Adapting the minority stress model: Associations between gender non-conformity stigma, HIV-related stigma and depression among men who have sex with men in South India

Longitudinal effects of sexual minority stigma on depressive symptoms among young men who have sex with men: Distinguish between and within person effects

BACKGROUND

Young men who have sex with men (YMSM) may experience high levels of sexual minority stigma (SMS) and depressive symptoms (DS) over the world and in China. However, there is a lack of studies investigating the longitudinal effects of SMS on DS of YMSM, especially focusing on YMSM and separating the between-person and within-person effects. This study aimed to fill the said gaps.

METHODS

Study data were derived from a prospective cohort of 349 YMSM from central China (Wuhan, Changsha, Nanchang), the baseline survey was started in 2017 with one follow-up visit every year. SMS and DS were measured three times using valid and reliable instruments. The cross-lagged panel model (CLPM) and the random intercept CLPM (RI-CLPM) were used to examine the between-person and within-person concurrent and lagged effects, respectively.

RESULTS

Findings of CLPM revealed bidirectional associations between SMS and DS over time. RI-CLPM suggested that at the between-person level, SMS was significantly associated with DS, echoing the results of CLPM. However, this reciprocal relationship has not been found at the within-person level.

CONCLUSION

The associations between SMS and DS among YMSM at the population level is more significant than that at the individual level. We suggest that interventions should be against the adverse effects of cultural marginalization and systemic change the social concepts to reduce the amount of SMS in society.

Burden of Vaccine-Preventable Diseases in People Living with HIV

Vaccine-preventable diseases (VPDs) pose a serious public health concern for people living with HIV (PLH). PLH experience a delayed and weakened response to many vaccines available, compared to the general population. Lower seroconversion rates, along with a decreased efficacy and durability of vaccines, increases the susceptibility of PLH to VPDs. Vaccination guidelines specifically targeting this population have been modified to overcome these challenges. However, vaccine uptake remains suboptimal due to multiple barriers, highlighting the need for further studies and the additional implementation of public health measures specifically tailored to PLH.

Labor Pains: Work-Related Barriers to Access to Health Care for People Living with HIV in Hyderabad, India

To explore themes regarding work-related barriers to access to health care, we conducted 32 interviews, 16 with third gender people and 16 with cisgender women, all of whom were all living with HIV in Hyderabad, India. Most respondents were members of Dalit castes and had been living with HIV for several years at the time of the interview. Using thematic content analysis, interviews were coded by two researchers using a social determinants of health conceptual framework. Themes highlighted in this study include the burden of taking time off from work, the loss of pay associated with missing work, and the interruption of gendered care work responsibilities that respondents faced when seeking treatment. Findings from this study support the claim that equitable work policies and practices for marginalized laborers can increase access to medical care for people living with HIV.

Qualitative description of interpersonal HIV stigma and motivations for HIV testing among gays, bisexuals, and men who have sex with men in Ghana's slums-BSGH-005

Despite significant progress in Ghana's HIV response, disparities in HIV prevalence persist among different populations. Gays, bisexuals, and other men who have sex with men (GBMSM) in the country remain vulnerable to HIV infection due to high levels of stigma and discrimination, limited access to healthcare services, and low HIV knowledge levels. While limited studies focus on HIV prevention and care in the Ghanaian GBMSM context, we did not find studies on GBMSM in slums. We, therefore, explored stigma and motivations of HIV testing among GBMSM in slums. In collaboration with our community partners, we recruited and conducted face-to-face interviews among 12 GBMSM from slums in Accra and Kumasi, Ghana. Our multiple-reviewer summative content analysis identified the following: under HIV stigma, we identified two categories, avoidance of GBMSM living with HIV and fear of testing positive for HIV. Under motivations for HIV testing, we identified three categories; HIV vulnerability, knowing one's HIV status, and positive messaging about HIV. Our findings provide valuable insights into stigma and motivations for HIV testing among GBMSM in Ghanaian slums. They also highlight the importance of targeted HIV education interventions to empower GBMSM to take responsibility for their sexual health and address the unique challenges they face accessing HIV testing services.

Measurement Instruments Assessing Multi-Faceted Stigma Regarding Sexual and Gender Minorities: A Systematic Review of Psychometric Properties

Stigma against sexual and gender minorities (SGM) populations has serious negative health effects for SGM populations. Despite the growing need for accurate stigma measurement in SGM, there are insufficient valid measurement instruments. Moreover, the lack of consistency in construct usage makes comparisons across studies particularly challenging. A critical review and comparative evaluation of the psychometric properties of the various stigma measures for SGM is necessary to advance our understanding regarding stigma measurement against/among SGMs. Based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a comprehensive search was conducted in 4 bibliographic databases (MEDLINE, PsycINFO, CINAHL, and Web of Science) for empirical articles published from 2010 to 2022 that evaluated the psychometrics properties of measurement instruments assessing stigma against SGMs. The screening, extraction, and scoring of the psychometric properties and methodological quality of selected instruments were performed by following the established standards and COSMIN (Consensus-based Standards for the selection of health Measurement Instruments) checklist, respectively. Of the 2031 studies identified, 19 studies were included that reported psychometric properties of 17 measurement instruments. All instruments, except two, were developed for SGMs (n = 15/17). Most instruments included men who have sex with men (MSM) or gay men (n = 11/15), whereas less than half of the instruments assessed stigma among SGM women (n = 6/15). Internal consistency (Cronbach's alpha) and content validity was reported for all instruments (n = 17); construct and structural validity was also reported for majority of the instruments (n = 15 and 10, respectively). However, test-retest reliability and criterion validity was reported for very few instruments (n = 5 each). Based on the COSMIN checklist, we identified the most psychometrically and methodologically robust instruments for each of the five stigma types: combined stigma, enacted stigma, internalized stigma, intersectional stigma, and perceived stigma. For each stigma type, except anticipated stigma, at least one instrument demonstrated strong promise for use in empirical research; however, the selection of instrument depends on the target population and context of the study. Findings indicated a growing use of instruments assessing multiple stigma types. Future studies need to develop intersectional stigma instruments that account for the multiple and intersecting social identities of SGMs. Additionally, most existing instruments would benefit from further psychometric testing, especially on test-retest reliability, criterion validity, adaptability to different LGBTQIA + populations and cultures.

Status-neutral community-based multilevel intervention to address intersectional stigma and discrimination, and increase HIV testing, PrEP, and ART uptake among YGBMSM in Ghanaian Slums: A clustered randomized control trial protocol

Background

While GBMSM constitute less than 2% of Ghana's population, their HIV prevalence surpasses the national average by more than eightfold, emphasizing the critical need for targeted interventions to improve detection, care linkage, and reduce community transmission. This study seeks to increase HIV testing, Pre-Exposure Prophylaxis (PrEP), and Antiretroviral Therapy (ART) uptake (HPART) among YGBMSM through the adaptation of an evidence-based intervention (LAFIYA).

Methodology

We will employ the ADAPTT-IT framework to adapt LAFIYA and evaluate its feasibility and effectiveness in addressing intersectional stigma and increasing HPART uptake among YGBMSM residing in Ghanaian slums. In aim 1, we will hold focus groups (n=5) and interviews (n=20) among YGBMSM and two FGDs among GBMSM-led organizations. At the HCF level, we will hold 6 FGDs and interviews (n=20) among nurses. In AIM 2, we will randomly assign 6 healthcare facilities (HCFs) to receive the LAFIYA (n=3) or wait-list control (n=3). Friend groups (cluster) of YGBMSM (N=240) will be assigned to receive LAFIYA (n=120) or a wait-list control (n=120). We will collect 3-, 6-, and 9-months post-intervention data among YGBMSM(n=240) and HCWs(n=300) to measure HPART adherence (primary outcomes), ISD reduction, HIV and status-neutral knowledge (secondary outcomes), and intervention acceptability, appropriateness, and feasibility (implementation outcomes).

Conclusion

The intervention group will observe increased HPART adherence, reduced ISD, and enhanced HPART knowledge and efficacy relative to the wait-list control group. The findings will inform ISD reduction and HIV status-neutral implementation strategies - and place-based interventions that address access to HIV prevention and care among YGBMSM, slum and in different settings.

Trail Registration

This study was registered on clinicalTrail.gov, with identifier number NCT06312514 on 03/14/2023. https://classic.clinicaltrials.gov/ct2/show/NCT06312514.

Measuring intersectional HIV, sexual diversity, and gender non-conformity stigma among healthcare workers in Ghana: scale validation and correlates of stigma

BACKGROUND

Men who have sex with men (MSM) are at heightened risk for HIV acquisition, yet they may delay or avoid HIV testing due to intersectional stigma experienced at the healthcare facility (HCF). Few validated scales exist to measure intersectional stigma, particularly amongst HCF staff. We developed the Healthcare Facility Staff Intersectional Stigma Scale (HCF-ISS) and assessed factors associated with stigma in Ghana.

METHODS

We analyzed baseline data from HCF staff involved in a study testing a multi-level intervention to reduce intersectional stigma experienced by MSM. Data are from eight HCFs in Ghana (HCF Staff n = 200). The HCF-ISS assesses attitudes and beliefs towards same-sex relationships, people living with HIV (PLWH) and gender non-conformity. Exploratory factor analysis assessed HCF-ISS construct validity and Cronbach's alphas assessed the reliability of the scale. Multivariable regression analyses assessed factors associated with intersectional stigma.

RESULTS

Factor analysis suggested an 18-item 3-factor scale including: Comfort with Intersectional Identities in the Workplace (6 items, Cronbach's alpha = 0.71); Beliefs about Gender and Sexuality Norms (7 items, Cronbach's alpha = 0.72); and Beliefs about PLWH (5 items, Cronbach's alpha = 0.68). Having recent clients who engage in same-gender sex was associated with greater comfort with intersectional identities but more stigmatizing beliefs about PLWH. Greater religiosity was associated with stigmatizing beliefs. Infection control training was associated with less stigma towards PLWH and greater comfort with intersectional identities.

CONCLUSIONS

Achieving the goal of ending AIDS by 2030 requires eliminating barriers that undermine access to HIV prevention and treatment for MSM, including HCF intersectional stigma. The HCF-ISS provides a measurement tool to support intersectional stigma-reduction interventions.

Homoprejudiced Violence Experiences and High-Risk Sexual Behaviors among Chinese Men Who Have Sex with Men: Depression Severity and Recreational Drug Usage as Potential Mediators

Homoprejudiced violence is a type of aggression against an individual or a community based on their actual or perceived sexual orientation. It may be linked to risks of acquiring HIV/STI via psychosocial variables. This study explored the association between homoprejudiced violence experiences and high-risk sexual behaviors, and potential psychosocial mediators. Using cross-sectional survey data collected in China through Blued among men who have sex with men (MSM) in January 2021, this study conducted multiple mediation analyses. Standard instruments were used to collect data on depressive symptoms in the last two weeks (PHQ-9), recreational drug usage in the last three months, and ever experiencing homoprejudiced violence (12-item survey instrument). Dependent variables were having condomless anal sex and having three or more sexual partners in the last three months. Among 1828 MSM, nearly half (847, 46%) had experienced homoprejudiced violence. Twenty-three percent (427) reached a score that suggested moderate or severe depression and 35% (644) had used recreational drugs. In the last three months, 40% (731) had condomless anal sex and 34% (626) had three or more sexual partners. The indirect mediational coefficients through depression on condomless anal sex and multiple sexual partners were 0.04 (95% CI: [0.02, 0.07]) and 0.02 (95% CI: [0.001, 0.05]), respectively. The indirect mediational coefficient of homoprejudiced violence experience on multiple sexual partners through recreational drug use was 0.05 (95% CI: [0.03, 0.08]). These findings suggest that more comprehensive interventions are needed to address the syndemic of homoprejudiced violence, mental health issues, and HIV/STI-related risks.

Associations between water insecurity and mental health outcomes among lesbian, gay, bisexual, transgender and queer persons in Bangkok, Thailand and Mumbai, India: Cross-sectional survey findings

Background

Water insecurity disproportionally affects socially marginalized populations and may harm mental health. Lesbian, gay, bisexual, transgender and queer (LGBTQ) persons are at the nexus of social marginalization and mental health disparities; however, they are understudied in water insecurity research. Yet LGBTQ persons likely have distinct water needs. We explored associations between water insecurity and mental health outcomes among LGBTQ adults in Mumbai, India and Bangkok, Thailand.

Methods

This cross-sectional survey with a sample of LGBTQ adults in Mumbai and Bangkok assessed associations between water insecurity and mental health outcomes, including anxiety symptoms, depression symptoms, loneliness, alcohol misuse, COVID-19 stress and resilience. We conducted multivariable logistic and linear regression analyses to examine associations between water insecurity and mental health outcomes.

Results

Water insecurity prevalence was 28.9% in Mumbai and 18.6% in Bangkok samples. In adjusted analyses, in both sites, water insecurity was associated with higher likelihood of depression symptoms, anxiety symptoms, COVID-19 stress, alcohol misuse and loneliness. In Mumbai, water insecurity was also associated with reduced resilience.

Conclusion

Water insecurity was common among LGBTQ participants in Bangkok and Mumbai and associated with poorer well-being. Findings signal the importance of assessing water security as a stressor harmful to LGBTQ mental health.

Mediating role of food insecurity in the relationship between perceived MSM related stigma and depressive symptoms among men who have sex with men in Nepal

BACKGROUND

Previous studies have indicated the association between stigma and depressive symptoms among frequently stigmatized groups, such as men who have sex with men (MSM). While this association has been suggested in the literature, there is a dearth of evidence that examines whether food insecurity statistically mediates the relationship between stigma and depressive symptoms.

METHODS

This cross-sectional study conducted between October and December 2022 among a sample of 250 MSM in Kathmandu, Nepal, recruited through respondent-driven sampling. An unadjusted model including the exposure (stigma), mediator (food insecurity), and outcome variables (depressive symptoms) and an adjusted model that controlled for sociodemographic, behavioral, and health-related confounders were used. Bootstrapping was utilized to estimate the coefficients of these effects and the corresponding 95% confidence intervals. Via bootstrap approach, we find out the mediating role of food insecurity in the association between stigma and depressive symptoms.

RESULTS

Depressive symptoms, stigma, and food insecurity were 19.6%, 24.4%, and 29.2%, respectively, among MSM. Food insecurity was associated with higher age (b = 0.094; 95% CI = 0.039, 0.150) and monthly income (b = -1.806; 95% CI = -2.622, -0.985). Depressive symptoms were associated with condom-less sex in past six months (b = -1.638; 95% CI = -3.041, -0.092). Stigma was associated with higher age (b = 0.196; 95% CI = 0.084, 0.323) and PrEP uptake (b = 2.905; 95% CI = 0.659. 5.248). Food insecurity statistically mediated 20.6% of the indirect effect of stigma in depressive symptoms.

CONCLUSION

Our findings show that food insecurity affects the relationship between stigma and depressive symptoms in this population. Reducing food insecurity and addressing the stigma surrounding sexual orientation should be a priority when addressing mental health concerns among MSM in Nepal and other resource-limited countries with similar socio-cultural settings.

The impact of anxiety, depression, and social support on the relationship between HIV-related stigma and mental health-related quality of life among Chinese patients: a cross-sectional, moderate-mediation study

BACKGROUND/OBJECTIVE

People living with HIV (PLWH) are prone to mental health problems and evidence indicates that HIV-related stigma can negatively impact mental health-related quality of life. This study explored potential mechanisms between HIV-related stigma and mental health-related quality of life, specifically whether anxiety or depression mediates, and whether social support moderates, the relationship.

METHOD

A total of 1197 Chinese PLWH participated in the study. The Berger HIV Stigma Scale, the Hospital Anxiety and Depression Scale (HADS), the 12-item Brief Health Survey (SF-12), and the Multidimensional Scale of Perceived Social Support (MSPSS) were employed.

RESULTS

HIV-related stigma was negatively associated with mental health-related quality of life. Anxiety and depression partially mediated the relationship between HIV-related stigma and mental health-related quality of life; social support played a moderating role.

CONCLUSIONS

The mental health-related quality of life in PLWH was shown to be indirectly affected by HIV-related stigma through anxiety and depression in China. The negative impact of HIV-related stigma decreased with increased social support.

Leveraging family-based assets for Black men who have sex with men in House Ball Communities: Protocol for a cluster randomized controlled trial

Black men who have sex with men (MSM) continue to have the highest incidence of new human immunodeficiency virus (HIV) diagnoses in the United States but are least likely to be engaged in care or to be virally suppressed. Many Black MSM face multiple stigmas, but some have found refuge in the House Ball Community (HBC)-a national network of Black lesbian, gay, bisexual, and transgender kinship commitments that provide care-giving, affirmation, and survival skills-building for its members. We propose to modify a skills-building and HIV prevention best-evidence, group-level intervention for HIV- negative Black MSM (Many Men Many Voices) into a family-based intervention to focus on asset-building for both HIV-negative and HIV-positive Black MSM within HBC families. The adapted intervention will be re-branded as Our Family Our Voices (OFOV). We proposed a mixed-methods study to test the feasibility and preliminary efficacy of OFOV adapted for HIV status-neutral use with HBC families. First, we will develop the intervention protocol using the ADAPT-ITT model for modifying behavioral interventions. Then, we will conduct a cluster randomized controlled trial with six HBC families in New York City. Families will be randomized to the OFOV intervention or waitlist control arm. Primary outcomes will be HIV testing, HIV pre-exposure prophylaxis use, currently in HIV care and on HIV treatment. Secondary outcomes will be the number of family-based assets, resilience, number of sexual partners, and relative frequency of condomless anal intercourse. The results of the formative research, including the pilot trial, will contribute to the evidence-base regarding the development of HIV status-neutral interventions that respond to the diversity and complexities of HBC families and that recognize the importance of asset-building for facilitating HBC resilience to stigma as a part of the United States' domestic policy objective of ending the HIV epidemic by 2030.

Transgender women in Kenya experience greater stigma, depressive symptoms, alcohol and drug use and risky sexual practices than cis-gendered men who have sex with men

BACKGROUND

Worldwide, sexual and gender minority individuals have disproportionate burden of HIV. There are limited quantitative data from sub-Saharan Africa on the intersection of risks experienced by transgender women (TGW) in comparison to cis-men who have sex with men (MSM). This analysis addresses this gap by comparing reported stigma, psychosocial measures of health, and sexual risk practices between TGW and cis-MSM in Kenya.

METHODS

We analyzed data from the baseline visit of an ongoing prospective cohort study taking place in three diverse metropolitan areas. Eligible participants were HIV-negative, assigned male at birth, ages 18-29 years, and reported anal intercourse in the past 3 months with a man or TGW. Data collected by audio computer assisted self-interview included sociodemographic measures, and sexual practices occurring in the past 3 months. Multivariable regressions assessed differences between TGW and cis-MSM in selected sexual practices, depressive symptoms, alcohol and drug use, and stigma.

RESULTS

From September, 2019, through May, 2021, 838 participants were enrolled: 108 (12.9%) TGW and 730 (87.1%) cis-MSM. Adjusting for sociodemographic variables, TGW were more likely than cis-MSM to report: receptive anal intercourse (RAI; adjusted prevalence ratio [aPR] = 1.59, 95% CI: 1.32 - 1.92), engaging in group sex (aPR = 1.15, 95% CI: 1.04 - 1.27), 4 or more male sex partners (aPR = 3.31, 95% CI: 2.52 - 4.35), and 3 or more paying male sex partners (aPR = 1.58, 95% CI: 1.04 - 2.39). TGW were also more likely to report moderate to severe depressive symptoms (aPR = 1.42, 95% CI: 1.01 - 1.55), and had similar alcohol and drug abuse scores as cis-MSM. In sensitivity analysis, similar to TGW, male-identifying individuals taking feminizing gender affirming therapy had an increased likelihood of reporting RAI and group sex, and greater numbers of male sex partners and paying male sex partners relative to cis-MSM.

CONCLUSIONS

Across three metropolitan areas in Kenya, TGW were more likely to report depressive symptoms and increased sexual risk taking. We identified a need for research that better characterizes the range of gender identities. Our analysis affirms the need for programmatic gender-affirming interventions specific to transgender populations in Kenya and elsewhere in Africa.

Associations among internalized and perceived stigma, state mindfulness, self-efficacy, and depression symptoms among men who have sex with men in China: A serial mediation model

Previous research has demonstrated that stigma is strongly related to depressive symptoms among men who have sex with men (MSM). However, data are limited regarding the associations between stigma, state mindfulness, self-efficacy, and depression symptoms. The current study aimed to analyze state mindfulness and self-efficacy as possible mediators between internalized and perceived stigma and depression symptoms. A sample of 2610 Chinese MSM (Mage = 23.99, SD = 6.09, age range: 18-68 years) was recruited from an online survey platform and completed the HIV and Homosexuality Related Stigma Scale, Patient Health Questionnaire-9, the short version of Five Facet Mindfulness Questionnaire, and the Chinese General Self-Efficacy Scale. Results indicated that state mindfulness significantly mediated the linkage between internalized and perceived stigma and depressive symptoms, and self-efficacy significantly mediated the relation between state mindfulness and depression symptoms. Furthermore, internalized and perceived stigma were associated with depression symptoms through a serial mediation of state mindfulness and self-efficacy. This study highlights that state mindfulness and self-efficacy might play important roles in the psychological response of MSM to stigmatization and psychopathology symptoms.

Access to healthcare for people living with HIV: an analysis of judgments of the European Court of Human Rights from an ethical perspective

Introduction

Although HIV has been part of our reality for over 30 years, people living with HIV (PLHIV) still experience restrictions regarding their access to healthcare. This poses a significant ethical problem, especially as it endangers achieving the goal of ending the HIV epidemic worldwide. The aim of this paper is to analyze the rulings of the European Court of Human Rights (ECtHR) regarding cases where PLHIV experienced restrictions on their access to healthcare.

Methods

We conducted an analysis of the ECtHR database and were able to identify N = 28 cases dealing with restricted access to healthcare for PLHIV. A descriptive and thematic analysis was conducted to identify ways in which access to healthcare for PLHIV was restricted.

Results

We were able to identify a total of four main categories, with denial of adequate therapeutic support as the main category with N = 22 cases (78.57%). Most of the judgments examined were filed against Russia (N = 12, 42.86%) and Ukraine (N = 9, 32.14%). A large proportion of PLHIV in the cases studied (N = 57, 85.07%) were detainees.

Discussion

The analysis shows a clear condemnation of limited access to healthcare for PLHIV by the ECtHR. Ethical implications of the analyzed cases are discussed in detail.

The mediating role of social support between HIV stigma and sexual orientation-based medical mistrust among newly HIV-diagnosed gay, bisexual, and other men who have sex with men

HIV-related stigma and medical mistrust are significant challenges to addressing HIV inequities among gay, bisexual, and other men who have sex with men (MSM). HIV-related stigma is associated with high levels of medical mistrust, but there is limited knowledge regarding the mechanisms that link these variables. We examined the potential mediating roles of social support and coping in the relationship between perceived HIV stigma and sexual orientation based-medical mistrust among newly HIV-diagnosed MSM. We hypothesized that HIV-related stigma would be associated with mistrust and that social support, and coping would mediate this relationship. Data were obtained from 202 newly HIV-diagnosed (<1 year) MSM receiving care at community HIV clinics in New York. A path model indicated that HIV stigma was directly related to greater sexual orientation based medical mistrust, and that this relationship was mediated by social support. However, coping did not mediate the relationship between HIV stigma and mistrust. Efforts to increase social support and decrease stigma are critical for strengthening relationships between MSM and HIV care networks. Future research should assess the feasibility of designing and implementing interventions focused on increasing social network support and improving trust in the medical community among newly HIV-diagnosed MSM.

A scoping review of lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI+) people's health in India

Amid incremental progress in establishing an enabling legal and policy environment for lesbian, gay, bisexual, transgender and queer-identified people, and people with intersex variations (LGBTQI+) in India, evidence gaps on LGBTQI+ health are of increasing concern. To that end, we conducted a scoping review to map and synthesize the current evidence base, identify research gaps, and provide recommendations for future research. We conducted a scoping review using the Joanna Briggs Institute methodology. We systematically searched 14 databases to identify peer-reviewed journal articles published in English language between January 1, 2010 and November 20, 2021, that reported empirical qualitative, quantitative or mixed methods data on LGBTQI+ people's health in India. Out of 3,003 results in total, we identified 177 eligible articles; 62% used quantitative, 31% qualitative, and 7% mixed methods. The majority (55%) focused on gay and other men who have sex with men (MSM), 16% transgender women, and 14% both of these populations; 4% focused on lesbian and bisexual women, and 2% on transmasculine people. Overall, studies reported high prevalence of HIV and sexually transmitted infections; multilevel risk factors for HIV; high levels of mental health burden linked to stigma, discrimination, and violence victimization; and non-availability of gender-affirmative medical care in government hospitals. Few longitudinal studies and intervention studies were identified. Findings suggest that LGBTQI+ health research in India needs to move beyond the predominant focus on HIV, and gay men/MSM and transgender women, to include mental health and non-communicable diseases, and individuals across the LGBTQI+ spectrum. Future research should build on largely descriptive studies to include explanatory and intervention studies, beyond urban to rural sites, and examine healthcare and service needs among LGBTQI+ people across the life course. Increased Indian government funding for LGBTQI+ health research, including dedicated support and training for early career researchers, is crucial to building a comprehensive and sustainable evidence base to inform targeted health policies and programs moving forward.

Conflicting signals: Exploring the socioeconomic implications of gender discordant names

We investigate the educational and employment consequences of having a gender discordant name - one that is also given to people of a different gender. People with discordant names may be more likely to experience stigma due to the conflicting signal between their gender and the perceptions of femininity or masculinity associated with their names. Our primary measure of discordance is based on the percentage of men and women with each first name, using a large administrative dataset from Brazil. We find that both men and women with gender discordant names attain significantly less education. Gender discordant names are also negatively and significantly associated with earnings though, after controlling for educational attainment, only people with the most discordant names have significantly lower earnings. These results are corroborated when using crowd-sourced gender perceptions of names in our dataset, which suggests that stereotypes and the judgments of others are a probable mechanism for the observed disparities.

Pathways Between Intersectional Stigma and HIV Treatment Engagement Among Men Who Have Sex with Men (MSM) in India

In India and other low-and-middle-income countries, little is known about how intersectional stigma affects MSM engagement in ART. Informed by the Health Stigma and Discrimination Framework, we qualitatively examined how multiple stigmas influence ART engagement among Indian MSM. We conducted 3 focus groups (N = 22) with MSM living with HIV, aged 21-58 years, in Delhi and Hyderabad to identify potential intervention targets and solutions to improve treatment outcomes. Framework analysis and techniques were used to code and analyze translated audio-recordings. Findings revealed enacted stigma, associated with HIV and MSM identity, manifested as familial shame and healthcare discrimination, inhibiting access to support, and decreasing HIV care engagement. Anticipated stigma led to worry about disclosure and societal repercussions. Community-Based-Organizations, ART centers, and family members were primary sources of support, leading to increased ART initiation and retention. Potential solutions included using MSM peer-counselors, increasing social support, and providing HIV education to the general community.

Mental health, economic well-being and health care access amid the COVID-19 pandemic: a mixed methods study among urban men who have sex with men in India

Scant empirical research from Asia has addressed the impact of COVID-19 on sexual minority health. We aimed to explore and understand the impact of COVID-19 on income security, mental health, HIV risk and access to health services among men who have sex with men (MSM) in India. We conducted a concurrent mixed methods study from April to June 2020, including a cross-sectional survey and in-depth semi-structured interviews with MSM recruited from three non-governmental organisations providing HIV prevention services in Chandigarh, India. We examined the associations of sexual minority stressors (sexual stigma, internalised homonegativity), economic stressors, and stress due to social distancing, with depression and anxiety, HIV risk, and access to health services. Survey findings (n = 132) indicated that internalised homonegativity and stress related to social distancing were significantly associated with depressive and anxiety symptoms. Results also showed reduced access to condoms, HIV testing and counselling services. Qualitative findings (n = 10) highlighted adverse economic impacts of COVID-19, including loss of employment/wages and engaging in survival sex work, which contributed to psychological distress and HIV risk. The COVID-19 pandemic has resulted in considerable psychological and financial distress among low socioeconomic status MSM in India, including those involved in sex work - communities already marginalised in economic, family and healthcare sectors. Structural interventions to improve access to mental health and HIV services and decrease financial burden are critical to mitigate the impact of COVID-19.

Associations between sexual stigma, enacted HIV stigma, internalized HIV stigma and homonegativity, and depression: testing an extended minority stress model among men who have sex with men living with HIV in India

Limited data is available on the associations between intersectional stigmas and mental health outcomes among men who have sex with men living with HIV (MSMLH) in India. The minority stress model postulates that sexual stigma contributes to depression through proximal stressors like internalized homonegativity (IHN). Using cross-sectional survey data from 119 MSMLH in 2015/16, we tested whether: (1) sexual stigma and enacted HIV stigma (EHS) are associated with depression; (2) their effects on depression are mediated through IHN and internalized HIV stigma (IHS); and (3) their effects on IHN are mediated through IHS. Significant direct associations were observed between scores on sexual stigma and IHS (β = .49, 95% CI .27, .70), EHS and IHN (β = .19, 95% CI .03, .36), and IHS and IHN (β = .07, 95% CI .03, .12). IHS scores mediated the associations of sexual stigma with depression (β = .17, 95% CI .07, .27) and IHN scores (β = .04, 95% CI .004, .07). EHS was not found to be significantly associated with depression or IHN. The findings partially support the minority stress model among MSMLH and highlight the importance of addressing both sexual and HIV-related stigmas to improve mental health of MSMLH, especially by screening for and reducing IHS, IHN and depression.

'No test, no disease': Multilevel barriers to HIV testing among young men who have sex with men and transgender women in three semi-urban areas in Thailand

Young gay and other men who have sex with men and young transgender women in Thailand continue to be at high risk for HIV infection. We explored multilevel influences on HIV testing in order to inform the design of tailored interventions. We conducted four focus group discussions with 16-20-year-old gay men and transgender persons (n = 25) and 17 key informant interviews with healthcare providers, NGO leaders, and youth advocates. Focus groups and interviews were transcribed and reviewed using thematic analysis in Thai and English language by a bilingual team. We identified intersecting, culturally situated barriers at individual (lack of HIV knowledge, low HIV risk perception, denial), social (intersectional sexual- and HIV-related stigma, lack of family communication), institutional (inadequate and non-LGBT-inclusive sexual health education in schools, lack of youth-friendly clinics) and policy levels (parental consent requirements for HIV testing by minors). Multilevel and multisystem factors coalesce to form extensive barriers to HIV testing access and utilisation and promote disengagement from HIV prevention more broadly. Multicomponent, youth-engaged interventions informed by Thai sociocultural history and practices are needed in renewed approaches to HIV prevention and testing to end the epidemic among young gay and transgender people in Thailand.

Characterizing Racial Differences of Mental Health Burdens, Psychosocial Determinants, and Impacts on HIV Prevention Outcomes Among Young Men Who have Sex With Men: a Community-based Study in Two U.S. Cities

Few studies examine racial differences (e.g., Black vs. White) regarding the psychosocial pathways linking mental health burdens and various HIV-related outcomes among young men who have sex with men (MSM) in the U.S. We conducted a community-based study to examine the racial differences of mental health burdens (e.g., depression, anxiety, stress), the psychosocial determinants (e.g., HIV stigma, homonegativity, resilience, social support, loneliness, housing/food security) and impact on HIV-related outcomes (e.g., event-level alcohol/drug use before sex, condomless insertive/receptive anal sex, recent HIV testing, and PrEP awareness/willingness/use) among young Black MSM (YBMSM; n = 209) and young White MSM (YWMSM; n = 109) from two cities (Nashville, TN and Buffalo, NY) in the United States. Overall, we found YBMSM were more likely (p < 0.05) to experience anxiety and depression compared to YWMSM. Among YBMSM, we found structural inequities (housing instability, food insecurity, internalized homonegativity) were positively associated with anxiety/depression/stress (p < 0.001); we also found anxiety/depression was associated with increased alcohol/drug use before sex, and stress was associated with reduced recent HIV testing and pre-exposure prophylaxis awareness/willingness/use. Among YWMSM, we found psychological buffers (perceived social support, resilience) were associated with reduced anxiety/depression/stress (p < 0.001); anxiety was associated with increased condomless insertive/receptive anal sex and recent HIV testing among this subgroup. YBMSM and YWMSM differed in psychosocial determinants and HIV-related consequences regarding their mental health. Our findings provide important implications for developing culturally and contextually tailored interventions to address mental health burdens and HIV prevention outcomes among young MSM at highest risk for HIV acquisition.

Using a mixed-methods approach to adapt an HIV stigma reduction to address intersectional stigma faced by men who have sex with men in Ghana

INTRODUCTION

In Ghana, men who have sex with men (MSM) are estimated to be 11 times more likely to be living with HIV than the general population. Stigmas at the intersection of HIV, same-sex and gender non-conformity are potential key drivers behind this outsized HIV disease burden. Healthcare workers (HCWs) are essential to HIV prevention, care and treatment and can also be sources of stigma for people living with HIV and MSM. This article describes the process and results of adapting an evidence-based HIV stigma-reduction HCW training curriculum to address HIV, same-sex and gender non-conformity stigma among HCWs in the Greater Accra and Ashanti regions, Ghana.

METHODS

Six steps were implemented from March 2020 to September 2021: formative research (in-depth interviews with stigma-reduction trainers [n = 8] and MSM living with HIV [n = 10], and focus group discussions with HCWs [n = 8] and MSM [n = 8]); rapid data analysis to inform a first-draft adapted curriculum; a stakeholder adaptation workshop; triangulation of adaptation with HCW baseline survey data (N = 200) and deeper analysis of formative data; iterative discussions with partner organizations for further refinement; external expert review; and final adaptation with the teams of HCWs and MSM being trained to deliver the curriculum.

RESULTS

Key themes emerging under four immediately actionable drivers of health facility intersectional stigma (awareness, fear, attitudes and facility environment) informed the adaptation of the HIV training curriculum. Based on the findings, existing curriculum exercises were placed in one of four categories: (1) Expand-existing exercises that needed modifications to incorporate deeper MSM and gender non-conformity stigma content; (2) Generate-new exercises to fill gaps; (3) Maintain-exercises to keep with no modifications; and (4) Eliminate-exercises that could be dropped given training time constraints. New exercises were developed to address gender norms, the belief that being MSM is a mental illness and stigmatizing attitudes towards MSM.

CONCLUSIONS

Getting to the "heart of stigma" requires understanding and responding to both HIV and other intersecting stigma targeting sexual and gender diversity. Findings from this study can inform health facility stigma reduction programming not only for MSM, but also for other populations affected by HIV-related and intersectional stigma in Ghana and beyond.

Socioeconomic Status and the Sense of Coherence among Japanese People Living with HIV

People living with HIV (PLWH) are forced to live with multiple and severe stressors. Focusing on sense of coherence (SOC), which is a concept of salutogenic and stress coping capacity, is useful in PLWH support. This study aimed to examine the association between SOC and socioeconomic status (SES) for Japanese PLWH. Methods: This study used data from the HIV Futures Japan national survey, which is an online survey with a cross-sectional design. This survey of PLWH in Japan was conducted from July 2013 to February 2014 and December 2016 to July 2017, resulting in 1422 valid responses. The mean age (SD) was 38.6 years (8.3). The 13-item SOC scale score was divided into two groups, based on Japanese standard score in a previous study, and logistic regression analysis was performed. Results: Education levels were indirectly associated with SOC through occupation. Compared to freelance-profession/self-employed, “unemployed job seekers” (OR [95%CI] = 2.16 [1.16, 4.04]) and “homemaker/recuperating/student” (2.09 [1.09, 4.02]) were directly related to poor SOC, regardless of income. Also, there is a clear SOC disparity in income (compared to “>8 million yen/year”, “<1 million yen/year” was 2.94 [1.46, 5.92], and “1−2.99 million yen/year” was 2.49 [1.33, 4.68]). Conclusion: It became clear that there is a relationship between SOC and SES. The results of this research provide important evidence for health promotion measures for PLWH.

Correlates of Substance Misuse, Transactional Sex, and Depressive Symptomatology Among Partnered Gay, Bisexual and Other Men Who Have Sex with Men in South Africa and Namibia

Despite having some of the world's highest rates of HIV, there is a lack of knowledge on correlates of transmission risk among gay, bisexual and other men who have sex with men in Southern Africa. There is even less known about the factors that shape HIV risk in male-male couples. Using data from Together Tomorrow, a study of partnered GBMSM in South Africa and Namibia, this study assessed the individual and dyadic correlates of three major HIV risk factors in this population: substance misuse, transactional sex, and depressive symptomatology. Data were collected during November 2016-March 2017 via a quantitative survey conducted with 140 partnered MSM (70 couples) in Windohoek, Keetmanshoop, Walvis Bay, and Swakopmund, Namibia and 300 partnered MSM (150 couples) in Pietermaritzburg and Durban, KwaZulu-Natal, South Africa for a total sample size of 440 partnered MSM (220 couples). Results of multilevel modeling analyses show several significant factors present in partnered GBMSM that differ from studies of single GBMSM, with intimate partner violence being a significant correlate across all three risk factors. Future interventions should consider dyadic approaches and integrate IPV prevention and mitigation efforts to reduce HIV in this population as part of a multisectoral approach. To reduce rates of HIV in partnered GBMSM in Namibia and South Africa multilevel, multisectoral work is needed in policy, social norms change, and relationship-focused dyadic interventions to reduce the social and structural stigma facing male couples.

HIV-Related Stigma, Sexual Identity, and Depressive Symptoms Among MSM Living With HIV in China: A Moderated Mediation Modeling Analysis

Depression is one of the biggest health issues among men who have sex with men (MSM) living with HIV, where sexual identity might play an intricate role. Yet, findings of the relationship between sexual identity and depression were mixed and few studies explored its underlying mechanisms. This study aimed to examine the association between sexual identity and depression, and the potential mediating role of HIV-related stigma and moderating role of age. A cross-sectional survey was conducted among 203 MSM living with HIV in Guangxi, China. Participants provided information on sexual identity, depression, HIV-related stigma, and background information. Descriptive statistics, bivariate analysis, and path analysis were applied to examine our hypotheses. Bivariate analysis demonstrated that participants who self-identified as gay reported a lower level of HIV-related stigma and depression. Path analysis revealed an insignificant direct effect of identifying as gay on depression. Yet, the indirect pathway was significant, with identifying as gay being associated with a lower level of HIV stigma and thus a lower level of depression. This indirect effect was moderated by age. The conditional indirect effect was significant in the younger group yet ceased in the older group. The study provided information to better understand the effect of sexual identity on mental health among stigmatized sexual and gender minorities by highlighting the mediating effect of HIV-related stigma and the protective effect of age. Interventions targeting mental health of MSM living with HIV might consider placing greater emphasis on addressing HIV-related stigma among younger MSM.

Secret lives and gender fluidity of people living with HIV in Hyderabad, India

This mixed-methods study sought to explore gender fluidity among people living with human immunodeficiency virus (HIV) in Hyderabad, India, almost all of whom did not identify as hijra. Sixteen gender-nonconforming people living with HIV completed both surveys and in-depth interviews, exploring their experiences with HIV and gender nonconformity stigma. Interviews were conducted in Hindi and Telugu, digitally audio-recorded, then subsequently translated and analyzed in English, using interpretative phenomenological analysis. Our study highlighted three categories of gender expression: (1) "We have to maintain secrecy about our hijra life": Living secret lives; (2) "What happens if my neighbor sees me here?": Contextual disclosure; (3) "Twenty-four hours a day I will wear a sari": Being fully out. Analysis revealed that many gender-nonconforming people reported identifying with two distinct gender identities: one in the daylight, where they identified as men and fulfilled a role of husband and father with their family, and another at night where they identified otherwise-as women, as third gender, as kothis, hijra, transgender. Themes reinforce a phenomenological interpretation of gender identity and expression in the south Indian context, which is grounded in practices regarding identity's embodiment in clothing, vocal intonation, makeup, and context.

"Being Born like This, I Have No Right to Make Anybody Listen to Me": Understanding Different Forms of Stigma among Thai Transgender Women Living with HIV in Thailand

This study explores the ways Thai transgender women are affected by internalized, perceived, vicarious and enacted stigma. Participants were eleven Thai transgender women living with HIV, who were asked about experiences of stigma in their daily lives. Various forms of verbal, psychological and physical harassment were reported. Internalized stigma and stigma within the transgender community itself were significant. Participants tended not to blame their family members or others in their social structure for their experiences of stigma. They tended to see the solution to tackle the problem of stigma mainly in changes in the behavior of transgender women themselves. This paper suggests that transgender people themselves should better understand how the structure, culture and institutions of mainstream society instill, reinforce and perpetuate stigma against, within and among them. There is a need for advocacy directed toward manifesting societal emancipation of Thai transgender people-starting with legal reform.

Multi-level intersectional stigma reduction intervention to increase HIV testing among men who have sex with men in Ghana: Protocol for a cluster randomized controlled trial

BACKGROUND

Men with have sex with men (MSM) in Africa face high levels of stigma due to elevated HIV exposure (actual or perceived), same-sex practices, and gender non-conformity. These stigmas are documented barriers to HIV prevention and treatment. Most stigma-reduction interventions have focused on single-level targets (e.g., health care facility level [HCF]) and addressed one type of stigma (e.g., HIV), without engaging the multiple intersecting stigmas that MSM encounter. Determining the feasibility and acceptability of multi-level intervention of reducing intersectional stigma and estimating its efficacy on increasing HIV testing are needed.

METHODS

We proposed a mixed method study among MSM in Ghana. First, we will develop the intervention protocol using the Convergence Framework, which combines three interventions that were previously implemented separately in Ghana for reducing stigma at the HCF-level, increasing HIV testing at the peer group-level, and increasing peer social support at the individual-level. Then, we will conduct a cluster randomized controlled trial with four pairs of HCFs matched on staff size. HCFs within each pair are randomized to the HCF-level stigma-reduction intervention or control arm. MSM (n = 216) will be randomized to receive the group-level and individual-level interventions or standard of care control arm. MSM will be assigned to receive HIV testing at one of the HCFs that match their study assignment (intervention or control facility). The frequency of HIV testing between MSM in the study arms at 3 and 6 months will be compared, and the predictors of HIV testing uptake at the HCF, peer group and individual-levels will be assessed using multi-level regression models.

DISCUSSION

These findings from this study will provide important evidence to inform a hybrid implementation-effectiveness trial of a public health intervention strategy for increasing HIV case detection among key populations in sub-Saharan African communities. Accurate information on HIV prevalence can facilitate epidemic control through more precise deployment of public health measures aimed at HIV treatment and viral load suppression, which eliminates risk of transmission.

TRIAL REGISTRATION

This study was prospectively registered on ClinicalTrials.gov, Identifier: NCT04108078, on September 27, 2019.

Anxiety and Depression Status and Influencing Factors of MSM in the Post-COVID-19 Epidemic Period: A Cross-Sectional Study in Western China

This study aimed to explore the psychological status and influencing factors of men who have sex with men (MSM) during the stable period of the COVID-19 epidemic, to provide a reference for the mental health counseling of MSM, and to provide a scientific basis for this group to actively respond to public health emergencies. A cross-sectional survey was conducted on the demographic characteristics, epidemic experiences, risk perception, and COVID-19-related attitudes of MSM in western China, and MSM anxiety and depression were assessed by using the Anxiety Self-Rating Scale and the Center for Epidemiological Studies Depression (CES-D) Scale. The incidences of MSM anxiety and depression in the post-COVID-19 epidemic period are 21.7% and 38.0%, respectively. Logistic regression analysis showed that in terms of anxiety, high controllability of the epidemic (OR = 0.7616) is a protective factor. Thinking that they are more susceptible to COVID-19 (OR = 1.6168) and worrying about another outbreak of the epidemic (OR = 1.4793) are risk factors. In terms of depression, being able to protect themselves from being infected with COVID-19 (OR = 0.6280) is a protective factor. The role of anal sex as “0”/“0.5,” and believing that they are more susceptible to COVID-19 (OR = 1.3408) are risk factors. The sudden outbreak affected the psychological state of MSM and even caused negative feelings of anxiety and depression. These findings suggest that prevention and education should be strengthened, and effective intervention measures should be taken as soon as possible, to improve the mental health of MSM.

Health and Lifestyle, Safety, Relationship and Personality Factors Influence Gender, Sex and Sexuality Issues among Youth—A Case Record Analysis from Youth Mental Health Promotion Clinics in Karnataka, India

Promoting positive identity and seeking early support for gender, sex and sexuality (GSS) issues among youth is vital. Understanding and addressing factors associated withGSS among them is critical. We assessed four-year case records (January 2017–December 2020) of all first visit youth mental health promotion clinic (YMHPC) clients (15–35 years) for factors associated with GSS issues in Karnataka. Overall, prevalence of GSS issues was 1.8% (189/10,340). Increased risk of GSS issues was observed among clients reporting suicidality (AOR = 4.27, 95% CI = 2.70–6.74) and relationship issues (AOR = 3.63, 95% CI = 2.36–5.57), followed by issues of safety (AOR = 2.56, 95% CI = 1.72–3.81), personality (AOR = 2.48, 95% CI = 1.60–3.85), health and lifestyle (AOR = 2.27, 95% CI = 1.77–4.19), smokers (AOR = 2.30, 95% CI = 1.24–4.27), and those who felt depressed (AOR = 2.10, 95% CI = 1.43–3.09) and worthless (AOR = 2.08, 95% CI = 1.28–3.39). Clients aged 21–25 years (AOR = 1.80,95% CI = 1.27–2.54), male (AOR = 1.72, 95% CI = 1.20–2.46) and who had been married (AOR = 2.32, 95% CI = 1.51–3.57) had a higher risk of GSS issues than those aged 15–20 years and other counterparts, respectively. Clients who drank alcohol (AOR = 0.49, 95% CI = 0.30–0.81) had reduced risk of GSS issues. The findings re-iterate the importance of early recognition of factors (essential precursors) of GSS issues among youth. The study highlights the importance of promoting awareness and improving primordial prevention of possible GSS issues in later life. This study has important implications on youth mental health promotion programs, especially in countries like India.

An intersectional burden: Gender and sexual stigma against toms in Thailand

Sexual stigma has deleterious effects on the health and wellbeing of sexual minority women. In low- and middle-income countries, theories and research on stigma against sexual minority women largely focus on sexuality-related stigma processes, such as internalized homophobia or perceived or enacted stigma due to sexual identity, attraction or practice. Yet, there is considerable gender diversity among sexual minority women. Further, sexuality and gender identity may intersect with broader gender inequalities to influence the experience of stigma among some groups. In this study, we conducted 21 qualitative life-history interviews with self-identified toms in Bangkok, the capital city of Thailand, to evaluate whether and how gender identity, independent of and together with same-sex sexuality, influences experiences of stigma among gender non-conforming sexual minority women. We find that the pervasive experiences of stigma against toms derive as much from their assumed masculinity in Thai society, as from their same-sex sexuality. Notably, coercive feminization (attempts by others to orient toms toward sexual and gendered expectations of Thai femininity) and boundary policing (expressed hostility toward tom gender performance and sexual intimacy with feminine Thai women) were manifestations of concurrent gender non-conformity and sexual stigma, shaped in turn by the unique location of toms within the Thai gender/sex system. We propose that research and theories on stigma and health among sexual minorities systematically integrate a gender perspective, to elucidate the effects of gender identity and location within the gender structure on sexual minority experiences of stigma.

Methodologies of Stigma-Related Research Amongst Men Who Have Sex With Men (MSM) and Transgender People in Asia and the Pacific Low/Middle Income Countries (LMICs): A Scoping Review

Much stigma-related research focuses on marginalized populations, including men who have sex with men (MSM) and transgender people. The importance of research in this area is widely recognized, however methodologies and measures vary between studies. This scoping review will collate existing information about how stigma-related research has been conducted in low/middle income countries (LMICs) within the Asia Pacific region, and will compare research designs, sampling frameworks, and measures. Strengths and limitations of these studies will inform recommendations for future stigma-related health research. A methodological framework for scoping studies was applied. Searches of Psych INFO, Scopus, ProQuest, Global Health and PubMed were used to identify articles. Stigma-related research amongst MSM and transgender communities, published between 2010 and 2019 in LMICs within the Asia Pacific region were included. A total of 129 articles based on 123 different studies were included. Of the 129 articles 51.19% (n = 66) were quantitative; 44.96% (n = 57) were qualitative and 3.88% (n = 5) were mixed methods studies. The majority of studies (n = 57; 86.36%) implemented a cross sectional survey. In-depth interviews (n = 20, 34.48%) were also common. Only 3.88% of studies utilized mixed-methods design. Non-probabilistic and probabilistic sampling methods were employed in 99.22 and 0.78% of studies respectively. The most common measures used in quantitative studies were the Center for Epidemiological Study on Depression (CES-D) (n = 18) and the Self Stigma Scale (SSS) (n = 6). Strengths and limitations proposed by researchers included in this review are summarized as lesson learnt and best practices in stigma-related research.

Experiences of Violence and Mental Health Concerns Among Sexual and Gender Minority Adults in Western Kenya

Purpose: Sexual and gender minority (SGM) populations throughout Kenya as well as other sub-Saharan African countries face systemic discrimination and substantial human rights violations, yet scant literature documents the potentially harmful mental health effects of these experiences. This study sought to understand the relationship among experiences of violence, social support, and mental health among SGM adults in Kenya. Methods: Members of a local LGBT community-based organization collected survey data in Western Kenya from October 2017 to April 2018, recruiting 527 SGM participants through an array of community outreach methods. Respondents in this cross-sectional study completed a survey regarding their mental health and other psychosocial factors. Multiple linear regression analyses were conducted to assess associations between experiences of violence (SGM violence and intimate partner violence [IPV]) and mental health outcomes (depressive symptoms and post-traumatic stress symptoms [PTSSs]) and to examine the potential moderating effect of social support on these relationships. Results: Relative to those who had never faced violence, participants who experienced IPV and/or violence based on their sexual orientation, gender identity, or gender expression (SGM violence) reported significantly higher levels of depressive symptoms and PTSSs. Emotional support was associated with lower levels of PTSSs. Social support did not moderate the relationship between SGM violence and mental health symptoms. Conclusions: These findings suggest that there may be a relationship between experiences of violence and poor mental health among SGM Kenyans. More studies are needed to better understand SGM-specific risk factors for poor mental well-being among SGM people in Kenya and the types of interventions that may help mitigate these challenges.

Classifying stigma experience of women living with HIV in Indonesia through the social ecological model

Little is known how stigma theories apply to women living with HIV (WLWH). To apply stigma theories to WLWH, and locate within the dimensions of the Social-Ecological Model (SEM). Using a literature review and a theoretical subtraction to apply stigma forms to the SEM dimensions. WLWH begin to self-stigmatize, receive stigma based on fear from the family and community. Healthcare providers and society stigmatize WLWH by ascribing character flaws to them. The SEM allowed us to locate the dimensions of stigma and identify areas for future interventions for WLWH in Indonesia and other countries.

Are skin color and body mass index associated with social network structure? Findings from a male sex market study

Objectives: There is a growing burden of HIV and sex-related diseases in South Asia and India. Sociological research illustrates that key axes of social stratification, such as race and ethnicity, affect social network structure which, in turn, impacts sexual health and wellbeing. Research on networks has increasingly begun to examine the ways in which networks drive or harness sexual behaviors, but has largely neglected the influence of culture and cultural markers in this continuum. Furthermore, much of the existing scholarship has been conducted in the U.S. or in Western contexts.Design: As part of an exploratory effort, we examined how skin color and body mass index (BMI) affected networks among 206 men who have with men (MSM) frequenting sex markets in Hyderabad, India. A novel phone-based network generation method of respondent-driven sampling was used for recruitment. In assessing how skin color and BMI drive these structures, we also compared how these factors contribute to networks relative to two more commonly referenced markers of social difference among Indians, caste and religion.Results: Our findings suggest that skin color and BMI contribute significantly more to network structure than do caste and religion.Conclusions: These findings tentatively illuminate the importance of individual-level heterogeneity in bodily attributes, factors which are seldom considered in conventional approaches to researching how social stratification and health inequalities are animated during the formation of networks.

Even Mists Have Silver Linings: Promoting LGBTQ+ Acceptance and Solidarity through Community-Based Theatre in India

OBJECTIVES

This project aimed to assess the effectiveness of a community-based theatre intervention to improve attitudes towards and increase knowledge about LGBTQ+ communities among audiences in Mumbai, India.

STUDY DESIGN

This study was a program evaluation using pre- and post-show surveys that incorporated an adapted version of The Riddle Scale: Attitudes Towards Difference and questions assessing self-reported knowledge about LGBTQ+-related issues to assess changes in attitudes and knowledge after viewing the theatre intervention.

METHODS

An original 90-min devised play was created by a company of Indian, American, and Canadian theatre artists using Participatory Action Research methods and was designed to bring audiences to a deeper understanding of LGBTQ+ identity. The show was performed four times in Mumbai, India, and pre-/post-show surveys were collected at each performance. Audience survey responses were analysed using parametric and non-parametric descriptive statistics as appropriate, and Likert scale questions were compared using Wilcoxon Signed Rank for non-parametric data.

RESULTS

A total 184 surveys were completed across four performances between March 7 and 14, 2020. Significant increases in audiences' self-reported knowledge of LGBTQ+ identity, impacts of discrimination, and struggles faced by LGBTQ+ communities were reported after viewing the show. Furthermore, attitudes towards LGBTQ+ rights, understanding of the challenges of being LGBTQ+ in India, and recognition of the contributions LGBTQ+ individuals make to society improved significantly among our audiences after test. The play further fostered increased acceptance of prosocial behaviours towards LGBTQ+ individuals with higher percentages of audiences recognizing the importance of standing up to homophobia and anti-gay attitudes. While these observations were seen across audiences, they were particularly pronounced among cisgender heterosexual men and audiences ages 18-24.

CONCLUSION

Community-based theatre intervention is highly acceptable and effective as a medium for informing positive attitudes, improving knowledge, and promoting acceptance of and solidarity towards LGBTQ+ communities among young adult heterosexual audiences.

Implications of Migration Patterns and Sex Work on Access to Health Services and Key Health Outcomes: A Qualitative Study on Male Migrant Sex Workers in London

Objectives

This paper describes migration toward the UK, sex work involvement, use of health services, and health issues.

Methods

This qualitative study interviewed twenty-five men. The data were analyzed using thematic analysis.

Results

Five main themes emerged: emigration, migration routes, sex work entrance, use of health services, and main health outcomes.

Conclusions

Discrimination and social exclusion were identified before and during migration. Participants had used the NHS system and told positive experiences. They reported STI-HIV, recreational drugs and mental health issues. Findings suggest the influence of migration and sex work on their vulnerabilities and health outcomes.

Mental Health Challenges and Needs among Sexual and Gender Minority People in Western Kenya

Background: Sexual and gender minority (SGM) people in Kenya face pervasive socio-cultural and structural discrimination. Persistent stress stemming from anti-SGM stigma and prejudice may place SGM individuals at increased risk for negative mental health outcomes. This study explored experiences with violence (intimate partner violence and SGM-based violence), mental health outcomes (psychological distress, PTSD symptoms, and depressive symptoms), alcohol and other substance use, and prioritization of community needs among SGM adults in Western Kenya. Methods: This study was conducted by members of a collaborative research partnership between a U.S. academic institution and a Kenyan LGBTQ civil society organization (CSO). A convenience sample of 527 SGM adults (92.7% ages 18-34) was recruited from community venues to complete a cross-sectional survey either on paper or through an online secure platform. Results: For comparative analytic purposes, three sexual orientation and gender identity (SOGI) groups were created: (1) cisgender sexual minority women (SMW; 24.9%), (2) cisgender sexual minority men (SMM; 63.8%), and (3) gender minority individuals (GMI; 11.4%). Overall, 11.7% of participants reported clinically significant levels of psychological distress, 53.2% reported clinically significant levels of post-traumatic stress disorder (PTSD) symptoms, and 26.1% reported clinically significant levels of depressive symptoms. No statistically significant differences in clinical levels of these mental health concerns were detected across SOGI groups. Overall, 76.2% of participants reported ever using alcohol, 45.6% home brew, 43.5% tobacco, 39.1% marijuana, and 27.7% miraa or khat. Statistically significant SOGI group differences on potentially problematic substance use revealed that GMI participants were less likely to use alcohol and tobacco daily; and SMM participants were more likely to use marijuana daily. Lifetime intimate partner violence (IPV) was reported by 42.5% of participants, and lifetime SGM-based violence (SGMV) was reported by 43.4%. GMI participants were more likely than other SOGI groups to have experienced both IPV and SGMV. Participants who experienced SGMV had significantly higher rates of clinically significant depressive and PTSD symptoms. Conclusions: Despite current resilience demonstrated by SGM adults in Kenya, there is an urgent need to develop and deliver culturally appropriate mental health services for this population. Given the pervasiveness of anti-SGM violence, services should be provided using trauma-informed principles, and be sensitive to the lived experiences of SGM adults in Kenya. Community and policy levels interventions are needed to decrease SGM-based stigma and violence, increase SGM visibility and acceptance, and create safe and affirming venues for mental health care. Political prioritization of SGM mental health is needed for sustainable change.

Getting by with a Little Help from Our Friends: The Role of Social Support in Addressing HIV-related Mental Health Disparities among Sexual Minorities in the Lower Rio Grande Valley

This study examines how social support and perceived discrimination influence depressive symptoms of sexual minorities (including, lesbian, gay, bisexual-identifying individuals, and others with same-sex sexual partners) relative to heterosexual peers, while considering the role of HIV-positive status. We surveyed low-income, predominantly Hispanic/Latino/as residents receiving STI-testing and/or HIV/AIDS care in the lower Rio Grande Valley of southernmost Texas. Respondents aged 18+ took a self-administered survey in English or Spanish in a clinic waiting room (N= 273). Based on OLS regression, HIV-positive status (OLS coefficient = 2.54, p< .01) and social support (OLS coefficient = -0.17, p< .001) were significant predictors of depressive symptoms among sexual minorities, but not those who identified as heterosexual. Perceived discrimination was uniquely associated with increased depressive symptoms among sexual minorities (interaction coefficient = 0.21, p< .05). Clinicians treating sexual minority patients for depression should consider developing and applying resources tailored to individuals' level of social support and ongoing experiences of social discrimination.

Gender Expression and Its Correlates in a Nationally Representative Sample of the U.S. Adult Population: Findings from the National Survey of Sexual Health and Behavior

We explored the associations of gender expression with childhood gender expression, sexual identity, and demographic characteristics in a representative sample of the U.S. population aged 18 to 65 years (N = 1277), using data from the 2015 National Survey of Sexual Health and Behavior. As expected, gay men were less gender conforming than heterosexual men. However, among women, persons with a bisexual identity were less gender conforming compared to heterosexual and lesbian persons. In multivariate analyses, childhood gender expression trumped the role of sexual identity. In terms of demographic characteristics, gender conformity seemed to be more present among persons with positions with less social status in terms of age, race/ethnicity, education, income, and relationship status. Finally, we found among both men and women, that a large proportion saw themselves as more masculine or feminine than men and women on average, respectively, suggesting that accentuating one's gender conformity has a psychological function.

Autonomy-Supportive Healthcare Climate and HIV-Related Stigma Predict Linkage to HIV Care in Men Who Have Sex With Men in Ghana, West Africa

In Ghana, the HIV prevalence among MSM is more than 10 times greater than the general population of adults, and rates of engagement in HIV medical care are low among MSM diagnosed with HIV. Using structured surveys, we investigated the impact of HIV-related stigma, same-sex behavior stigma, and gender nonconformity stigma on linkage to HIV care (LTC) in MSM (N = 225) living with HIV in Ghana. Autonomy-supportive healthcare climate (OR = 1.63, p < .01), vicarious HIV stigma (OR = 2.73, p < .01), and age (OR = 1.06, p < .004) predicted LTC. Conversely, felt normative HIV stigma negatively predicted LTC (OR = 0.65, p < .05). Finally, we identified regional disparities, with MSM from Takoradi being 4 times and 5 times more likely to be LTC compared to Kumasi and Accra, respectively. Our findings highlight the nuanced roles of stigmas in shaping the HIV care continuum among MSM living with HIV, while revealing potential gaps in current measures of HIV-related stigma.

HIV Preexposure Prophylaxis and Treatment as Prevention - Beliefs and Access Barriers in Men Who Have Sex With Men (MSM) and Transgender Women: A Systematic Review

Purpose

While the annual rate of new HIV infections and diagnoses has remained stable for most groups, troubling increases are seen in transgender women and racial/ethnic-minority men who have sex with men (MSM), groups that are disproportionately affected by HIV. The primary purpose of this systematic review is to examine factors that impact attitudes and beliefs about preexposure prophylaxis (PrEP) and treatment as prevention (TasP) and to explore barriers to PrEP uptake in MSM and transgender women.

Methods

Using MeSH terms and relevant keywords, we conducted a systematic review of studies published between 2010 and 2019. We searched 4 literature databases and identified studies on MSM and transgender women to elucidate perceptions of PrEP and TasP as well as barriers to access.

Results

The search yielded several prominent themes associated with beliefs about HIV prevention approaches and barriers to PrEP access in MSM and transgender women. One was a lack of awareness or insufficient knowledge of PrEP and TasP. Structural barriers and geographic isolation also prevent access to HIV prevention. Sexual minority and HIV-related stigma, internalized homonegativity, and misinterpretations of messages within HIV prevention campaigns have negatively impacted PrEP uptake and beliefs about PrEP and TasP. Quality of the relationship MSM or transgender people have with their health care provider can facilitate or hinder HIV prevention. Finally, variability in beliefs about the efficacy of TasP has negatively affected the impact of TasP messaging campaigns.

Conclusions

Although there is evidence of increasing PrEP use in at-risk individuals, several barriers prevent wider acceptance and uptake. Misunderstanding about the meaning of "undetectable" and skepticism about the evidence behind TasP messaging campaigns are likely to delay the World Health Organization's stated goal of getting to zero transmissions.

HIV Vaccine Preparedness among Men Who Have Sex with Men in Taiwan: Sociocultural and Behavioral Factors

In Taiwan, men who have sex with men (MSM) are at disproportionate risk of HIV infection. We examined awareness and acceptability of future HIV vaccines. From July to August 2014, we conducted a cross-sectional survey with MSM recruited through community-based organizations (CBOs) in 2 cities. Among 200 participants (mean age, 27.6 years), half reported multiple partners and one-third condomless anal sex (past 3 months); 12% were HIV-positive. Traditional Chinese medicine (TCM) use was reported by 42.7%. Over two-thirds (69.0%) were aware of HIV vaccine research, but less than half (43.8%) would accept an HIV vaccine if available. In multivariable analysis, higher educational attainment, >5 sex partners, and TCM use were positively associated with HIV vaccine awareness. Culturally informed HIV vaccine preparedness in Taiwan may be supported by a complementary approach to TCM and HIV prevention technologies, tailoring information for MSM with lower education and targeting those at high risk through gay-identified CBOs.

What Do We Know About LGBTQIA+ Mental Health in India? A Review of Research From 2009 to 2019

Background: The period from 2009 to 2019 has seen a lot of conversation about issues of LGBTQIA+ (lesbian, gay, bisexual, transgender, queer/ questioning, intersex, asexual, and others) individuals in India, but they continue to be a group showing poor health equity.

Objective: This descriptive content review attempted to explore 5 questions: what is the nature of existing research on mental health of LGBTQIA+ individuals, what are the pathways that contribute to mental health issues, whether the existing health facilities mitigate or facilitate these pathways, what are the interventions proposed for this group, and what are the gaps in research that can be addressed in the next decade.

Method: “Mental health aspects” were described as variables relevant to understanding individuals’ cognitions, emotions, and behavior. We searched for literature in online journal databases, in archives of the most prominent journals, on websites of prominent LGBTQIA+ organizations, and through cross-referencing of papers obtained. The data were abstracted and coded into themes and subthemes. We found 22 reviews and reports, 4 viewpoints and comments, 7 editorials, 1 conference proceeding, and 60 original articles.

Conclusions: Prevalence studies reveal that LGBTQIA+ individuals were found to show high rates of mental health concerns, and that the adapted minority stress model may be a crucial pathway for the same. Lived experiences, factors related to mental well-being, and societal attitudes have also been studied. Intervention studies are relatively fewer, and certain subgroups of LGBTQIA+ identities are less represented in research. Gaps in research were identified and recommendations for research in the coming decade were proposed.

Relationship Between Depressive Symptoms and Engagement With the Health Care Provider in People Living With HIV: A Two-Wave Cross-Lag Model

Depressive symptoms in persons living with HIV (PLWH) negatively affect retention in care, antiretroviral therapy adherence, and health outcomes. Patient-provider relationships and depressive symptoms are associated, but less is known regarding their bidirectional relationship. We assessed whether depressive symptoms in PLWH are a risk factor or a consequence of the patient-provider relationship or both. We used a two-wave cross-lag model to test the prospective and reciprocal relationship between depressive symptoms and the patient-provider relationship, from baseline to 28-week follow-up. The findings from our study found no causal association between depressive symptoms and the patient-provider relationship. Specifically, findings revealed that available social support and HIV stigma weaken the effect of the baseline patient-provider relationship on later depressive symptoms. Findings from our study suggest that although the patient-provider relationship is beneficial for mental health outcomes in PLWH, addressing sociodemographic factors may be of greater importance.