Coping with discrimination among HIV-positive Black men who have sex with men

Examining the Impact of Adverse Childhood Experiences and Active Coping in Black Older Adults: A Mixed Methods Study

PURPOSE

To gain a deeper understanding of Black older adults' (aged ≥65 years) experiences with adverse childhood experiences (ACEs), including racism, and their use of active coping throughout their life course.

METHOD

Qualitative interviews were conducted with 21 Black older adults followed by administration of the First 18 Years Survey (measuring ACEs) and the John Henryism Active Coping Scale. Qualitative data were analyzed using thematic narrative analysis. Quantitative data were analyzed using descriptive statistics. Qualitative and quantitative data were integrated using a triangulation process.

RESULTS

Four major themes emerged from the qualitative data. Participants reported experiencing pervasive racism throughout their lives. Quantitative results indicated participants experienced fewer ACEs and made high use of active coping. Triangulation indicates qualitative findings and explains the quantitative results.

CONCLUSION

Although participants faced ACEs including racism, they found strategies to help them actively cope. [Research in Gerontological Nursing, xx(x), xx-xx.].

Socio-cognitive facilitators of ART-adherence among predominantly black sexual and gender minoritized persons living with HIV in Atlanta, Georgia: a latent profile analysis

The Integrated Change Model describes several social and cognitive factors (e.g., health attitudes, social support, self-efficacy) that can affect medication adherence. Guided by this model, we sought to identify profiles of socio-cognitive facilitators of ART (antiretroviral therapy) adherence among diversely minoritized persons living with HIV enrolled in a behavioral intervention trial in Atlanta, Georgia (N = 477). To do this, we performed latent profile analysis on baseline responses to scales assessing 6 indicators of interest: HIV-care self-efficacy, social support, TasP (treatment-as-prevention) beliefs, trust in healthcare providers, perceived need for ART, and trust in ART. We regressed emergent profiles on internalized, enacted, and microaggressive HIV stigma and compared prospective 30-day ART adherence and several cross-sectional HIV outcomes across profiles. Mean age was 29 years; 83% of participants were non-Hispanic Black, 53% were gay/homosexual-identifying, and 12% were gender expansive. Three profiles emerged: "Constrained/Capable" (6%), featuring high self-efficacy but low-moderate provider trust, social support, TasP beliefs, ART trust, and ART need; "Conflicted" (13%), featuring high TasP beliefs, provider trust, and ART need but moderate self-efficacy, ART trust, and social support; and "Motivated" (81%), featuring high levels of all indicators. Greater internalized, enacted, and microaggressive stigma were positively associated with "Conflicted" relative to "Motivated" profile membership. ART-nonadherence, unsuppressed viral load, and viral load unawareness were more likely for the "Conflicted" relative to the "Motivated" profile. Personalized HIV care tailored to such profiles may improve ART adherence and related outcomes for minoritized persons living with HIV.

Psychometric Assessment of a Homophobia Management Scale Among Cisgender Sexual Minority Men in Midlife and Older Adulthood

Interpersonal management of homophobic stigma (e.g., selectively constructing one's social network; confronting stigma) is an understudied area of resilience among sexual minority people. Among a sample of cisgender sexual minority men (SMM; N = 798) in midlife and older adulthood, we assessed the psychometric properties and characterized the sociodemographic differences of our newly developed, theory-informed homophobia management scale. Data come from the Healthy Aging substudy of the Multicenter AIDS Cohort Study, which is a prospective longitudinal study implemented to evaluate the natural trajectories of HIV risk and treatment among sexual minority men. Guided by the proactive coping processes model, the Healthy Aging team proposed eight items to measure homophobia management, which were included at four waves of survey data collection completed at semiannual study visits. Using factor analyses and linear regressions, we assessed our scale's construct validity, convergent validity, and internal consistency, and characterized scores by age, race/ethnicity, sexual orientation, and HIV status. Factor analyses yielded a six-item scale with adequate construct validity and acceptable internal consistency (Cronbach's alpha = .69). Our final scale exhibited convergent validity given its statistically significant inverse association with internalized homophobia and positive association with psychological connections to the gay community. Bivariate differences in homophobia management emerged by age, race/ethnicity, and sexual orientation but were not statistically significant in multivariable analyses. Our study provides a validated, unidimensional scale to assess homophobia management among SMM in midlife and older adulthood. We provide recommendations to improve the implementation of our scale in future surveillance.

Culturally Relevant Africultural Coping Moderates the Association Between Discrimination and Antiretroviral Adherence Among Sexual Minority Black Americans Living with HIV

Exposure to discrimination has been linked to lower HIV antiretroviral therapy (ART) adherence and poor HIV care outcomes among Black Americans. Coping has been shown to mitigate the harmful effects of discrimination on health behaviors, but the use of cultural relevant Africultural coping strategies is understudied as a moderator of the association between intersectional discrimination and ART adherence among Black Americans. We used adjusted logistic regression to test whether Africultural coping strategies (cognitive/emotional debriefing; collective; spiritual-centered; ritual-centered) moderated associations between multiple forms of discrimination (HIV, sexual orientation, race) and good ART adherence (minimum of 75% or 85% of prescribed doses taken, as measured by electronic monitoring in separate analyses) among 92 sexual minority Black Americans living with HIV. Mean adherence was 66.5% in month 8 after baseline (36% ≥ 85% adherence; 49% ≥ 75% adherence). Ritual-centered coping moderated the relationship between each of the three types of discrimination at baseline and good ART adherence in month 8 (regardless of the minimum threshold for good adherence); when use of ritual coping was low, the association between discrimination and adherence was statistically significant. The other three coping scales each moderated the association between racial discrimination and good ART adherence (defined by the 75% threshold); cognitive/emotional debriefing was also a moderator for both HIV- and race-related discrimination at the 85% adherence threshold. These findings support the benefits of Africultural coping, particularly ritual-centered coping, to help sexual minority Black Americans manage stressors associated with discrimination and to adhere well to ART.

The Inherent Violence of Anti-Black Racism and its Effects on HIV Care for Black Sexually Minoritized Men

The goal of this study was to examine the effects of racial discrimination, depression, and Black LGBTQ community support on HIV care outcomes among a sample of Black sexually minoritized men living with HIV. We conducted a cross-sectional survey with 107 Black sexually minoritized men living with HIV in Chicago. A path model was used to test associations between racial discrimination, Black LGBTQ community support, depressive symptoms, and missed antiretroviral medication doses and HIV care appointments. Results of the path model showed that men who had experienced more racism had more depressive symptoms and subsequently, missed more doses of HIV antiretroviral medication and had missed more HIV care appointments. Greater Black LGBTQ community support was associated with fewer missed HIV care appointments in the past year. This research shows that anti-Black racism may be a pervasive and harmful determinant of HIV inequities and a critical driver of racial disparities in ART adherence and HIV care engagement experienced by Black SMM. Black LGBTQ community support may buffer against the effects of racial discrimination on HIV care outcomes by providing safe, inclusive, supportive spaces for Black SMM.

Five point initiative: a community-informed bundled implementation strategy to address HIV in Black communities

BACKGROUND

Black individuals in the U.S. remain the most disproportionately impacted by new HIV diagnoses, represent the highest portion of individuals living with HIV, and have the highest morbidity rates. Structural inequities and historical oppression are the primary drivers. Such drivers limit access to HIV prevention tools that need to be delivered with culturally congruent and community-informed approaches.

METHODS

The Five Point Initiative (FPI) is a community-informed bundled implementation strategy developed and piloted between September 2019 and March 2020 in Miami, Florida in communities heavily impacted by HIV. Key components of the strategy included community consultants/experts, five categories (hence the "Five Point") of community businesses (e.g., corner stores, beauty supply stores, laundromats, mechanics, barbershops), local health organizations, an academic research program engrossed in community engaged research, and community residents who provided ongoing feedback throughout. Outcomes of FPI included (a) survey information (e.g., knowledge of and access to PrEP, barriers to care) and pilot data (acceptability and feasibility), (b) expansion of reach to Black individuals in HIV high impact zip codes in Miami, (c) insights on our bundled implementation strategy, (d) condom distribution, and (e) HIV testing.

RESULTS

Over the course of six months FPI carried out 10 outreach events, partnered with 13 community businesses and 5 health organizations, engaged 677 community residents, collected health information via a survey, distributed 12,434 condoms, provided information on PrEP, and offered voluntary HIV testing (131 completed). FPI's ability to reach residents who are not being reached (e.g., 68.8% never heard of PrEP, 8% no HIV testing ever, 65.9% no primary care provider), positive feedback from residents (e.g., 70% very satisfied, 21% satisfied; 62% strongly agree and 25% agree they would participate again) and qualitative interviews with businesses provide evidence of acceptability and feasibility. Further, survey data provided insights on factors such as socio-demographics, discrimination experiences, barriers to care, social-structural factors, physical and sexual health, and mental health and substance use.

CONCLUSIONS

The FPI bundled implementation strategy shows promise to deliver health prevention/intervention for HIV and other health conditions to communities facing health inequities and for whom the current system for delivering care is insufficient.

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

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

The impact of depression and post-traumatic stress symptoms on physical health perceptions and functional impairment among sexual minority men living with HIV with histories of trauma

Mental health symptoms may compromise health-related quality of life (HRQOL), including among men who have sex with men (MSM) living with HIV, who experience high rates of trauma and other stressors. This study sought to examine the relative contributions of post-traumatic stress disorder (PTSD) symptoms, depression symptoms, and biological indices of HIV disease status on HRQOL in this population. Participants were 79 MSM with HIV (49% White; 35% Black; 8% Hispanic/Latinx) with trauma histories (52% met current PTSD diagnostic criteria). HRQOL outcomes were general perceptions of health (0-100 visual analog scale) and functional disability (WHODAS 2.0). Dominance analysis was applied to examine the relative share of variance in these outcomes accounted for by PTSD symptom severity, depression symptom severity, viral suppression status, and CD4 count. Depression symptom severity accounted for 70% and 92% of variance in perceived health, respectively, across models (p's < 0.05). Both PTSD symptom severity (45%) and depression symptom severity (43%) scores also accounted for significant variance in functional disability (p's < 0.05). Medical indices of HIV disease progression did not explain significant variance in HRQOL in any model. A trauma-informed approach may aid clinicians in interpreting reports of health and physical functioning in MSM with HIV.

Socio-Ecological Influences on HIV Care Engagement: Perspectives of Young Black Men Who Have Sex with Men Living with HIV in the Southern US

Young Black men who have sex with men (MSM) living with HIV evidence the lowest rates of linkage to care and viral suppression of all US MSM. Kentucky, identified by the US Department of Health and Human Services as a "hot spot" state with elevated HIV incidence compared to the rest of the country, exhibits similar racialized outcomes. Structural, interpersonal, and individual drivers of engagement along the HIV care continuum among people living with HIV have been identified, primarily through quantitative designs. However, the mechanisms by which these factors shape HIV care engagement, and the ways they may combine or reinforce each other, as well as from the lived experience of young Black MSM living with HIV, have been studied to a lesser extent. In this study, a purposive sample of n = 29 HIV-positive young Black MSM (age M = 25 years old; 38% retained in care) residing in Kentucky participated in in-depth interviews. Factors that were most influential on engagement varied along the continuum, with health insurance status and knowledge of HIV being relatively more influential to diagnosis, and housing stability, psychological processes, and interpersonal relationships being more influential on retention. For some participants, barriers to care at multiple levels had a mutually influencing and intensifying impact on care engagement. Additional efforts to center the voices of young Black MSM living with HIV will help illuminate acceptable and sustainable interventions for increasing their care engagement and narrowing persistent racial disparities in HIV morbidity and mortality.

Intersectional Resilience Among Black Gay, Bisexual, and Other Men Who Have Sex With Men, Wisconsin and Ohio, 2019

Objectives. To investigate resilience strategies used by Black gay, bisexual, and other men who have sex with men (MSM) to navigate racism and heterosexism. Methods. In 2019, we conducted in-depth interviews with 46 Black MSM in Milwaukee, Wisconsin, and Cleveland, Ohio. Thematic analysis, informed by intersectionality, was used to identify intersectional resilience within the context of participants' lives. Results. Our analyses revealed ways in which Black MSM respond to stigma and oppression. We identified the following themes that capture these experiences: pride in intersectional identities, perseverance, community advocacy, and social support. Our analyses reveal how men draw on these assets and resources to positively adapt despite experiences of racism and heterosexism. Conclusions. Intersectional resilience can support Black MSM in navigating racism and heterosexism. However, public health interventions at the institutional and system levels are needed to directly target the root causes of oppression and support resources that facilitate intersectional resilience. (Am J Public Health. 2022;112(S4):S405-S412. https://doi.org/10.2105/AJPH.2021.306677).

Associations Between Experienced HIV Stigma, Resulting Consequences, and the HIV Care Continuum: Moderating Effects of Two Resilience Characteristics Among Persons Living with HIV (PLWH) in Louisiana

INTRODUCTION

HIV-related stigma continues to serve as a major barrier to HIV care. HIV stigma reduction interventions are urgently needed to promote and protect the health of persons living with HIV (PLWH). Resilience has been identified as a potential leverage to mitigate the impact of HIV-related stigma among PLWH.

METHODS

We examined whether two resilience measures (i.e., social support and resilience assets and resources [RAR]) moderated the relationship between experienced HIV stigma and the HIV care continuum as well as how they moderated the relationship between the consequences of experienced HIV stigma (CES) and the HIV care continuum among 300 PLWH in Louisiana. Separate bootstrapping analyses were conducted to test for evidence of moderated moderation.

RESULTS

Most participants were Black (79%) and had been living with HIV for 10 years or more. A relatively high sample of men who have sex with men (MSM) were enrolled (37%). The most common CES were depression (67%). The most common manifestation of experienced HIV stigma was being gossiped about (53%). Participants reported moderate levels of social support. In terms of RAR, most participants (71%) reported that they knew of groups that could support them in responding to experienced HIV stigma. After adjusting for potential covariates, social support and RAR both significantly moderated the relationship between experienced HIV stigma and length of time since their last HIV care visit, B(SE) = .003(.001), p = .03. At high levels of RAR and high levels of social support, those with higher levels of experienced HIV stigma reported a longer length of time since their last HIV care visit than those who reported lower levels of experienced HIV stigma (B(SE) = .17(.04), p < .001). RAR moderated the relationship between social support and HIV care, B(SE) = .01(.004), p < .001. Those who experienced greater CES reported a longer length of time since their last doctor's visit B(SE) = .04(.02), p < .05. Experienced HIV stigma was not significantly associated with viral load results. However, social support significantly moderated the relationship between experienced stigma and viral load results. At higher levels of social support, those who experienced lower levels of stigma were more likely to report an undetectable viral load than those who had higher levels of stigma, B(SE) = - .13(.03), p < .001. Finally, both RAR and social support moderated the relationship between CES and viral load results. Those who reported higher levels of RAR B(SE) = - .07(.02), p < .001, and social support, B(SE) = - .02(.01), p < .05, also reported having an undetectable viral load at most recent HIV care visit. CES was not significantly related to reporting an undetectable viral load (p = .61).

CONCLUSIONS

Enrolled PLWH already have some level of resilience which plays an important protective role within the context of the HIV care continuum up to a certain extent. Interventions to enhance the RAR and social support components may be useful especially among MSM and persons who have been living with HIV for a shorter period of time.

Correlates of PrEP Uptake Among Young Sexual Minority Men and Transgender Women in New York City: The Need to Reframe "Risk" Messaging and Normalize Preventative Health

Pre-exposure prophylaxis (PrEP) is an effective form of HIV prevention, but young sexual minority men face myriad barriers to PrEP uptake. Participants (n = 202) completed a survey on healthcare experiences and beliefs about HIV and PrEP. While 98% of the sample knew about PrEP, only 23.2% reported currently taking PrEP. Participants were more likely to be taking PrEP if they received PrEP information from a healthcare provider and endorsed STI-related risk compensation. Conversely, PrEP uptake was less likely among those with concerns about medication use and adherence. While there were no racial/ethnic differences in PrEP uptake, there were differences in correlates of PrEP use for White participants and participants of color. To facilitate PrEP uptake, clinicians should provide PrEP education and screen all patients for PrEP candidacy. Additionally, public health messaging must reframe HIV "risk", highlight benefits of STI testing, and emphasize the importance of preventive healthcare for SMM.

Conceptualizing the Effects of Continuous Traumatic Violence on HIV Continuum of Care Outcomes for Young Black Men Who Have Sex with Men in the United States

The United States (US) is on track to achieve the 90-90-90 targets set forth by UNAIDS and the National HIV/AIDS strategy, yet significant racial disparities in HIV care outcomes remain, particularly for young Black men who have sex with men (YBMSM). Research has demonstrated that various types of violence are key aspects of syndemics that contribute to disparities in HIV risk. However, little research has looked collectively at cumulative violent experiences and how those might affect HIV treatment and care outcomes. Drawing on extant literature and theoretical underpinnings of syndemics, we provide a conceptual model that highlights how continuous traumatic violence experienced by YBMSM may affect HIV outcomes and contribute to racial disparities in HIV outcomes. The findings of this focused review suggest a need for research on how continuous exposure to various types of violence influence HIV prevention and treatment outcomes for young Black MSM.

Are Sexual Minority Stressors Associated with Young Men who Have Sex with Men's (YMSM) Level of Engagement in PrEP?

Sexual minority stressors (community homophobia, sexuality-related discrimination, and internalized homonegativity) are negatively associated with accessing HIV prevention services among men who have sex with men (MSM). Few studies have tested minority stressors' associations with PrEP engagement among high-HIV risk young MSM (YMSM). Therefore, we assessed the associations between PrEP-indicated YMSM's progression along the PrEP continuum and their experiences of minority stress. N = 229 YMSM completed a web-survey on PrEP-related behaviors and minority stress. Adjusted for covariates, we developed two partial-proportional odds models examining the associations between PrEP continuum progression and minority stressors, as a composite, and community homophobia, sexuality-related discrimination, and internalized homonegativity, respectively. Our multivariable model demonstrated minority stress levels to be negatively associated with PrEP continuum location (AOR = 0.76, 95% CI: 0.58-0.99). Broken down, discrimination was positively associated with reporting being at an advanced location along the continuum (AOR = 1.39, 95% CI: 1.06-1.82). Internalized homonegativity was negatively associated with continuum location between PrEP-aware participants with no intention to initiate and participants who intended to initiate PrEP (AOR = 0.45, 95% CI: 0.27-0.77) and between those who intended to initiate and those who had ever used PrEP (AOR = 0.39, 95% CI: 0.22-0.69). Our findings suggest that minority stress, especially internalized homonegativity, remains a barrier to PrEP among PrEP-indicated YMSM. Sexuality-related discrimination was associated with PrEP continuum progression, suggesting potentially well-developed, adaptive coping skills (e.g., ability to locate sexuality-affirming providers). Coupled with stigma reduction efforts, HIV prevention services aiming to promote PrEP should incorporate internalized homonegativity screenings and referrals into sexuality-affirming resources for PrEP-indicated YMSM.

Inter-Group and Intraminority-Group Discrimination Experiences and the Coping Responses of Latino Sexual Minority Men Living With HIV

Discrimination negatively impacts the health of HIV-positive Latino sexual minority men (LSMM+). A growing literature on LSMM+ chronicles associations based on multiple devalued identities and mental health symptoms, HIV medication nonadherence, and sexual behaviors with the potential to transmit HIV. To gain additional insights on identity-based discrimination-as well as the associated coping responses-we conducted 30 qualitative interviews with LSMM+.Participantswereprobedregardingrecentdiscriminationevents(context,details,perpetrator, type) based on their intersecting identities (Latinx ethnicity, residency status, sexual minority orientation, HIV-positive serostatus) and their coping responses. We transcribed and translated the interviews and conducted a content analysis. Participants reported inter-group (i.e., between majority and minority group members) and intraminority-group (i.e., within minority group members) experiences as common. Participants described their intraminority-group experiences with discrimination based on being a Latinx sexual minority person in their families and home communities. Participants reported a range of coping responses to discrimination experiences. However, participants reported only functional (and no dysfunctional) coping strategies, and they endorsed using similar strategies in response to inter-group and intraminority-group discrimination. Coping strategies included strategic avoidance, social support, self-advocacy, and external attribution. Additional coping strategies (spirituality and positive reframing) emerged more strongly in response to inter-group experiences with discrimination. Our results underscore the need to address both inter-group and intraminority-group discrimination experiences. Future interventions can focus on strengthening the effective coping skills that LSMM+ currently employ as potential levers to address LSMM+ health disparities.

Social Distancing to Mitigate COVID-19 Risks Is Associated With COVID-19 Discriminatory Attitudes Among People Living with HIV

BACKGROUND

Severe acute respiratory syndrome coronavirus-2, the virus that causes COVID-19, is an emerging pandemic with heightened concerns for people with compromised immune systems, including people living with HIV.

PURPOSE

In the absence of a vaccine, public health messaging to mitigate risks for COVID-19 primarily focuses on social distancing. Because people living with HIV commonly experience mistreatment associated with HIV, their response to social distancing may be complicated by psychosocial attitudes associated with COVID-19.

METHODS

To evaluate these relationships, we conducted a rapid-response, cross-sectional survey with people living with HIV (N = 149) to assess social distancing practices, COVID-19 discriminatory attitudes, COVID-19 xenophobic attitudes, HIV microaggressions, and concern over contracting COVID-19. Data were collected from participants enrolled in a larger ongoing study between March 30, 2020 and April 17, 2020.

RESULTS

Results indicated that choosing to socially distance to reduce COVID-19 exposure was associated with COVID-19 discriminatory attitudes, concerns of contracting COVID-19, and identifying as transgender. Likewise, social distancing imposed by others (e.g., cancelations and restrictions) was associated with concerns of contracting COVID-19.

CONCLUSIONS

Findings demonstrate that social distancing measures are related to concerns of contracting the virus and discriminatory attitudes toward those who are presumed to be living with COVID-19. These potentially negative psychosocial attitudes toward people perceived to have COVID-19 echo the discriminatory actions and attitudes that we continue to observe in HIV social sciences research.

Exploring the role of LGBT-affirming churches in health promotion for Black sexual minority men

In the USA, Black sexual minority men (BSMM) remain disproportionately impacted upon by HIV and other sexual health issues. Individuals who attend church have lower rates of morbidity and mortality than those that do not; however, church attendance presents a paradox of being protective for some health outcomes and a risk for others among this population. Lesbian, gay, bisexual, and transgender (LGBT) affirming churches may offer support, but little is known about the role of LGBT-affirming churches in the lives of BSMM and how they may impact HIV and other health outcomes. This study explored the role of LGBT-affirming churches in the lives of BSMM. Nine focus groups (N = 52) were conducted in Baltimore City, Maryland between December 2017 and April 2018. Thematic analysis evaluated domains related to how men perceived, experienced, and engaged with LGBT-affirming churches. Three primary themes identified: (1) preferring traditional church environments over LGBT-affirming churches; (2) experiencing the LGBT-affirming church as a space of acceptance, emotional healing, and modelling loving same-sex relationships; and (3) perceiving LGBT-affirming churches as opportunities to engage community members to promote the well-being of BSMM. A secondary theme identified involvement in the house and ballroom community as an LGBT-affirming religious experience.

An Exploratory Study of Resilience, HIV-Related Stigma, and HIV Care Outcomes Among Men who have Sex with Men (MSM) Living with HIV in Louisiana

The various forms of HIV-related stigma continue to serve as major barriers to HIV care and treatment among men who have sex with men (MSM). The study of resilience within the context of HIV-related stigma among MSM living with HIV represents a promising area of research to inform the development of future HIV interventions for this population. We examined resilience within the context of HIV related stigma among MSM living with HIV in Louisiana with a particular interest in how resilience may be more relevant for Black MSM. We utilized Pearson's correlations and layered chi-square non-parametric tests to examine associations and racial differences in resilience, four HIV-related stigma measures/consequences (i.e., anticipated, internalized, enacted, and consequences of enacted HIV stigma), and HIV care outcomes (i.e., length of time since last HIV care visit, time since last HIV lab result, most recent HIV viral load result) among 110 MSM living with HIV in Louisiana who participated in the Louisiana HIV Stigma Index Project. The majority of MSM participants were Black (75%), lived in New Orleans (52%), and reported limited education (52%) and income (76%). MSM who reported higher levels of enacted HIV stigma, consequences of enacted HIV stigma, and internalized HIV stigma reported poorer HIV care outcomes. Both internalized and anticipated HIV stigma significantly negatively impacted Black MSM perceptions of their overall health compared with White MSM. Compared with White MSM, Black MSM who reported greater consequences of enacted HIV stigma had poorer HIV care outcomes. Resilience was associated with positive HIV care outcomes for both Black and White MSM. However, having higher levels of resilience may have been more protective for Black MSM such that higher levels of resilience were associated with less time since last HIV care visit for Black MSM than for White MSM. The current study provides preliminary information on the potential positive relationship between resilience and HIV care outcomes among MSM, particularly Black MSM. However, these findings need to be confirmed among a more representative sample of Black and White MSM in Louisiana.

Multifactorial discrimination, discrimination salience, and prevalent experiences of internalized homophobia in middle-aged and older MSM

Objectives: We sought to test whether discrimination salience and multifactorial discrimination were associated with prevalent experiences of internalized homophobia among middle-aged and older men who have sex with men (MSM).Methods: We analyzed data from 498 middle-aged and older MSM from the Multicenter AIDS Cohort Study (MACS) who reported any lifetime discrimination experience. We estimated the prevalence ratio of current internalized homophobia using multivariable Poisson regressions, accounting for discrimination salience, multifactorial discrimination, and covariates. We then assessed whether multifactorial discrimination moderated the association between discrimination salience and internalized homophobia.Results: Over half (56.4%) of our sample reported any current experience of internalized homophobia. More than two-thirds reported multifactorial discrimination (68.2%) and more than one-third (36.7%) reported moderate-to-high discrimination salience. Increases in discrimination salience (PR = 1.11; 95% CI: 1.03-1.20) were associated with any current internalized homophobia among middle-aged and older MSM. Multifactorial discrimination was not statistically associated with internalized homophobia and did not moderate the association between discrimination salience and internalized homophobia.Conclusions: Our study underscores internalized homophobia as a persisting concern among MSM in midlife and older adulthood. Our findings suggest that salience, as a characteristic of discrimination experiences, may have a greater impact on internalized homophobia compared with exposure. Future research efforts should assess facets of discrimination salience, such as severity, frequency, and chronicity, to better understand how discrimination shapes psychosocial well-being across the life course. Mental health advocates at policy, organizational, and community levels should aim to reduce intersectional stigma and address individual experiences of internalized homophobia.

A Systematic Review and Meta-Analysis of Combination Behavioral Interventions Co-Targeting Psychosocial Syndemics and HIV-Related Health Behaviors for Sexual Minority Men

In the U.S., sexual minority men (SMM) are disproportionately affected by HIV. Interventions are needed to increase HIV prevention and treatment behaviors, especially among syndemically exposed SMM. In recent years, researchers have created and tested combination behavioral interventions co-targeting syndemics and HIV-related health behaviors. We evaluated that literature via systematic review and meta-analysis, identifying 44 trials targeting mental health symptoms, alcohol use, and drug use, as well as sexual risk behavior, antiretroviral adherence, and healthcare engagement. For the randomized controlled trials, we computed between-group, pre-post effect sizes and tested them via random-effects models. Results supported the efficacy of combined interventions with significant, small, positive effects for improving mental health and reducing substance use (d = .20, CIs: 0.12, .29), and reducing sexual risk behavior and improving antiretroviral adherence (d = .16, CIs: .03, .30). Stratification analyses indicate that longer (9+ sessions) and individual (vs. group) interventions resulted in stronger effects on syndemic but not health behavior outcomes. Intervention developers should attend to intervention intensity and format. More evidence is needed about the importance of additional factors, such as novel intervention targets and cultural tailoring, as well as broadening the focus to multi-level interventions to address both interpersonal and structural mechanisms of change.

HIV testing barriers and intervention strategies among men, transgender women, female sex workers and incarcerated persons in the Caribbean: a systematic review

BACKGROUND

This systematic review summarises evidence on the HIV testing barriers and intervention strategies among Caribbean populations and provides pertinent implications for future research endeavours designed to increase rates of HIV testing in the region.

METHODS

We used a systematic approach to survey all literature published between January 2008 and November 2018 using four electronic databases (MEDLINE/PubMed, Embase, Web of Science and Global Health). Only peer-reviewed articles published in English that examined HIV testing uptake and interventions in the Caribbean with men, men who have sex with men, female sex workers, transgender women and incarcerated individuals were included.

RESULTS

Twenty-one studies met the inclusion criteria. Lack of confidentiality, access to testing sites, stigma, discrimination, poverty and low HIV risk perception were identified as key barriers to HIV testing. These barriers often contributed to late HIV testing and were associated with delayed treatment initiation and decreased survival rate. Intervention strategies to address these barriers included offering rapid HIV testing at clinics and HIV testing outreach by trained providers and peers.

CONCLUSION

HIV testing rates remain unacceptably low across the Caribbean for several reasons, including stigma and discrimination. Future HIV testing interventions should target places where at-risk populations congregate, train laypersons to conduct rapid tests and consider using oral fluid HIV self-testing, which allows individuals to test at home.

AWARENESS: Development of a cognitive-behavioral intervention to address intersectional minority stress for sexual minority men living with HIV who use substances

Sexual minority (i.e., nonheterosexual) individuals are at greater risk than heterosexual individuals for substance use and poor mental health attributed to exposure to minority stress (Meyer, 2003). Minority stress is stress that places an additional burden on sexual minority people over and above the stress experienced by heterosexual people. Sexual minority men may also be subject to minority stress related to intersecting identities or individual characteristics (e.g., HIV status, race). This study obtained initial feedback about the AWARENESS intervention from sexual minority men living with HIV who use substances and determined the feasibility of the intervention to address minority stress related to intersecting identities. AWARENESS is a 9-session cognitive-behavioral intervention targeting minority stress as a driver of greater substance use and poorer mental and physical health. Ten sexual minority men living with HIV who were episodic substance users (>1 episode of illicit drug use or binge drinking in the previous 3 months) began the intervention. Feedback on the intervention was obtained through open-ended interviews analyzed using thematic analysis and Likert scale questionnaires about experiences with the intervention. Therapists tracked identities discussed in relation to minority stress to evaluate feasibility of AWARENESS to address intersectional minority stress. Participants identified they gained cognitive-behavioral skills to cope with intersectional minority stress and described destigmatization and integration of identities. Participants discussed an average of 3.2 identity characteristics in addition to sexual minority status in relation to intervention content. This study lays the groundwork for additional testing of this intervention. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

"It Truly Does Get Better:" Young Sexual Minority Men's Resilient Responses to Sexual Minority Stress

Due to minority stress, sexual minority men experience mental health disparities. Sexual minority men who engaged in cognitive-behavioral therapy to address the minority stress underlying their distress completed an exercise eliciting their own resilience. This exercise involved writing an advice letter to a hypothetical peer about coping with minority stress. Qualitative analysis of these letters yielded 18 codes grouped into three categories reflecting resilience to minority stress. Categories included (1) cultivating internal affirmation strategies, (2) building supportive relationships and community, and (3) using cognitive and behavioral skills to cope with minority stress. Findings highlight this population's resilience and suggest building resilience through treatment.

Experienced homophobia and gene expression alterations in Black and Latino men who have sex with men in Los Angeles County

Men who have sex with men (MSM) experience high rates of homophobic victimization, which is linked to myriad chronic physical and mental health disparities. Social adversity such as rejection, isolation, and racial discrimination can induce a conserved transcriptional response to adversity (CTRA) involving upregulation of proinflammatory genes and downregulation of type I interferon and antibody synthesis genes. This study specifically examines whether homophobic victimization is associated with expression of CTRA profiles in Black and Latino MSM living in Los Angeles. Analyses linked behavioral survey data with quantified RNA from leukocytes from blood samples of 70 participants over 12 months. CTRA gene expression was increased by 3.1-fold in MSM who experienced homophobic victimization while adjusting for major leukocyte subsets and sociodemographics. Accounting for all these factors, CTRA gene expression was significantly enhanced in MSM who identified as Black compared to Latino. Our findings identify experiences of homophobic victimization as drivers of inflammatory and type I interferon gene expression profiles, which can contribute to physical and mental health challenges in Black and Latino MSM.

Association of Medical Mistrust and Poor Communication with HIV-Related Health Outcomes and Psychosocial Wellbeing Among Heterosexual Men Living with HIV

Studies have suggested that effective patient-provider relationships may reduce health disparities and foster engagement across the HIV care continuum among people living with HIV/AIDS. However, no studies have explored specific mechanisms between medical mistrust/poor communication and HIV-related/psychosocial health outcomes among HIV-positive men of color who have sex with women (MCSW) in the United States. From 2011 to 2012, the research team recruited 317 eligible participants in New York City. Using validated explanatory and predictive modeling strategies, we explored the associations between mistrust/poor communication and HIV-related/psychosocial health outcomes among this group. Subgroup analyses were further conducted to assess the different effects of non-Hispanic black and Hispanic men. A total of 313 males (204 black, 93 Hispanic, and 16 others) reported that valid responses were included in the current analysis. In the explanatory models, both mistrust and poor communication were negatively associated with various HIV-related and psychosocial outcomes among this group of HIV-positive MCSW. In the predictive models, predictors of mistrust for the overall sample and the black subsample were nearly the same. On the contrary, predictors of poor communication were substantially different when comparing black and Hispanic HIV-positive MCSW. Our findings confirm that patient-provider relationship quality is associated with poor HIV-related and psychosocial outcomes in black and Hispanic MCSW. A different set of multi-level predictors are associated with mistrust and poor communication comparing black and Hispanic MCSW. We call for interventions addressing patient-provider relationship quality that are tailored differently for black and Hispanic men.

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.

Reframing masculinity: structural vulnerability and HIV among black men who have sex with men and women

This paper calls for a critical reframing of masculinity as an intersectional construct in the HIV epidemic and in public health. In-depth qualitative interviews were conducted with a sample of 56 Black men who have sex with men and women in the San Francisco Bay Area. Men described their sexual identities and practices via complex narratives of masculinity that drew on subordinated and resourceful adaptations to the structural effects of racism, economic marginalisation and homophobia. By focusing on men whose experience of masculinity operates outside fixed identity categories, the paper draws attention to the intersectionality that is, by necessity, constitutive of men's lived experiences. Findings suggest the value of an integrative framework for understanding Black masculinities as processes and practices simultaneously informed by structural inequalities (racism, economic marginalisation and/or homophobia, in particular) and cultural meanings of gender. By utilising an intersectional approach, public health and sociology can better understand the concurrent resilience and vulnerability of masculinities, while building an interdisciplinary understanding of the symbolic role of Black masculinities in the USA, as well as a means by which to promote health and well-being in and through these gendered contexts.

A Demographic Analysis of Racial/Ethnic Minority Enrollment Into HVTN Preventive Early Phase HIV Vaccine Clinical Trials Conducted in the United States, 2002-2016

OBJECTIVES

Racial/ethnic minority communities in the United States are overrepresented among new HIV diagnoses, yet their inclusion in preventive HIV vaccine clinical trials is inadequate. An analysis of enrollment demographic characteristics from US preventive HIV vaccine clinical trials from 1988 through 2002 showed that enrollment of racial/ethnic minority groups increased. We analyzed enrollment in preventive HIV vaccine clinical trials from 2002 through 2016 and compared our data with data from the previous study, described demographic characteristics of trial participants, and assessed how well this distribution reflected the racial/ethnic distribution of new HIV diagnoses in the United States.

METHODS

We examined data on demographic characteristics from 43 Phase 1 and Phase 2A preventive HIV vaccine clinical trials conducted in the United States and compared the results with those of the previous study. We also compared racial/ethnic distributions from 2011 through 2015 with Centers for Disease Control and Prevention data on the number of new HIV diagnoses during the same period.

RESULTS

Of 3469 participants, 1134 (32.7%) identified as a racial/ethnic minority, a 94% increase from the previous period (634/3731; 17.0%). Percentage annual enrollment of all racial/ethnic minority participants fluctuated from 17% to 53% from mid-2002 to 2016. Percentages of new HIV diagnoses among the general population were 1.9 to 2.9 times the percentage enrollment of black participants and 1.3 to 6.6 times the percentage enrollment of Hispanic/Latino participants in clinical trials for the same period.

CONCLUSIONS

Although enrollment of racial/ethnic minority groups into HIV vaccine clinical trials has increased, it is not proportional to the number of new HIV diagnoses among these groups. To enhance recruitment of racial/ethnic minority groups, the HIV Vaccine Trials Network has prioritized community partnerships and invested resources into staff training.

Pilot intervention for discrimination-related coping among HIV-positive Black sexual minority men

OBJECTIVES

Discrimination is associated with worse health. Although interventions have been developed to improve coping with general stressors and chronic illness, no literature to date has reported the development and testing of an intervention specifically to address coping with discrimination. We examined the feasibility, acceptability, and preliminary effects of Still Climbin', a pilot intervention created to improve coping with discrimination experienced by HIV-positive Black sexual minority men, who face significant HIV-related disparities.

METHOD

Still Climbin' was culturally tailored using community stakeholder input and formative qualitative research. Still Climbin' consists of 8 weekly group sessions and a graduation session, based on principles of cognitive behavior therapy. Sixty-four HIV-positive Black sexual minority men were recruited from community venues; 38 were randomized to the intervention and 26 to a wait-list control group. Participants completed assessments at baseline and 3- and 6-months postbaseline. Intervention participants completed postsession feedback forms.

RESULTS

Repeated-measures regressions indicated significant intervention effects on improved coping in response to discrimination, including functional (problem-solving) coping [b (SE) = 0.39 (0.19), p = .04], humor [b (SE) = 0.48 (0.22), p = .03], and cognitive/emotional debriefing [b (SE) = 0.30 (0.14), p = .04], a culturally relevant form of coping that includes self-protective strategies (e.g., strategic avoidance of certain places or people). Intervention participants rated the sessions positively in response to closed- and open-ended questions.

CONCLUSIONS

Still Climbin' was feasible and acceptable to participants, and showed promise for improving coping with discrimination, which ultimately can lead to better health outcomes and reduced disparities. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Victimisation and life satisfaction of gay and bisexual individuals in 44 European countries: the moderating role of country-level and person-level attitudes towards homosexuality

We examined the link between victimisation and life satisfaction for 85,301 gay and bisexual individuals across 44 European countries. We expected this negative link to be stronger when the internalised homonegativity of the victim was high (e.g. because the victim is more vulnerable) and weaker when victimisation occurs in countries that express intolerance towards homosexuality (e.g. because in such contexts victims expect victimisation more and they attribute it to their external environment). Additionally, we expected internalised homonegativity to relate negatively to life satisfaction. Multilevel analyses revealed that victimisation (i.e. verbal insults, threats of violence, minor or major physical assaults) and internalised homonegativity were negatively related to life satisfaction. Furthermore, as we expected, the negative link between victimisation and life satisfaction was stronger when high internalised homonegativity was reported (and the interaction effect occurred for verbal insults and major assaults as outcome variables), while it was weaker when there was low national tolerance of homosexuality (and the interaction effect occurred for verbal insults and for minor assaults). Future research and social policy should consider how the consequences of victimisation are dependent on personal as well as national attitudes towards homosexuality.

"It's Almost Like a Crab-in-a-Barrel Situation": Stigma, Social Support, and Engagement in Care Among Black Men Living With HIV

Social support is associated with improved health outcomes for people living with HIV (PLWH), including initiation and engagement in HIV care and antiretroviral therapy (ART) adherence. Yet, stigma may negatively affect the availability and utilization of social support networks, especially among African American PLWH, subsequently impacting HIV care and health out-comes. This qualitative study examines the relationship between stigma and social support relationships among African American PLWH. We conducted 23 interviews with Black men living with HIV who reported being out of care or non-adherent to ART. Thematic content analysis revealed three primary themes including variation in social support, experiences of stigma and discrimination, and coping mechanisms used to deal with stigma. Findings reveal that although social support may be protective for some men, many African American PLWH face challenges in harnessing and sustaining needed social support, partly due to stigma surrounding HIV and homo-sexuality.

Ricky and Lucy: gender stereotyping among young Black men who have sex with men in the US Deep South and the implications for HIV risk in a severely affected population

HIV disproportionately affects young Black men who have sex with men in the USA, with especially high rates in the Deep South. In this Alabama study, we interviewed 24 pairs of young Black men who have sex with men aged 19-24 and their close friends (n = 48) about sexual scripts, dating men and condom use. Three main themes emerged from the study: the power dynamics of 'top' and 'bottom' sexual positions for condom use; gender stereotyping in the iconic style of the 'I Love Lucy' show of the 1950s; and the sexual dominance of 'trade' men. Gender stereotyping was attributed to the cultural mores of Black families in the South, to the preferences of 'trade' men who exerted sexual and financial control and to internalised stigma relating to being Black, gay and marginalised. The findings suggest that HIV prevention education for young Black men who have sex with men is misguided if gendered power dynamics are ignored, and that funded access to self-protective strategies such as pre-exposure prophylaxis and post-exposure prophylaxis could reduce HIV risk for this severely affected population.

Still I rise: The need for self-validation and self-care in the midst of adversities faced by Black women with HIV

OBJECTIVES

Psychosocial factors of trauma and abuse, racial discrimination, HIV stigma, and gender-related stressors (e.g., prioritizing others' needs) have been associated with antiretroviral treatment (ART) nonadherence and poor viral suppression among Black women living with HIV (BWLWH). To inform the development of an intervention addressing these psychosocial factors to improve ART adherence, the authors sought the insight of BWLWH.

METHOD

Qualitative semistructured interviews were conducted with 30 BWLWH to gather information on their experiences with trauma, racism, HIV stigma, gender-related stressors, ART adherence, and coping strategies, and their insights on the proposed intervention. Participants' interviews were audio-recorded, transcribed, and coded using thematic content analysis and grounded theory.

RESULTS

Participants shared (a) their experiences with trauma/abuse, racism, HIV-stigma, gender-related stress, and medication adherence; (b) coping strategies they use (e.g., social support, awareness [acknowledging systemic racism], assertiveness, selective disclosure of HIV status, and prioritizing the self); (c) how each of these adversities relate to their medication adherence and how they found ways to self-validate and practice self-primacy and self-care, including medication adherence in spite of adversities; and (d) enthusiasm for the proposed intervention.

CONCLUSIONS

Culturally adapted interventions are needed to improve the health of BWLWH by enhancing coping strategies for the multiple adversities they face and promoting self-validation, self-primacy, and self-care in spite of adversities. (PsycINFO Database Record

Striving Towards Empowerment and Medication Adherence (STEP-AD): A Tailored Cognitive Behavioral Treatment Approach for Black Women Living With HIV

In the U.S. Black women with HIV face numerous psychosocial challenges, particularly trauma, racism, HIV-related discrimination, and gender role expectations, that are associated with negative HIV health outcomes and low medical treatment adherence. Yet many of these factors are unaddressed in traditional cognitive behavioral approaches. This study presents a case series of a tailored cognitive behavioral treatment approach for Black women living with HIV. Striving Towards EmPowerment and Medication Adherence (STEP-AD) is a 10-session treatment aimed at improving medication adherence for Black women with HIV by combining established cognitive behavioral strategies for trauma symptom reduction, strategies for coping with race- and HIV-related discrimination, gender empowerment, problem-solving techniques for medication adherence, and resilient coping. A case series study of five Black women with HIV was conducted to evaluate the preliminary acceptability and feasibility of the treatment and illustrate the approach. Findings support the potential promise of this treatment in helping to improve HIV medication adherence and decrease trauma symptoms. Areas for refinement in the treatment as well as structural barriers (e.g., housing) in the lives of the women that impacted their ability to fully benefit from the treatment are also noted.