events. Path analyses were used to estimate the direct effects of MST and SOBD on alcohol use and the indirect effects of MST and SOBD on alcohol use through psychological distress. Results: All bivariate associations were positive and significant between MST, SOBD, anxiety and depression, distress in response to military events, and alcohol use. In multivariable analyses, after adjusting for demographic covariates, a significant indirect effect was observed for SOBD on alcohol use through psychological distress. MST was not directly or indirectly associated with alcohol use when SOBD was included in the path model. Conclusion: Overall, findings suggest SOBD is associated with poorer mental health, which in turn places LGB military personnel at greater risk of alcohol use and associated problems. These results affirm the need for interventions that reduce SOBD in the military and suggest that these interventions will have a positive impact on the health of LGB military personnel.

Sociodemographic and behavioural factors associated with testing for HIV and STIs in a US nationwide sample of transgender men who have sex with men

OBJECTIVES

Transgender men who have sex with men (TMSM) represent an understudied population in relation to screening for HIV and sexually transmitted infections (STIs). We examined HIV and STI testing prevalence among TMSM along with the factors associated with testing in a diverse US nationwide sample of TMSM.

METHODS

Data from a cross-sectional online convenience sample of 192 TMSM were analysed using multivariable binary logistic regression models to examine the association between sociodemographic and behavioural factors and lifetime testing for HIV, bacterial STIs and viral STIs, as well as past year testing for HIV.

RESULTS

More than two-thirds of TMSM reported lifetime testing for HIV (71.4%), bacterial STIs (66.7%), and viral STIs (70.8%), and 60.9% had received HIV testing in the past year. Engaging in condomless anal sex with a casual partner whose HIV status is different or unknown and having fewer than two casual partners in the past 6 months were related to lower odds of lifetime HIV, bacterial STI, viral STI and past year HIV testing. Being younger in age was related to lower probability of testing for HIV, bacterial STIs and viral STIs. Furthermore, TMSM residing in the South were less likely to be tested for HIV and viral STIs in their lifetime, and for HIV in the past year. Finally, lower odds of lifetime testing for viral STIs was found among TMSM who reported no drug use in the past 6 months.

CONCLUSIONS

These findings indicate that a notable percentage of TMSM had never tested for HIV and bacterial and viral STIs, though at rates only somewhat lower than among cisgender MSM despite similar patterns of risk behaviour. Efforts to increase HIV/STI testing among TMSM, especially among those who engage in condomless anal sex, are needed.

Measuring Experiences of Minority Stress for Transgender Women: Adaptation and Evaluation of Internalized and Anticipated Transgender Stigma Scales

Purpose: Transgender women (TGW) experience high rates of stigma based on their gender identity. Research has documented how transgender stigma and other discrimination negatively contribute to health inequities, including higher rates of depression compared with the general population. However, few scales measuring transgender stigma exist, even fewer that specifically assess anticipated or internalized transgender stigma. We sought to validate an adapted transgender stigma scale in a diverse sample of TGW. Methods: We adapted an existing stigma measure to capture experiences of anticipated and internalized transgender stigma for TGW. Adapted measures were completed by 213 diverse TGW. Factor analysis was completed to reduce the number of items in each scale and sociodemographic differences in each construct were explored. Results: The final nine items comprising anticipated transgender stigma and the five items for internalized transgender stigma both showed evidence of adequate model fit, unidimensionality, and internal consistency. The two constructs were moderately correlated with one another (r=0.36, p<0.001). We identified educational and HIV status differences in anticipated transgender stigma but no sociodemographic differences in internalized transgender stigma. Conclusion: We developed brief measures of internalized and anticipated transgender stigma through initial adaptation by TGW themselves and subsequent psychometric evaluation, demonstrating evidence of unidimensionality and internal consistency. These subscales were only moderately associated with one another and may provide unique insights in future research on minority stress among TGW.

Factors Associated With HIV Testing in Teenage Men Who Have Sex With Men

BACKGROUND

Adolescent men who have sex with men (AMSM) have a high rate of HIV diagnoses. An estimated 14.5% of HIV infections in the United States are undiagnosed; but among 13- to 24-year-olds, the rate is 51.4%. We describe HIV testing rates and identifies salient individual, family, school, and health care influences among AMSM.

METHODS

Data were collected as part of SMART, an ongoing pragmatic trial of an online HIV prevention intervention for AMSM (N = 699). Measures included lifetime HIV testing, demographics, sexual behaviors, condom use, HIV education from school and family, sexual health communication with doctors, HIV knowledge, and risk attitudes.

RESULTS

Only 23.2% of participants had ever had an HIV test. Rates of testing increased with age (5.6% in 13- to 14-year-olds; 15.8% in 15- to 16-year-olds; 37.8% in 17- to 18-year-olds), and sexual experience was a strong predictor of testing (odds ratio: 6.54; 95% confidence interval: 3.95-11.49; P < .001). Most participants had a regular doctor (67.5%), but few had conversations about same-sex sexual behaviors (21.3%), HIV testing (19.2%), or sexual orientation (29.2%). Speaking to a doctor about HIV testing had a large effect (odds ratio: 25.29; confidence interval: 15.91-41.16; P < .001), with 75.4% who had such conversations having been tested, compared to only 10.8% of those who had not had such conversations.

CONCLUSIONS

Despite higher risk, few participants reported ever having received an HIV test. Data indicate pediatricians are an important, but largely untapped, source of testing and could be integral to achieving testing rates needed to end the epidemic.

Intersectional discrimination, positive feelings, and health indicators among Black sexual minority men

OBJECTIVE

This study examined psychological and sexual health indicators associated with positive feelings and discrimination at the intersection of race and gender among Black gay, bisexual, and other sexual minority men (SMM).

METHOD

Participants were a national sample of 1,064 Black SMM (Mdn age = 28) who responded to self-report measures of positive feelings and discrimination associated with being a Black man, psychological distress, self-efficacy, emotional awareness, and sexual HIV risk and protective behavior. Using structural equation modeling, we examined associations between the positive feelings and discrimination scales and the psychological and sexual health indicators. We also tested age as a moderator of these associations.

RESULTS

Our results indicated that positive feelings about being a Black man were significantly positively associated with self-efficacy (b = 0.33), emotional awareness (b = 0.16), and sexual protective behavior (b = 0.93) and negatively associated with psychological distress (b = -0.26) and sexual risk behavior (b = -0.93). Except for emotional awareness and sexual protective behavior, discrimination as a Black man was also associated with these variables, though to a lesser magnitude for positive health indicators. Moderation results showed that, except for the association between positive feelings and emotional awareness, younger men generally had stronger associations between health indicators and the positive feelings and discrimination scales.

CONCLUSIONS

These results suggest that positive feelings, in addition to discrimination, at the intersection of race and gender play an important role in the psychological and sexual health of Black SMM, especially earlier in their lives. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Rates of Pre-exposure Prophylaxis Use and Discontinuation Among a Large U.S. National Sample of Sexual Minority Men and Adolescents

Pre-exposure prophylaxis (PrEP) is highly effective in the prevention of HIV acquisition and was recently approved for those under 18 years of age. The primary goal of the present study was to understand the prevalence of and factors associated with PrEP use among a large sample of young and adult sexual minority men (Y/SMM). Participants came from a larger national sample of SMM. Data collected included demographics, substance use, PrEP use, and sexual risk. Participants were recruited via sexual networking/dating applications and resided in the U.S. including Puerto Rico, were at least 13 years old, self-reported being HIV-negative, and identified as male. The sample was divided into two groups: YSMM (13-24 years of age) and adult SMM (25 years of age and up). Multinomial logistic regressions examining associations with never, current, and former PrEP use were run with all variables of interest simultaneously entered into the models. Age was positively associated with both former and current PrEP use among YSMM. Additionally, YSMM who identified as gay (vs. bisexual), lived in the Northeast, Midwest, and West (vs. South), had their own health insurance (vs. those on their parent's), had recently been diagnosed with an STI, and had recently used a drug all had higher odds of being a current PrEP user compared to those that had never used PrEP. Among adult SMM, those who were older did not have higher odds of current PrEP use compared to those that had never used PrEP. Those who identified as queer (vs. gay), single, had their own or were on their partner's insurance (vs. parent's), recent condomless anal sex, recent STI diagnosis, recent drug use, and recent substance use all had higher odds of being a current PrEP user compared to those that had never used PrEP. Research is needed to address the disparities in PrEP uptake among YSMM. Interventions for PrEP access among those on their parents' insurance may also be necessary.

Seeing Is Believing? Unique Capabilities of Internet-Only Studies as a Tool for Implementation Research on HIV Prevention for Men Who Have Sex With Men: A Review of Studies and Methodological Considerations

BACKGROUND

In 2014, Grov et al published a comprehensive review cataloguing both men who have sex with men's (MSM's) sexual behavior transitions in online environments from the 1990s through 2013, as well as researchers' efforts in tandem to use the internet to engage MSM into research, treatment, and prevention.

METHODS

In this article, we discuss historical events and research having occurred in the half decade since the Grov et al publication.

RESULTS

Notable transitions include MSM's expanded use of geosocial networking apps, as well as other forms of social media accessed primarily through mobile devices, as well as the addition of biomedical prevention strategies (eg, pre-exposure prophylaxis and undetectable = untransmittable) to the proverbial HIV prevention toolkit. In tandem, researchers have rapidly expanded their employment of internet-mediated methods for the recruitment and engagement of key populations for HIV research, treatment, and prevention. In this article, we discuss methodological considerations for using the internet to conduct HIV prevention research with MSM: (1) sources of recruitment (eg, geosocial apps, Facebook, crowdsourced online panels); (2) design (eg, cross sectional, longitudinal, diaries); (3) incentives (including disincentivizing fraudulent participants and/or spam bots); (4) confidentiality; and (5) representativeness.

CONCLUSION

We conclude by discussing future directions in HIV prevention research in light of forthcoming technologies such as fifth generation (5G) mobile networks, combined use of self-collected biological data alongside self-report, and the utility of metadata and metaresearch to document, evaluate, and inform best practices.

The Impact of Pre-Exposure Prophylaxis (PrEP) Use on Sexual Anxiety, Satisfaction, and Esteem Among Gay and Bisexual Men

Gay and bisexual men (GBM) with heightened fears of human immunodeficiency virus (HIV) acquisition have reported high levels of sexual anxiety and low sexual self-esteem. Similarly, sexual satisfaction has been reported to be lower among some GBM who rely solely on condom use as HIV prevention. We sought to explore whether pre-exposure prophylaxis (PrEP) had an impact on the sexual satisfaction, anxiety, and esteem of GBM. As part of a longitudinal cohort study of 1,071 GBM, participants reported at three time points on PrEP use and completed the Multidimensional Sexual Self-Concept Questionnaire (MSSCQ). A total of 137 GBM began taking PrEP in the 24 months following baseline. Comparing their responses during times before initiating PrEP and after, within adjusted multilevel models, there was a significant decrease in sexual anxiety (B = -0.27, p = 0.03) but no significant changes in sexual esteem or satisfaction. Our findings indicate important psychological improvements resulting from PrEP initiation. Further research should explore the potential for other psychological benefits of PrEP use among GBM.

Attachment as a Predictor of Psychological and Sexual Wellbeing Among Transgender Women in New York City

Transgender women are disproportionately affected by HIV and experience high rates of depression and anxiety. The importance of secure attachment in buffering against negative sexual and mental health outcomes is well established. However, few studies have examined attachment among transgender women. We recruited a community-based convenience sample of 213 transgender women in New York City (M_age =34.3; SD = 11.7). The majority were women of color (75.6%), almost half identified as heterosexual (47.4%), and 34.7% were HIV-positive. Preliminary analyses examined the sample distribution across attachment categories using the Revised Experiences in Close Relationships scale. Specifically, Brennan, Clark and Shaver's guidelines were used for categorization (43.19% fearful, 22.5% preoccupied, 21.6% dismissive, and 12.7% secure). Regression analyses examined the association of dimensional attachment anxiety, attachment avoidance, and their interaction with depression, anxiety, self-efficacy for condom use, temptations for condomless sex, and condomless sex acts. Results indicated a positive association between attachment anxiety and depression, anxiety, temptations and probability for condomless sex; and also between attachment avoidance and condomless sex probability. A significant interaction indicated that individuals with low attachment anxiety and attachment avoidance (i.e., secure) had the greatest condom use self-efficacy and the lowest probability of engaging in condomless sex.

The Somatic Marker Hypothesis and Sexual Decision Making: Understanding the Role of Iowa Gambling Task Performance and Daily Sexual Arousal on the Sexual Behavior of Gay and Bisexual Men

Background

The sexual decision-making literature suggests that sexual arousal and behavior are associated. The somatic marker hypothesis suggests that individual neuropsychological differences in decision making, as measured by the Iowa Gambling Task (IGT), may moderate these associations; however, this hypothesis has yet to be tested with event-level sexual behavior data.

Purpose

We hypothesized that (a) daily sexual arousal would be positively associated with likelihood of engaging in sex and condomless anal sex (CAS) and (b) IGT scores would moderate these associations such that the associations would be stronger among those with higher IGT scores.

Methods

We used daily diary data from 334 highly sexually active gay and bisexual men to examine the main and interaction effects of sexual arousal and IGT scores on sexual engagement and CAS.

Results

As hypothesized, daily sexual arousal was positively associated with greater odds of both sexual engagement and CAS with casual male partners. Individual-level IGT performance significantly moderated the day-level association between arousal and sexual engagement, which was stronger for men with higher IGT scores. There was no main effect of IGT scores on either sexual behavior outcome, nor did it moderate the association between arousal and CAS.

Conclusions

These findings highlight the influence of sexual arousal on sexual engagement, which differed by IGT scores; the effect of arousal on CAS was much less variable and may not be moderated by neurocognitive factors. This study supports the importance of exploring integrated behavioral/biomedical interventions to improve individual decision making to prevent HIV infection.

Gay and bisexual men's experiences using self-testing kits for HIV and rectal and urethral bacterial sexually transmitted infections: Lessons learned from a study with home-based testing

This study investigated the experiences of gay, bisexual, and other men who have sex with men (GBM) conducting HIV and sexually transmitted infection (STI) self-testing procedures. We analyzed mixed-methods data from 11 GBM who self-tested HIV-positive and 1,070 HIV-negative GBM who completed the HIV self-testing and STI self-sampling procedures. Nearly all (99%) reported ease in urine-based STI self-sampling and most (90%) found rectal swab self-collection easy. Most (94%) checked their rapid-HIV self-testing results during the correct window (20-40 minutes), and nearly all (99%) trusted their HIV results. Recommendations for future self-testing procedures are provided based on findings from free-response data.

High willingness to use novel HIV and bacterial sexually transmitted infection partner notification, testing, and treatment strategies among gay and bisexual men

OBJECTIVES

We sought to determine willingness of gay and bisexual men (GBM) to give HIV self-testing (HIVST) kits with patient-delivered partner therapy (PDPT) and engage in geosocial sexual networking (GSN) app-based partner notification.

METHODS

A nationwide sample of GBM who self-tested HIV negative (n=786) were asked about their willingness to give recent sex partners (main and casual) PDPT with an HIVST kit (PDPT+HIVST) after hypothetical bacterial STI (BSTI) diagnosis. Men were also asked about their willingness to notify sexual partners met on GSN apps using an anonymous app function after BSTI diagnosis. We examined associations of relationship status and condomless anal sex with casual partners, recent BSTI diagnosis and perceived risk of HIV on PDPT+HIVST and anonymous app-based partner notification willingness (dichotomised) using binary logistic regressions, adjusting for age, race/ethnicity, education and US region. From the partner's perspective after receiving an app-based referral, frequency measures were used to report intentions for obtaining subsequent HIV/BSTI counselling and testing, engaging in HIVST if provided a free voucher, and obtaining BSTI treatment from a pharmacy with prescription voucher.

RESULTS

Most (90.1%) were willing to give PDPT+HIVST to recent sex partners after STI diagnosis, and nearly all (96.4%) were willing to notify sex partners met online using an anonymous function within GSN apps. Regardless of casual partner condomless anal sex engagement, partnered GBM had higher odds of reporting willingness to give PDPT+HIVST compared with single men who recently engaged in condomless anal sex with a casual partner. If anonymously notified via an app, 92.5% reported they would likely obtain counselling and testing, 92.8% would engage in HIVST if provided a free voucher, and 93.4% would obtain treatment from a pharmacy with prescription voucher.

CONCLUSIONS

GBM generally found novel partner notification, testing, and treatment strategies acceptable, indicating the need for feasibility and cost-effectiveness evaluations.

Transactional sex, condomless anal sex, and HIV risk among men who have sex with men

To understand the HIV epidemic among men who have sex with men who engage in transactional sex (MSM-TS) in Paris, France, we sought to examine the association between engagement in transactional sex and HIV risk behaviors among MSM in Paris, France. Users of a geosocial-networking application in Paris were provided an anonymous web-based survey ( N = 580), which included questions about transactional sex and behavioral risk factors for HIV along with sexually transmitted infection (STI)/HIV status. Multivariate analyses showed that engagement in transactional sex was associated with condomless receptive and insertive anal intercourse (adjusted relative risk [aRR] = 1.34, 95% confidence interval [CI] = 1.04–1.72 and aRR = 1.41, 95% CI = 1.04–1.91, respectively). MSM-TS were more likely to have engaged in substance use before or during sex (aRR = 1.35, 95% CI = 1.13–1.62), to have participated in group sex (aRR = 1.37, CI = 1.13–1.62), and to have had an STI during the last year (aRR = 1.68, 95% CI = 1.16–2.45). Transactional sex was not associated with HIV status. MSM-TS in Paris engaged in higher HIV risk behaviors, however, did not have higher rates of HIV infection. Sexual health interventions should continue to target MSM-TS; however, future studies should characterize the social, cultural, and structural factors that interact with individual behaviors to elevate HIV risk for MSM-TS.

Factors associated with perceived accuracy of the Undetectable = Untransmittable slogan among men who have sex with men: Implications for messaging scale-up and implementation

INTRODUCTION

Recent research has shown high efficacy of HIV treatment for reducing the risk of HIV transmission to sexual partners. As the efficacy of treatment as prevention (TasP) has proliferated, a new messaging campaign, Undetectable = Untransmittable, has been gaining popularity. The purpose of this paper was to assess factors associated with the perceived accuracy of this TasP messaging strategy among a large and diverse sample of gay, bisexual, and other men who have sex with men (GBMSM) in order to inform subsequent efforts at large-scale and implementation of the HIV prevention message.

METHODS

We conducted a nationwide survey of GBMSM in the U.S. recruited from an online social networking site and a mobile sexual networking app. We analysed data from 12,222 GBMSM separately by HIV status to examine sociodemographic and behavioural factors associated with ratings of the accuracy of the Undetectable = Untransmittable message, which included the option to indicate not understanding what "undetectable" meant.

RESULTS

Among HIV-negative and unknown men, multivariable linear regression indicated that being on pre-exposure prophylaxis (PrEP), identifying as gay or queer (versus bisexual or straight), recent serodiscordant condomless anal sex (CAS), testing every six months or more often, less concern about sexually transmitted infection (STI) infection, and lower perceived risk of HIV infection were the factors with the largest independent effect on rating the Undetectable = Untransmittable statement as more accurate. Fewer factors emerged as associated with accuracy ratings among HIV-positive participants-reporting an undetectable viral load, a lifetime acquired immune deficiency syndrome (AIDS) diagnosis, and lower concern about STI infection were the factors most strongly associated with rating the statement as more accurate.

CONCLUSIONS

The findings of the current study highlight variability in the perceived accuracy of the Undetectable = Untransmittable message, suggesting potential subgroups who might benefit from targeted educational campaigns, perhaps broadcast utilizing sexual networking apps. Numerous factors, particularly among HIV-negative and unknown GBMSM, were associated with rating the message as more accurate. In particular, being on PrEP and testing regularly were two of the variables most strongly associated with higher accuracy ratings among HIV-negative GBMSM, suggesting HIV prevention services as potential points of intervention for increasing HIV knowledge and decreasing HIV stigma.

The Role of Self-Conscious Emotions in the Sexual Health of Gay and Bisexual Men: Psychometric Properties and Theoretical Validation of the Sexual Shame and Pride Scale

Researchers have theorized about the role of sexual shame as a mechanism through which sexual minority stress manifests into mental health difficulties, such as sexual compulsivity for gay and bisexual men (GBM), and about the resilience-promoting effects of sexual pride. However, no validated measures to date have directly tapped into these constructs rather than using proxies for them, such as internalized homonegativity. We developed the Sexual Shame and Pride Scale (SSPS) and conducted a psychometric evaluation of it using a sample of 260 highly sexually active GBM. The scale had the expected structure in factor analysis and showed evidence of internal consistency and test-retest reliability. Correlational analyses demonstrated the convergent validity of sexual shame and sexual pride with relevant constructs. Regression analyses demonstrated the predictive validity of sexual shame in relation to sexual compulsivity, accounting for unique variability even after adjusting for previously demonstrated etiological factors, and the predictive validity of both shame and pride, which interacted to consistently predict four sexual behavior outcomes. Findings suggest the SSPS is a psychometrically valid and reliable measure that may be useful in future empirical work and highlight preliminary evidence for the role of these constructs in the sexual health of GBM.

Determining the Roles that Club Drugs, Marijuana, and Heavy Drinking Play in PrEP Medication Adherence Among Gay and Bisexual Men: Implications for Treatment and Research

Researchers have established that substance use interferes with anti-retroviral medication adherence among gay and bisexual men (GBM) living with HIV. There is limited parallel examination of pre-exposure prophylaxis (PrEP) adherence among HIV-negative GBM. We conducted retrospective 30-day timeline follow-back interviews and prospective semi-weekly diary data for 10 weeks with 104 PrEP-using GBM, half of whom engaged in club drug use (ketamine, ecstasy, GHB, cocaine, or methamphetamine)-generating 9532 days of data. Participants reported their day-by-day PrEP, club drug, marijuana, and heavy alcohol use (5 + drinks in one sitting). On average, club drug users were no more likely to miss a dose of PrEP than non-club drug users (M = 1.6 doses, SD = 3.0, past 30 days). However, we found that club drug use (at the event level) increased the odds of missing a dose on the same day by 55% and the next day (e.g., a "carryover effect") by 60%. Further, missing a dose on one day increased the odds of missing a dose the following day by eightfold. We did not identify an event-level effect of marijuana use or heavy drinking on PrEP adherence. Our data suggest club drug users could have greater protective effects from daily oral or long-acting injectable PrEP compared to a time-driven PrEP regimen because of the concurrence of club drug use and PrEP non-adherence.

Model-Based Methods to Translate Adolescent Medicine Trials Network for HIV/AIDS Interventions Findings Into Policy Recommendations: Rationale and Protocol for a Modeling Core (ATN 161)

Background

The United States Centers for Disease Control and Prevention estimates that approximately 60,000 US youth are living with HIV. US youth living with HIV (YLWH) have poorer outcomes compared with adults, including lower rates of diagnosis, engagement, retention, and virologic suppression. With Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) support, new trials of youth-centered interventions to improve retention in care and medication adherence among YLWH are underway.

Objective

This study aimed to use a computer simulation model, the Cost-Effectiveness of Preventing AIDS Complications (CEPAC)-Adolescent Model, to evaluate selected ongoing and forthcoming ATN interventions to improve viral load suppression among YLWH and to define the benchmarks for uptake, effectiveness, durability of effect, and cost that will make these interventions clinically beneficial and cost-effective.

Methods

This protocol, ATN 161, establishes the ATN Modeling Core. The Modeling Core leverages extensive data—already collected by successfully completed National Institutes of Health–supported studies—to develop novel approaches for modeling critical components of HIV disease and care in YLWH. As new data emerge from ongoing ATN trials during the award period about the effectiveness of novel interventions, the CEPAC-Adolescent simulation model will serve as a flexible tool to project their long-term clinical impact and cost-effectiveness. The Modeling Core will derive model input parameters and create a model structure that reflects key aspects of HIV acquisition, progression, and treatment in YLWH. The ATN Modeling Core Steering Committee, with guidance from ATN leadership and scientific experts, will select and prioritize specific model-based analyses as well as provide feedback on derivation of model input parameters and model assumptions. Project-specific teams will help frame research questions for model-based analyses as well as provide feedback regarding project-specific inputs, results, sensitivity analyses, and policy conclusions.

Results

This project was funded as of September 2017.

Conclusions

The ATN Modeling Core will provide critical information to guide the scale-up of ATN interventions and the translation of ATN data into policy recommendations for YLWH in the United States.