Social risk, stigma and space: key concepts for understanding HIV vulnerability among black men who have sex with men in New York City

Growing up in the shadow of HIV: post-AIDS generation of HIV-negative men who have sex with men in Sweden and their perceptions of HIV and stigma

Despite growing understanding and acceptance of the concept of Undetectable = Untransmittable (U = U) among gay men, HIV stigma remains a burden for people living with HIV. This study explored perceptions of HIV among HIV seronegative gay men in Sweden in this new context. Using snowball sampling, 15 gay men born between 1980 and 2000 were recruited to the study. Semi-structured interviews were conducted and data were subjected to reflexive thematic analysis. Men grew up experiencing gay stigma and were repeatedly informed by parents, schools, communities, peers, and popular culture about the dangers of HIV, and that gay men were a high-risk group. As men grew older, and the premise of HIV shifted dramatically due to U = U, some remained emotionally anchored to the pre-U = U era, while others realigned their perceptions, often after a process of reconciling emotional responses (e.g. HIV = death) with the logical-rational claims made about U = U. The study highlights key areas for future efforts, namely establishing a balance between HIV education strategies and stigma reduction initiatives. Study findings underscore the need to care for the memory of those lost during the crisis years, while also addressing the stigma faced by those currently living with HIV.

Scoping review of HIV-related intersectional stigma among sexual and gender minorities in sub-Saharan Africa

OBJECTIVES

Sexual and gender minority (SGM) populations in sub-Saharan Africa (SSA) are disproportionately impacted by HIV and often face multiple HIV-related stigmas. Addressing these stigmas could reduce SGM HIV vulnerability but little is known about how the stigmas operate and intersect. Intersectional stigma offers a lens for understanding the experiences of stigmatised populations and refers to the synergistic negative health effects of various systems of oppression on individuals with multiple stigmatised identities, behaviours or conditions. This review aims to (1) assess how often and in what ways an intersectional lens is applied in HIV-related stigma research on SGM populations in SSA and (2) understand how intersectional stigma impacts HIV risk in these populations.

DESIGN

Scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews.

DATA SOURCES

Public health and regional databases were searched in 2020 and 2022.

ELIGIBILITY CRITERIA

Articles in French and English on HIV-related stigma and HIV outcomes among men who have sex with men, women who have sex with women and/or transgender individuals in SSA.

DATA EXTRACTION AND SYNTHESIS

Articles were screened and extracted twice and categorised by use of an intersectional approach. Study designs and stigma types were described quantitatively and findings on intersectional stigma were thematically analysed.

RESULTS

Of 173 articles on HIV-related stigma among SGM in SSA included in this review, 21 articles (12%) applied an intersectional lens. The most common intersectional stigmas investigated were HIV and same-sex attraction/behaviour stigma and HIV, same-sex attraction/behaviour and gender non-conformity stigma. Intersectional stigma drivers, facilitators and manifestations were identified across individual, interpersonal, institutional and societal socioecological levels. Intersectional stigma impacts HIV vulnerability by reducing HIV prevention and treatment service uptake, worsening mental health and increasing exposure to HIV risk factors.

CONCLUSION

Intersectional approaches are gaining traction in stigma research among SGM in SSA. Future research should prioritise quantitative and mixed methods investigations, diverse populations and intervention evaluation.

The stigma of smoking among women: A systematic review

BACKGROUND

Smoking stigma has been well documented, but little is known regarding its specific features and effects on women. Notably, women face unique social, cultural, and economic challenges that may interact with smoking stigma and impact health outcomes. This review investigates the extent to which smoking women encounter and internalise stigma, while examining the various coping mechanisms they employ to manage these negative experiences.

METHODS

In November 2022, major databases were systematically searched with no time restrictions. After applying inclusion and exclusion criteria, 23 studies (three quantitative and 20 qualitative) met our criteria. We conducted a quality assessment and summarised the findings pertaining to public stigma, self-stigma, and coping strategies.

RESULTS

The stigma about smoking emerges from a variety of sources, such as family, healthcare providers, or internet forums. Women smokers are universally aware of the negative image they have in society. Yet, their experiences and management of the stigma of smoking are shaped by other variables such as cultural background, social class, or motherhood status. Smoking stigma produces ambivalent effects, such as concealment, reduced usage of support services, and to a lesser extent, smoking cessation motivation.

CONCLUSIONS

These results indicate that smoking stigma is an important social justice and public health issue and that further research is needed to better prevent its effects on women's well-being and health behaviours.

"The Fight is Two Times as Hard": A Qualitative Examination of a Violence Syndemic Among Young Black Sexual Minority Men

Young Black men who have sex with men (YBMSM) are disproportionately impacted by violence, including violence rooted in anti-Black racism, sexual identity bullying, and neighborhood violence rooted in structural racism and inequities. These multiple forms of violence are frequently co-occurring and interactive creating syndemic conditions that can negatively impact HIV care. This qualitative study is based on in-depth interviews with 31 YBMSM, aged 16-30 years, living with HIV in Chicago, IL, to examine how violence has impacted their lives. Using thematic analysis, we identified five themes that reflect how YBMSM experience violence at the intersection of racism, homonegativity, socioeconomic status, and HIV status: (a) the experience of intersectional violence; (b) long histories of violence contributed to hypervigilance, lack of safety, and lack of trust; (c) making meaning of violence and the importance of strength; (d) normalizing violence for survival; and (e) the cyclical nature of violence. Our study highlights how multiple forms of violence can accumulate across an individual's life and contribute to social and contextual situations that further contribute to violence and negatively impact mental health and HIV care.

The Ongoing Process of HIV-Stigma (Re)Production

HIV stigma negatively affects the social experiences of people living with HIV (PLWH) and remains a challenge to HIV prevention, treatment, and care. Research has overwhelmingly focused on individual cognitive measures of HIV stigma (e.g., internalized, anticipated, and experienced). However, little research explores the interactions and societal structures through which HIV stigma is produced. Data from qualitative interviews with 30 black gay and bisexual men living with HIV in the U.S. Deep South revealed an interconnected and interdependent set of processes that produce and reproduce HIV stigma. These included social interactions (silence, euphemism, and gossip), witnessed acts of marginalization, word-of-mouth transmission of HIV misinformation, and laws and policies carried out within the education and criminal justice systems. Efforts to reduce stigma that focus on individual beliefs and attitudes are critical to improving the well-being of PLWH. However, reducing HIV stigma requires intervening on the social interactions and structures through which HIV stigma is produced and reproduced.

Migrant and refugee youth perspectives on sexual and reproductive health and rights in Australia: a systematic review

Migrant and refugee youth (MRY) in Australia face specific experiences that inform their sexual and reproductive health and rights (SRHR). Migrant and refugee communities experience poor health outcomes and low service uptake. Additionally, youth are vulnerable to poor sexual health. This review examines the understandings and perspectives of MRY. A systematic review was conducted as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The protocol is registered with PROSPERO: CRD42021241213. Nine databases were systematically searched. Inclusion criteria specified literature reporting on migrant and/or refugee youth perspectives and attitudes towards sexual and reproductive health; peer-reviewed qualitative, mixed-methods and/or quantitative studies or grey literature reports; records using Australian research; literature published in English between January 2000 and March 2021. Records that did not report on MRY and did not examine participant views or perspectives; were abstract-only, reviews, pamphlets, protocols, opinion pieces or letters; did not include Australian research; were published before 2000 and/or in a language other than English were excluded. Two reviewers screened titles, abstracts and full-text articles. The Mixed Method Appraisal Tool was used to assess studies' methodological quality. Thematic synthesis methods guided data extraction and analysis. Twenty-eight papers were included in the final review. Three themes were identified in MRY constructions of SRHR: (1) experiences of silence and shame; (2) understandings of and responses to SRHR risks; (3) navigation of relationships and sexual activity. Socioecological factors shaped MRY perspectives at individual, interpersonal, institutional and societal levels. Societal factors and interpersonal relationships significantly influenced decision making.

Public health services and intersectional stigma: a social sciences perspective with implications for HIV service design and delivery

PURPOSE OF REVIEW

Understanding stigma is important for improving HIV care services and gaps in HIV service delivery have been attributed to stigma. This review article synthesizes recent evidence on stigma and its implications for HIV service design and delivery. Given the intersectional nature of stigma, we will focus on HIV stigma as well as related forms of stigma based on one's race, sexual identity, gender identity and other identities.

RECENT FINDINGS

Stigma remains a barrier to achieving equity in HIV services. Individualistic measures of stigma remain influential and are associated with barriers to accessing HIV health services. Recent work also highlights stigma measured at a structural level and its impact on HIV services contexts. Individuals situated at intersections of marginalized identities continue to face greatest injustices, and although intersectional approaches have been adapted to design services at a micro level, few focus on structural change. Recent evidence for mitigating stigma indicates some success for psychosocial interventions that target internalized stigma. Furthermore, community-led approaches show promise in addressing stigma that manifests in HIV health services settings.

SUMMARY

Interventions that address individual-level stigma and structural stigma are needed. Theoretical and applied antistigma research is needed to make HIV services more equitable.

Employment as HIV Prevention: An Employment Support Intervention for Adolescent Men Who Have Sex With Men and Adolescent Transgender Women of Color

BACKGROUND

The purpose of this study was to adapt and pilot-test an employment support, primary HIV intervention tailored to the needs of adolescent men who have sex with men and adolescent transgender women of color.

SETTING

The intervention was implemented in 2 settings: controlled environment (Phase 1) and real-world community-based (Phase 2) setting in Chicago, IL.

METHODS

Eighty-seven adolescent men who have sex with men and adolescent transgender women of color ages 16-24 participated in Work2Prevent , a 4-session employment and HIV prevention intervention, designed to increase job-readiness and reduce HIV risk. Intervention sessions consisted of group activities: educational games, roleplaying/modeling behavior, and self-regulation exercises. Participants were assessed at baseline, postintervention, and 8-month (Phase 1) or 3-month follow-up (Phase 2).

RESULTS

Participants evaluated Work2Prevent as feasible and acceptable, rating intervention quality, usefulness, and satisfaction highly. Overall, 59.6% (Phase 1) and 85.0% (Phase 2) participants attended 2 or more sessions. At 8 months, Phase 1 participants reported a mean increase of 11.4 hours worked per week. Phase 2 participants reported a mean increase of 5.2 hours worked per week and an increase in job-seeking self-efficacy. Phase 2 participants also reported a decrease in transactional sex work.

CONCLUSION

Work2Prevent is one of the first structural primary HIV interventions to specifically focus on adolescent employment readiness. Findings suggest Work2Prevent is feasible and acceptable, improved adolescent employment outcomes, and reduced HIV risk associated with transactional sex work. Our study underscores the need for alternative pathways, such as addressing socioeconomic determinants, to prevent adolescent HIV infection.

Engagement with HIV and COVID-19 prevention: a national cross-sectional analysis of users on a geosocial networking app (Preprint)

Background

Objective

Methods

Results

Conclusions

Integrated molecular and affiliation network analysis: Core-periphery social clustering is associated with HIV transmission patterns

This study investigates the two-mode core-periphery structures of venue affiliation networks of younger Black men who have sex with men (YBMSM). We examined the association between these structures and HIV phylogenetic clusters, defined as members who share highly similar HIV strains that are regarded as a proxy for sexual affiliation networks. Using data from 114 YBMSM who are living with HIV in two large U.S. cities, we found that HIV phylogenetic clustering patterns were associated with social clustering patterns whose members share affiliation with core venues that overlap with those of YBMSM. Distinct HIV transmission patterns were found in each city, a finding that can help to inform tailored venue-based and network intervention strategies.

Mapping LGBTQ+ Youth Resource Density Across Four High HIV Prevalence Corridors in the US

INTRODUCTION

Studies using geospatial data to understand LGBTQ+-friendly sexual health and wellness resource availability have often focused on services catered to adults. While HIV rates have increased in adolescents in recent years, few studies have explored disparities in resource access for adolescent gay and bisexual men (AGBMSM).

METHODS

We used geospatial data of resources (collected and verified 2017-2018) from the iReach app to understand disparities in resource access for AGBMSM within and between 4 high HIV prevalence corridors in the US.

RESULTS

AGBMSM in non-metro areas had access to fewer resources and some rural counties had no LGBTQ+ -friendly resources. Corridors comprising states with legacies of punitive laws targeting sexual and gender minorities demonstrate stark geographic disparities across the US.

CONCLUSIONS

Policy-makers must understand the granularity of disparities within regions. Online resources may be able to surmount LGBTQ+ resource deserts. However, physical access to LGBTQ+ -friendly services must be improved as a fundamental strategy for reducing HIV among AGBMSM.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s13178-021-00660-0.

Living While Black, Gay, and Poor: The Association of Race, Neighborhood Structural Disadvantage, and PrEP Utilization Among a Sample of Black Men Who Have Sex With Men in the Deep South

Utilizing the Andersen Healthcare Utilization Model, we examined the role of neighborhood context on pre-exposure prophylaxis (PrEP) utilization among a sample of Black men who have sex with men (MSM) residing in a medium-sized city in the Deep South. Data were derived from a sample of 142 Black MSM aged 18-64 years who were eligible for PrEP from a community-based study known as "ACCELERATE!" We used multilevel structural equation modeling to assess PrEP use. Social support, sexual risk, and health care access were predictive of PrEP use. Notably, residing in a neighborhood with concentrated poverty was associated with decreased PrEP use. Our findings reveal neighborhood structural disadvantage is associated with decreased PrEP use among Black MSM, after adjusting of individual-level sociodemographic characteristics. There is an urgent need to develop HIV prevention interventions and programs that explicitly address structural-level factors to eliminate racial/ethnic differences in HIV.

Structural and intersectional biographical disruption: The case of HIV disclosure among a sample of black gay and bisexual men

HIV disclosure has been considered key to prevention and privileged as a "healthy" behavior for people living with HIV. Although research has documented potential negative outcomes of disclosure, we know little about its potential of these consequences to disrupt one's biography, or the intersectional and structural inequities that shape disclosure/nondisclosure and its outcomes. Exploring HIV disclosure as a discrete, measurable event cannot account for the experience of the self in illness, and how disclosure can fundamentally shift everyday reality and social relationships. To fill this gap, I employed the framework of structural intersectionality, and the medical sociology theory of biographical disruption to explore HIV disclosure among a sample of Black gay and bisexual men living with HIV in the Deep South. Between June 2019 and June 2020, I conducted in-depth qualitative interviews with 30 Black gay and bisexual men living with HIV in the Baton Rouge, Louisiana metropolitan area. Interviews were recorded and transcribed verbatim and analyzed using a grounded theory approach. Disruptions as a result of HIV disclosure included: assaults on self; disturbance to social and familial networks; and socioeconomic impacts. Further, findings illustrate that disruptions were not discrete events, but evolved over time, and that the nature of disruption was constituted by previous traumatic disruptions, social and structural contexts, and men's social location at the intersections of race, class, sexuality, HIV-status, and geography. I highlight that consequences of HIV disclosure among a sample of Black gay and bisexual men, were shaped by their unique social location and the persistence of intersecting structural inequities. Future research should account for preceding and cumulative experiences, how intersecting inequities constitute disclosure experiences, and that disclosure is a complex process occurring in the context of ongoing social relations.

A review of current strategies to improve HIV prevention and treatment in sexual and gender minority Latinx (SGML) communities

INTRODUCTION

The HIV epidemic continues to disproportionately impact sexual and gender minority Latinxs (SGML). Several syndemic conditions have been linked with HIV acquisition and transmission among SGML including immigration, discrimination, environmental racism, substance use, and mental health.

AREAS COVERED

We provide a summary of biomedical, behavioral, and social/structural interventions to reduce risks for acquiring HIV and improve outcomes along the HIV care continuum among SGML. We also discuss intervention approaches and opportunities that respond at the intersection of HIV and COVID-19 prevention and treatment.

EXPERT OPINION

There is a dire need for the combination of biomedical, behavioral, and social/structural interventions to reduce risks for acquiring HIV and improve outcomes along the HIV care continuum. Interventions and combination approaches should be driven by community-based participatory action research. The inclusion of community members in all stages of the research process can assure successful implementation of program activities and deliverables, including the provision of culturally and linguistically appropriate services. Given the current COVID-19 pandemic, which is disproportionately impacting individuals living with HIV and other comorbidities, the elderly, and under-resourced communities with a ferocity not seen in other communities, intervention approaches that respond at the intersection of HIV and COVID-19 prevention and treatment are also urgently needed.

Spatial analysis of COVID-19 clusters and contextual factors in New York City

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Proportion positive tests were positively associated with marginalized statuses.

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Low testing and high positivity were associated with public transportation use.

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We recommend testing and health care resources be directed to eastern Brooklyn.

Identifying areas with low access to testing and high case burden is necessary to understand risk and allocate resources in the COVID-19 pandemic. Using zip code level data for New York City, we analyzed testing rates, positivity rates, and proportion positive. A spatial scan statistic identified clusters of high and low testing rates, high positivity rates, and high proportion positive. Boxplots and Pearson correlations determined associations between outcomes, clusters, and contextual factors. Clusters with less testing and low proportion positive tests had higher income, education, and white population, whereas clusters with high testing rates and high proportion positive tests were disproportionately black and without health insurance. Correlations showed inverse associations of white race, education, and income with proportion positive tests, and positive associations with black race, Hispanic ethnicity, and poverty. We recommend testing and health care resources be directed to eastern Brooklyn, which has low testing and high proportion positives.

Changes in Characteristics and Behavior Among African American Men Who Have Sex with Men and Women in the Context of Reductions in HIV Diagnoses Among Women

Men who have sex with men and women (MSMW) connect lower prevalence populations of women to higher prevalence populations of men who have sex with men only. We hypothesize that HIV testing and treatment among MSMW have increased in recent years, and this increase can help explain the declining rates of new HIV diagnoses among African American women. We analyzed data from 2008, 2011, and 2014 of the National HIV Behavioral Surveillance system. African American men who have sex with men (MSM) were surveyed from 19 United States cities using venue-based sampling and tested for HIV infection. We used generalized estimating equations, using year of survey as an independent variable, adjusting for age, to determine differences for selected outcomes regarding healthcare and risk behaviors over time. Among the 1299 African American MSMW interviewed, significant increases were observed in the percent of men who had an HIV test in the previous 12 months (2008: 54%, 2011: 69%, and 2014: 68%, p-value < 0.001). Among HIV-positive men, the percentage of men who were aware of their infection at the time of the interview increased significantly over time (26, 35, and 48%, p-value = 0.002). Among those men, the percentage who reported currently being on antiretroviral therapy also increased significantly over time (46, 69, and 72%, p-value = 0.050). The percentage of men reporting high-risk sexual risk behaviors increased or remained stable. Our findings support the hypothesis that HIV testing and treatment has increased among African American MSM from 2008 to 2014. Additional research is needed to fully explore the population-level impact it has on HIV transmission among women.

Collective Avoidance of Social and Health Venues and HIV Racial Inequities: Network Modeling of Venue Avoidance on Venue Affiliation, Social Networks, and HIV Risk

Many younger Black men who have sex with men (YBMSM) are exposed to homonegativity, societal stigma, and racial discrimination in their social environment. This study uses a social network modeling methodology to identify aspects of the social environment that are not often described, that is, the places and spaces or "venues" where YBMSM socialize or where they receive HIV prevention services. In particular, we identify the structural features of avoidance of these venues as an indicator of negative experiences, using bipartite exponential random graph models. Our study theorizes that YBMSM avoid certain venues en masse through information diffusion among social network members. We specify two social mechanisms of collective venue avoidance-(1) homophily (i.e., ego-alter similarity in venue avoidance) and (2) popular opinion leaders (as early adopters)-and test the corresponding hypotheses that (Hypothesis 1) socially connected individuals avoid venues together and that (Hypothesis 2) popular individuals would be more likely to avoid venues. Based on data collected from YBMSM aged 16 to 29 years between 2014 and 2016 in Houston, Texas (N = 227) and Chicago, Illinois (N = 241), results indicate that Hypothesis 1 was supported in both cities but that Hypothesis 2 was supported only in Chicago. The findings suggest that the structural patterns of venue avoidance are different between cities and may inform dissemination of prevention messages and delivery of venue- and social influence-based HIV interventions.

Structures of Sexuality: Sexual Stigma, Disclosure, and HIV Risk with Primary Female Partners Among Behaviorally Bisexual Black Men

HIV continues to disproportionately impact bisexual Black men, as well as their female partners, in the U.S. There is a need to better understand how stigma and disclosure affect sexual risk for men and their female partners. This article describes the relationship between sexual stigma and HIV risk with primary female partners among a sample of 121 behaviorally bisexual Black men of mixed HIV status in the San Francisco Bay Area. Multivariate analyses tested to see if each of three stigma measures (bisexual stigma, internalized homophobia, difficulty with bisexual identity) would have any effect on participants' condom use. Quantitative analyses found that sexual stigma increased men's sexual risk through inhibiting disclosure of their sexual activity with men to their female partners. Men who reported higher levels of bisexual stigma and internalized homophobia reported that it was harder to disclose having sex with men to their primary female partner, which was significantly related to lower levels of condom use. Stigma reduction HIV prevention interventions are needed that address bisexual stigma experienced by Black men. HIV prevention interventions, including stigma reduction programs, must target both men and women to effectively reduce bisexual stigma and address the structural and relationship contexts of HIV.

PrEP indicators, social capital and social group memberships among gay, bisexual and other men who have sex with men

Efforts to reduce HIV among gay, bisexual and other men who have sex with men include increasing awareness and uptake of pre-exposure prophylaxis (PrEP). Social capital may facilitate engagement in HIV prevention. Membership of social groups including chosen families (i.e. friends as family relationships) - one potential indicator of social capital - may be protective against HIV risk and infection. In this cross-sectional quantitative study, we examined social capital items and social group membership in association with PrEP outcomes. In 2014, the New Orleans arm of the National HIV Behavioral Surveillance recruited 353 HIV-negative men, of whom 46% identified as Black, Latino or Other Race and 54% as Non-Hispanic White, using venue-based sampling to complete a structured survey. Multivariable logistic regression models tested the relations between social group membership and social capital with PrEP indicators. Men who reported community group participation were more likely to be aware of PrEP compared to those who did not. Men in chosen families associated with a family name were least likely to be aware of and willing to take PrEP compared to those not in any other social groups. Social group membership is a potential social capital indicator for assessing HIV prevention among men.

The Motivational PrEP Cascade Guides Interpretation of Early PrEP Linkage to Care for Young Black Men Who Have Sex With Men: The Case of Chicago's PrEPLine

Pre-exposure prophylaxis (PrEP) uptake remains low among Black men who have sex with men (BMSM). PrEPLine, launched in August 2015, based in Chicago, was designed to support PrEP linkage among BMSM. PrEPLine moves clients through the Motivational PrEP Cascade, addresses barriers, and tracks outcomes. Study findings suggest that three variables (i.e., being gay/same gender loving, living more than 15 miles from a clinic location, rescheduling an appointment) demonstrated a significant positive association with initiating PrEP. A subanalysis of BMSM found that two variables (i.e., living on the West Side of Chicago relative to those living on the South Side, and among those living in communities with a higher rate of poverty [more than 30%], relative to those living in communities with a lower rate of poverty [less than 20%]) demonstrated a significant negative association with initiating PrEP.

HIV-Related Training and Correlates of Knowledge, HIV Screening and Prescribing of nPEP and PrEP Among Primary Care Providers in Southeast United States, 2017

The Southeast accounted for most HIV diagnoses (52%) in the United States in 2015. Primary care providers (PCPs) play a vital role in HIV prevention for at-risk persons and treatment of persons living with HIV. We studied HIV-related training, knowledge, and clinical practices among PCPs in the Southeast to address knowledge gaps to inform HIV prevention strategies. Between April and August 2017, we conducted an on-line survey of a representative sample of PCPs in six Southeast jurisdictions with high rates of HIV diagnoses (Atlanta; Baltimore; Baton Rouge; District of Columbia; Miami; New Orleans). We defined HIV-related training as self-reported completion of any certified HIV/STD course or continuing education in past 24 months (prior to survey completion). We assessed associations between training and HIV testing practices, familiarity with nonoccupational post-exposure prophylaxis (nPEP) and pre-exposure prophylaxis (PrEP), and ever prescribing nPEP or PrEP. There were 820 participants after fielding 4595 surveys (29.6% adjusted response rate). In weighted analyses, 36.3% reported HIV-related training. Using adjusted prevalence ratio (aPR) and confidence intervals (CI), we found that PCPs with HIV-related training (compared to those with no training) were more likely to be familiar with nPEP (aPR = 1.32, 95% CI 1.05, 1.67) and PrEP (aPR = 1.67, 95% CI 1.19, 2.38); and to have ever prescribed PrEP to patients (aPR = 1.75, 95% CI 1.10, 2.78). Increased HIV-related trainings among PCPs in high HIV prevalence Southeast jurisdictions may be warranted. Strengthening nPEP and PrEP familiarity among PCPs in Southeast may advance national HIV prevention goals.

Stigma, discrimination, and substance use among an urban sample men who have sex with men in Massachusetts

Men who have sex with men (MSM) who have intersecting stigmatized identities or characteristics are differentially at risk for acquiring HIV. However, the relationships between specific identities, discrimination and stigma, and HIV risk behaviors require investigation to develop more effective interventions. Data from Boston's 2014 National HIV Behavioral Surveillance MSM cycle were used to assess associations between socio-demographics, structural factors, substance use, discrimination, HIV-stigma, and condomless anal sex. Of the total sample (n = 382), 17.6% reported verbal abuse, 8.3% work-place discrimination, 2.6% health discrimination, and 3.8% physical assault. HIV-stigma beliefs differed by race, sexual-orientation, and income. Those with histories of drug treatment were 9.47 (OR 95%CI: 2.09, 42.79) and 8.29 (OR 95%CI: 2.27, 30.21) times more likely to report health discrimination and physical assault, respectively. Healthcare discrimination and physical assault moderated relationships between substance use and number of condomless anal sex partners such that those who experienced discrimination and substance use reported more partners. Even in Massachusetts, MSM with identities or characteristics marginalized in society disproportionately experienced discrimination and stigma and healthcare discrimination or physical assault were associated with increased sexual risk behavior among MSM who use substances. Decreasing HIV transmission requires reducing discrimination and stigma among those most vulnerable, particularly those using substances.

Effect of a Community-Level HIV Prevention Intervention on Psychosocial Determinants of HIV Risk Behaviors among Young Black Men Who Have Sex with Men (YBMSM)

In contrast to intervention studies that assess psychosocial factors only as mediators or moderators of HIV risk, the present study assessed the effects of an Mpowerment-based community-level intervention on psychosocial determinants (e.g., depressive symptoms, sexual stigma) of HIV risk behavior among young black MSM. Approximately 330 respondents were surveyed annually for 4 years in each of two sites. General linear models examined change across time between the intervention and comparison communities, and participation effects in the intervention site. Social diffusion (spreading information within networks) of safer sex messages (p < 0.01) and comfort with being gay (p < 0.05) increased with time in intervention versus control. Cross-sectionally, intervention participants responded more favorably (p < 0.05) on social diffusion and depressive symptoms, but less favorably (p < 0.01) on sex in difficult situations and attitudes toward condom use. Findings suggest a need to address broader health issues of MSM as well as sexual risk.

"Automatic assumption of your gender, sexuality and sexual practices is also discrimination": Exploring sexual healthcare experiences and recommendations among sexually and gender diverse persons in Arctic Canada

Sexual and mental health disparities are reported in Arctic Canada as in other Arctic regions that experience shared challenges of insufficient healthcare resources, limited transportation, and a scarcity of healthcare research. Lesbian, gay, bisexual, transgender, and queer persons (LGBTQ+) report sexual and mental health disparities in comparison with their heterosexual and cisgender counterparts, and these disparities may be exacerbated in rural versus urban settings. Yet limited research has explored sexual healthcare experiences among LGBTQ+ persons in the Arctic who are at the juncture of Arctic and LGBTQ+ health disparities. We conducted a qualitative study from May 2015 to October 2015 with LGBTQ+ persons in the Northwest Territories, Canada that involved in-depth individual interviews with LGBTQ+ youth (n = 16), LGBTQ+ adults (n = 21), and key informants (e.g. coaches, teachers, nurses, social workers, and healthcare providers) (n = 14). We conducted thematic analysis, a theoretically flexible approach that integrates deductive and inductive approaches, to identify and map themes in the data. Findings reveal geographical, social, and healthcare factors converge to shape healthcare access. Specifically, the interplay between heterosexism and cisnormativity, intersectional forms of stigma, and place limited LGBTQ+ persons' sexual healthcare access and produced negative experiences in sexual healthcare. Limited healthcare facilities in small communities resulted in confidentiality concerns. Heteronormativity and cisnormativity constrained the ability to access appropriate sexual healthcare. LGBTQ+ persons experienced LGBTQ+, HIV, and sexually transmitted infections stigma in healthcare. Participants also discussed healthcare provider recommendations to better serve LGBTQ+ persons: non-judgment, knowledge of LGBTQ+ health issues, and gender inclusivity. Findings can inform multi-level strategies to reduce intersecting stigma in communities and healthcare, transform healthcare education, and build LGBTQ+ persons' healthcare navigation skills.

Passivos, ativos and versáteis: men who have sex with men, sexual positions and vulnerability to HIV infection in the northeast of Brazil

In Brazil, men who practise receptive anal sex (passivos) and both insertive and receptive anal sex (versáteis) are at greater risk of HIV infection than men who practise only insertive anal sex (ativos). In this study, which combined participant observation, 25 biographical interviews and a behavioural survey of 380 self-identified men who had sex with men in the metropolitan region of Recife (Brazil), we investigated how the sex-gender system, through body stylisation (masculine and effeminate) engenders desire and sexual positioning in men's sexual scenes. The analysis indicated that the sex-gender system tends to reinforce images that portray masculine men as ativos and effeminate men as passivos. However, regarding sexual positioning, sexual versatility is most common (83.3%), which can increase the likelihood of HIV infection and transmission. Stylisations also engender differences in violence related to sexual orientation (e.g. effeminate men were 1.9 times more likely to have experienced violence than masculine men) and desirability (e.g. effeminate men are 6.1 times more likely to be rejected erotically than masculine men). Sexual positioning and stylisation jointly enable community sexual scripts and pathways for HIV to circulate, producing individual and social vulnerability to the epidemic.

Network Properties Among Gay, Bisexual and Other Men Who Have Sex with Men Vary by Race

The HIV burden among gay, bisexual, and other men who have sex with men (GBM) may be related to variations in network characteristics of the individual's social and sexual network. This study investigates variations in network properties among 188 Black and 295 White GBM recruited in New Orleans during the National HIV Behavioral Surveillance in 2014. Participants described up to five people who provided social support and five sex partners in the past 3 months. Network properties and network dissimilarity indicators were aggregated to the participant level as means or proportions and examined using PROC GLM. White participants reported larger networks (p = 0.0027), had known network members longer (p = 0.0033), and reported more substance use (p < 0.0001) within networks. Black participants reported networks with fewer men (p = 0.0056) and younger members (p = 0.0110) than those of White GBM. Network properties among GBM differ by race in New Orleans which may inform prevention interventions.

Network Properties Among Gay, Bisexual and Other Men Who Have Sex with Men Vary by Race

The HIV burden among gay, bisexual, and other men who have sex with men (GBM) may be related to variations in network characteristics of the individual's social and sexual network. This study investigates variations in network properties among 188 Black and 295 White GBM recruited in New Orleans during the National HIV Behavioral Surveillance in 2014. Participants described up to five people who provided social support and five sex partners in the past 3 months. Network properties and network dissimilarity indicators were aggregated to the participant level as means or proportions and examined using PROC GLM. White participants reported larger networks (p = 0.0027), had known network members longer (p = 0.0033), and reported more substance use (p < 0.0001) within networks. Black participants reported networks with fewer men (p = 0.0056) and younger members (p = 0.0110) than those of White GBM. Network properties among GBM differ by race in New Orleans which may inform prevention interventions.

Challenges and opportunities in examining and addressing intersectional stigma and health

BACKGROUND

'Intersectional stigma' is a concept that has emerged to characterize the convergence of multiple stigmatized identities within a person or group, and to address their joint effects on health and wellbeing. While enquiry into the intersections of race, class, and gender serves as the historical and theoretical basis for intersectional stigma, there is little consensus on how best to characterize and analyze intersectional stigma, or on how to design interventions to address this complex phenomenon. The purpose of this paper is to highlight existing intersectional stigma literature, identify gaps in our methods for studying and addressing intersectional stigma, provide examples illustrating promising analytical approaches, and elucidate priorities for future health research.

DISCUSSION

Evidence from the existing scientific literature, as well as the examples presented here, suggest that people in diverse settings experience intersecting forms of stigma that influence their mental and physical health and corresponding health behaviors. As different stigmas are often correlated and interrelated, the health impact of intersectional stigma is complex, generating a broad range of vulnerabilities and risks. Qualitative, quantitative, and mixed methods approaches are required to reduce the significant knowledge gaps that remain in our understanding of intersectional stigma, shared identity, and their effects on health.

CONCLUSIONS

Stigmatized identities, while often analyzed in isolation, do not exist in a vacuum. Intersecting forms of stigma are a common reality, yet they remain poorly understood. The development of instruments and methods to better characterize the mechanisms and effects of intersectional stigma in relation to various health conditions around the globe is vital. Only then will healthcare providers, public health officials, and advocates be able to design health interventions that capitalize on the positive aspects of shared identity, while reducing the burden of stigma.

Social contexts as mediator of risk behaviors in Rwandan men who have sex with men (MSM): Implications for HIV and STI transmission

INTRODUCTION

Men who have sex with men (MSM) are disproportionately impacted by HIV/AIDS resulting from risky sexual behaviors. Social and contextual factors are known to mediate risk behaviors, but there is limited information about the prevalence of risky sexual practices of Rwandan MSM and the concomitant socio-contextual determinants making it difficult to assess implications for preventing HIV/STI transmission in this key population.

METHODS

Using exploratory qualitative design, we obtained socio-contextual information regarding prevalence of risky sexual behavior and assessed implications for HIV/ STIs transmission and preventive measures taken by MSM to improve sexual health and wellbeing. Thirty MSM were recruited to participate in in-depth interviews using respondent-driven sampling from LGBT associations in Kigali. Data were analyzed using standard qualitative data analysis procedures.

RESULTS

Respondents' were between 18-40 years old; all completed primary education and are mostly low-socioeconomic status. Risky sexual practices were common, but differed by peculiar individual and contextual factors. Older MSM often reported occasional sexual relations with women to avoid suspicion and social stigma. Younger MSM's risky sexual practices are mostly transactional and mediated by the need for social acceptance and support. Knowledge of STIs was poor, but prevalence, especially of HPV was high. The options for improving sexual wellbeing are limited and mostly clandestine.

CONCLUSION

Risky sexual behavior of Rwandan MSM has major implications for HIV/STI transmission. An environment of intense social stigma and social isolation makes it difficult to obtain information or services to improve sexual health. Effective interventions that address individual and contextual determinants of risk and access to health services are urgently needed to limit the consequence of MSM as a bridge for HIV transmission to the general population.

Structural Effects on HIV Risk Among Youth: A Multi-level Analysis

We proposed a multilevel model of structural influences on HIV-risky sexual partnerships in a diverse sample of 1793 youth residing in 23 states and the District of Columbia. We examined the influence of concentrated disadvantage, HIV stigma, and sexual and gender minority stigma on engagement in HIV risky sexual partnerships and whether youth's participation in opportunity structures, anticipation of HIV stigma, and perceptions of their community as youth-supportive settings mediated structural effects. After controlling for age, HIV status, and race, we found structural HIV stigma had deleterious indirect effects on youth's participation in HIV-risky sexual partnerships. Concentrated disadvantage and structural sexual and gender minority stigma had direct negative effects on youth's perceptions of their communities as supportive and on their participation in prosocial activity. Support perceptions had direct, protective effects on avoidance of HIV-risky sexual partnerships. Structural stigma undermines youth's belief that their communities invest in their safety and well-being.

'WTF is PrEP?': attitudes towards pre-exposure prophylaxis among men who have sex with men and transgender women in New York City

In the USA, gay and other men who have sex with men and transgender women are disproportionately affected by HIV. Uptake of pre-exposure prophylaxis (PrEP), anti-retroviral therapy to prevent HIV-negative individuals from seroconverting if exposed to HIV, by members of this population remains low, particularly among African-Americans. We conducted two focus groups to assess responses to an online social media campaign focusing on PrEP use in New York City. We designed, produced and disseminated the campaign to address knowledge of PrEP; its physical and psychological side effects; and psychosocial barriers related to PrEP adherence and sex shaming. Focus group participants demonstrated a relatively high knowledge of PrEP, although considerable concern remained about side effects, particularly among Black participants. Participants suggested that stigma against PrEP users was declining as PrEP use became more common, but stigma remained, particularly for those not using condoms. Many focus group participants reported distrust of medical providers and were critical of the commodification of HIV prevention by the pharmaceutical industry. Participants reported that those in romantic relationships confronted unique issues regarding PrEP, namely suspicions of infidelity. Finally, Black participants spoke of the need for more tailored and sensitive representations of Black gay men in future programmes and interventions.

The Impact of Urban US Policing Practices on Black Men Who Have Sex with Men's HIV Vulnerability: Ethnographic Findings and a Conceptual Model for Future Research

This paper advances research on racism and health by presenting a conceptual model that delineates pathways linking policing practices to HIV vulnerability among Black men who have sex with men in the urban USA. Pathways include perceived discrimination based on race, sexuality and gender performance, mental health, and condom-carrying behaviors. The model, intended to stimulate future empirical work, is based on a review of the literature and on ethnographic data collected in 2014 in New York City. This paper contributes to a growing body of work that examines policing practices as drivers of racial health disparities extending far beyond violence-related deaths.

'Church hurt can be the worst hurt': community stakeholder perceptions of the role of Black churches in HIV prevention among young Black gay and bisexual men

Black gay and bisexual men aged 15-29 are disproportionately represented among new cases of HIV in the USA. Researchers have argued that community-based prevention cannot succeed without the participation of faith-based organisations, particularly given the salience of religion and spirituality in the lives of young Black gay and bisexual men. Yet some Black churches may be hesitant to engage in HIV prevention efforts given their beliefs about same-sex behaviour. It is less clear, however, whether and how public health practitioners in the field of HIV prevention have approached church inclusion. We therefore explored how community stakeholders describe the involvement of Black churches with the HIV continuum of care. We draw on a qualitative dataset of 50 in-depth semi-structured interviews conducted in Detroit, USA. Participants offered multiple perspectives on the response of Black churches to the HIV epidemic, from overt stigma to gradual acceptance and action. Nevertheless, participants agreed that when stigma was present in the pews and the pulpit, young Black gay and bisexual men were at potential risk of social isolation. Furthermore, tensions may exist between Black churches and secular community-based organisations that are attributable to histories of mistrust. These findings have important implications for future community-based intervention strategies among young Black gay and bisexual men.

"People try and label me as someone I'm not": The social ecology of Indigenous people living with HIV, stigma, and discrimination in Manitoba, Canada

Indigenous peoples (First Nations, Inuit, and Métis) are currently overrepresented in the HIV epidemic in Canada and are infected at a younger age than those who are not Indigenous. This article presents our findings on the stigma and discrimination (as well as related themes such as disclosure) experienced by Indigenous people who contracted HIV in their youth and live in urban and non-urban settings in Manitoba, Canada. The findings were derived from a qualitative study that sought to understand the experiences and needs of Indigenous people living with HIV (including AIDS). We situate such experiences within a social ecological framework towards developing a better structural understanding of the impacts of stigma and discrimination on the lives of Indigenous people who are HIV positive. Stigma and discrimination caused barriers for Indigenous people living with HIV through inhibiting their ease of access to supports including family, peers, community, and long- and short-term health services. Creative forms of outreach and education that are culturally appropriate and/or rooted in culture were considered to be possibly impactful ways of reducing stigma and discrimination at the community level. Learning from communities who are successfully managing stigma also showed promise for developing new programming.

Barriers to access and uptake of antiretroviral therapy among HIV-positive men who have sex with men in Hanoi, Vietnam: from HIV testing to treatment

Little is known about the experiences of Vietnamese men who have sex with men in accessing HIV testing and treatment. We aimed to explore barriers to access and uptake of antiretroviral therapy (ART) among HIV-positive men who have sex with men in Hanoi. During 2015, we conducted qualitative interviews with 35 participants recruited using snowball sampling based on previous research and social networks. Key individual impediments to ART uptake included inadequate preparation for a positive diagnosis and the dual stigmatisation of homosexuality and HIV and its consequences, leading to fear of disclosure of HIV status. Health system barriers included lack of clarity and consistency about how to register for and access ART, failure to protect patient confidentiality and a reticence by providers to discuss sexual identity and same-sex issues. Results suggest fundamental problems in the way HIV testing is currently delivered in Hanoi, including a lack of client-centred counselling, peer support and clear referral pathways. Overcoming these barriers will require educating men who have sex with men about the benefits of routine testing, improving access to quality diagnostic services and building a safe, confidential treatment environment for HIV-positive men to access, receive and remain in care.

Individual- and contextual-level factors associated with client-initiated HIV testing

ABSTRACT: Background: Knowing the reasons for seeking HIV testing is central for HIV prevention. Despite the availability of free HIV counseling and testing in Brazil, coverage remains lacking. Methods: Survey of 4,760 respondents from urban areas was analyzed. Individual-level variables included sociodemographic characteristics; sexual and reproductive health; HIV/AIDS treatment knowledge and beliefs; being personally acquainted with a person with HIV/AIDS; and holding discriminatory ideas about people living with HIV. Contextual-level variables included the Human Development Index (HDI) of the municipality; prevalence of HIV/AIDS; and availability of local HIV counseling and testing (CT) services. The dependent variable was client-initiated testing. Multilevel Poisson regression models with random intercepts were used to assess associated factors. Results: Common individual-level variables among men and women included being personally acquainted with a person with HIV/AIDS and age; whereas discordant variables included those related to sexual and reproductive health and experiencing sexual violence. Among contextual-level factors, availability of CT services was variable associated with client-initiated testing among women only. The contextual-level variable “HDI of the municipality” was associated with client-initiated testing among women. Conclusion: Thus, marked gender differences in HIV testing were found, with a lack of HIV testing among married women and heterosexual men, groups that do not spontaneously seek testing.