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Jewell TI, Petty EM. LGBTQ+ health education for medical students in the United States: a narrative literature review. MEDICAL EDUCATION ONLINE 2024; 29:2312716. [PMID: 38359164 PMCID: PMC10877666 DOI: 10.1080/10872981.2024.2312716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 01/26/2024] [Indexed: 02/17/2024]
Abstract
INTRODUCTION People who identify as lesbian, gay, bisexual, transgender, queer/questioning, intersex, and other sexual/gender minorities (LGBTQ+) may experience discrimination when seeking healthcare. Medical students should be trained in inclusive and affirming care for LGBTQ+ patients. This narrative literature review explores the landscape of interventions and evaluations related to LGBTQ+ health content taught in medical schools in the USA and suggests strategies for further curriculum development. METHODS PubMed, ERIC, and Education Research Complete databases were systematically searched for peer-reviewed articles on LGBTQ+ health in medical student education in the USA published between 1 January 2011-6 February 2023. Articles were screened for eligibility and data was abstracted from all eligible articles. Data abstraction included the type of intervention or evaluation, sample population and size, and key outcomes. RESULTS One hundred thirty-four articles met inclusion criteria and were reviewed. This includes 6 (4.5%) that evaluate existing curriculum, 77 (57.5%) study the impact of curriculum components and interventions, 36 (26.9%) evaluate student knowledge and learning experiences, and 15 (11.2%) describe the development of broad learning objectives and curriculum. Eight studies identified student knowledge gaps related to gender identity and affirming care and these topics were covered in 34 curriculum interventions. CONCLUSION Medical student education is important to address health disparities faced by the LGBTQ+ community, and has been an increasingly studied topic in the USA. A variety of curriculum interventions at single institutions show promise in enhancing student knowledge and training in LGBTQ+ health. Despite this, multiple studies indicate that students report inadequate education on certain topics with limitations in their knowledge and preparedness to care for LGBTQ+ patients, particularly transgender and gender diverse patients. Additional integration of LGBTQ+ curriculum content in areas of perceived deficits could help better prepare future physicians to care for LGBTQ+ patients and populations.
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Affiliation(s)
- Tess I. Jewell
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Elizabeth M. Petty
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Sedney C, Cowher A, Turiano NA, Cox S, Dekeseredy P, Haggerty T. Understanding the Intersectional Relationship of Pain Stigma, Weight Bias Internalization, and Clinical Indicators in a Rural Population with Back Pain: A Survey-Based Study. World Neurosurg 2023; 171:e846-e851. [PMID: 36603648 DOI: 10.1016/j.wneu.2022.12.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 12/28/2022] [Accepted: 12/29/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Stigma is understood to be intersectional, meaning multiple characteristics can be stigmatizing, and they may be both overlapping and coconstitutive. Chronic pain and overweight are common complaints in the spinal surgery clinic. Since being overweight may relate to back pain in a complex fashion, we sought to understand if there is a moderating effect between weight bias and pain stigma. METHODS This study involves a survey-based, quantitative, cross-sectional, observational design using previously validated measures and demographic and clinical information. There were 192 participants. Statistical calculations were done with statistical package for the social sciences. RESULTS Pain stigma was not significantly correlated with BMI (body mass index), and weight bias was not significantly correlated with back pain. There was a strong positive correlation between weight bias and pain stigma. There was a strong positive correlation between weight bias and BMI when pain stigma was also high. CONCLUSIONS Given the relationship between weight stigma and pain, the intersection of weight and pain stigma is important because it indicates the vulnerability of patients with higher BMI to other forms of stigma, such as stigma for their pain complaints. Clinicians should be mindful of expressing pain stigma more significantly amongst patients with higher BMI.
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Affiliation(s)
- Cara Sedney
- Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA.
| | - Abigail Cowher
- School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Nicholas A Turiano
- Department of Psychology, West Virginia University, Morgantown, West Virginia, USA
| | - Stephanie Cox
- Behavioral Medicine & Psychiatry, West Virginia University, Morgantown, West Virginia, USA
| | - Patricia Dekeseredy
- Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, West Virginia, USA
| | - Treah Haggerty
- Department of Family Medicine, West Virginia University, Morgantown, West Virginia, USA
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Maragh-Bass AC, Hucks-Ortiz C, Beyrer C, Remien RH, Mayer K, del Rio C, Batey DS, Farley JE, Gamble T, Tolley EE. Multilevel Stigma and Its Associations with Medical Care Ratings Among Men Who Have Sex With Men in HPTN 078. J Prim Care Community Health 2023; 14:21501319231175362. [PMID: 37243342 PMCID: PMC10226292 DOI: 10.1177/21501319231175362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/31/2023] [Accepted: 04/25/2023] [Indexed: 05/28/2023] Open
Abstract
INTRODUCTION Our research assessed associations between stigma-related variables and medical care ratings among clients with HIV in HIV Prevention Trials Network (HPTN) 078 who were men who have sex with men (MSM). METHODS Logistic regression explored care ratings, stigma, socio-demographics (N = 637). Qualitative thematic coding and themes explored stigmatizing experiences in different settings (N = 111). RESULTS Whites were twice as likely as African-Americans to report high care ratings (P < .05). Clients who reported familial exclusion due to having sex with men were 40% less likely to report high medical care ratings (P < .05). Clients who agreed healthcare providers think people with HIV "sleep around" were half as likely to report high care ratings (P < .08). Stigmatization included "treating me like they'll catch HIV from my hand," and care avoidance so others didn't "know I was having sex with men". CONCLUSIONS Providers can promote African American MSM client retention with more affirming healthcare provision, namely minimizing assumptions and addressing identities and client needs beyond just HIV care.
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Affiliation(s)
| | - Christopher Hucks-Ortiz
- Black AIDS Institute, Los Angeles, CA,
USA
- HIV Prevention Trials Network Black
Caucus, Los Angeles, CA, USA
| | - Chris Beyrer
- Johns Hopkins Bloomberg School of
Public Health, Baltimore, MD, USA
| | | | - Kenneth Mayer
- The Fenway Institute and Harvard
Medical School, Boston, MA, USA
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Mol MM, Visser MJ, Rai SS, Peters RMH. Measuring health-related stigma: Exploring challenges and research priorities to improve assessment. Glob Public Health 2023; 18:2264960. [PMID: 37801723 DOI: 10.1080/17441692.2023.2264960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 09/21/2023] [Indexed: 10/08/2023]
Abstract
Despite the advances in stigma research, measuring health-related stigma continues to be challenging and knowledge gaps remain. This study gained insight into challenges and research priorities related to the assessment of health-related stigma. Interviews were conducted with 14 stigma researchers, followed by a survey that was completed by 36 respondents. The findings showed a diverse range of research priorities. Among the top ranked priorities were the need for robust measurement properties of existing scales (content validity, responsiveness, validation across settings), exploration and assessment of subtle changes in stigma, and investigation on ways to assess actual behaviour and discrimination. Various challenges with the cross-cultural use of measures were identified, along with a research opportunity to shorten the cross-cultural validation process. Other identified research priorities related to: studying multi-level intersectional stigma; focusing on positive features that counter stigma; rephrasing negative and offending scale items; developing generic measures; and, the further development of practical tools to support researchers with scale implementation. The defined research priorities can guide future studies to advance stigma measurements and, as our ability to measure is critical for our understanding, enhance our knowledge about the complex stigma processes.
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Affiliation(s)
- Marente M Mol
- Faculty of Science, Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Marlies J Visser
- Faculty of Science, Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Sarju S Rai
- Faculty of Science, Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Ruth M H Peters
- Faculty of Science, Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
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Chen C, Baral S, Comins CA, Mcingana M, Wang L, Phetlhu DR, Mulumba N, Guddera V, Young K, Mishra S, Hausler H, Schwartz SR. HIV- and sex work-related stigmas and quality of life of female sex workers living with HIV in South Africa: a cross-sectional study. BMC Infect Dis 2022; 22:910. [PMID: 36474210 PMCID: PMC9724359 DOI: 10.1186/s12879-022-07892-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 11/23/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Environmental quality of life (QoL) assesses individually perceived factors such as physical safety and security, accessibility, quality of healthcare, and physical environment. These factors are particularly relevant in the context of sex work and HIV, where stigma has been identified as an important barrier across several prevention and treatment domains. This study aims to examine the association between different types of HIV- and sex work-related stigmas and environmental QoL among female sex workers (FSW) living with HIV in Durban, South Africa. METHODS We conducted cross-sectional analyses using baseline data from the Siyaphambili randomized controlled trial. FSW who reported sex work as their primary source of income and had been diagnosed with HIV for ≥ 6 months were enrolled from June 2018-March 2020, in eThekwini, South Africa. We evaluated the association between environmental QoL, dichotomizing the environmental domain score collected by the WHO Quality of Life HIV Brief (WHOQOL-HIV BREF) questionnaire at the median, and stigma using modified robust Poisson regression models. Five stigma subscales were assessed: sex work-related (anticipated, enacted, or internalized stigma) and HIV-related (anticipated or enacted stigma). RESULTS Among 1373 FSW, the median environmental QoL was 10.5 out of 20 [IQR: 9.0-12.5; range 4.0-19.0], while the median overall QoL was 3 out of 5 [IQR: 2-4; range 1-5]. One-third of FSW (n = 456) fell above the median environmental QoL score, while 67% were above the median overall QoL (n = 917). Reporting anticipated sex work stigma was associated with lower environmental QoL (adjusted prevalence ratio [aPR] 0.74 [95% CI 0.61, 0.90]), as was severe internalized sex work stigma (aPR: 0.64, 95% CI 0.48, 0.86). Reporting enacted HIV stigma versus none was similarly associated with lower environmental QoL (aPR: 0.65, 95% CI 0.49, 0.87). Enacted sex work stigma and anticipated HIV stigma were not statistically associated with environmental QoL. CONCLUSIONS This study highlights the need to consider the impact of multiple stigmas on FSW's non-HIV related clinical outcomes, including safety and physical well-being. Moreover, these results suggest that addressing underlying structural risks may support the impact of more proximal HIV prevention and treatment interventions. Trial registration NCT03500172 (April 17, 2018).
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Affiliation(s)
- Claire Chen
- grid.21107.350000 0001 2171 9311Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, W3503, Baltimore, MD 21205 USA
| | - Stefan Baral
- grid.21107.350000 0001 2171 9311Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, W3503, Baltimore, MD 21205 USA
| | - Carly A. Comins
- grid.21107.350000 0001 2171 9311Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, W3503, Baltimore, MD 21205 USA
| | - Mfezi Mcingana
- grid.438604.dTB HIV Care Association, Cape Town, South Africa
| | - Linwei Wang
- grid.415502.7MAP-Centre for Urban Health Solutions, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON Canada
| | - Deliwe Rene Phetlhu
- grid.438604.dTB HIV Care Association, Cape Town, South Africa ,grid.8974.20000 0001 2156 8226University of Western Cape, Cape Town, South Africa
| | - Ntambue Mulumba
- grid.438604.dTB HIV Care Association, Cape Town, South Africa
| | - Vijay Guddera
- grid.438604.dTB HIV Care Association, Cape Town, South Africa
| | - Katherine Young
- grid.438604.dTB HIV Care Association, Cape Town, South Africa
| | - Sharmistha Mishra
- grid.415502.7MAP-Centre for Urban Health Solutions, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON Canada ,grid.17063.330000 0001 2157 2938Department of Medicine, Division of Infectious Disease, University of Toronto, Toronto, ON Canada ,grid.17063.330000 0001 2157 2938Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON Canada
| | - Harry Hausler
- grid.438604.dTB HIV Care Association, Cape Town, South Africa
| | - Sheree R. Schwartz
- grid.21107.350000 0001 2171 9311Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, W3503, Baltimore, MD 21205 USA
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Mihatsch L, von der Linde M, Knolle F, Luchting B, Dimitriadis K, Heyn J. Survey of German medical students during the COVID-19 pandemic: attitudes toward volunteering versus compulsory service and associated factors. JOURNAL OF MEDICAL ETHICS 2022; 48:630-636. [PMID: 34021060 PMCID: PMC8142677 DOI: 10.1136/medethics-2020-107202] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 04/29/2021] [Accepted: 05/04/2021] [Indexed: 06/12/2023]
Abstract
Due to the spread of COVID-19, a key challenge was to reduce potential staff shortages in the healthcare sector. Besides recruiting retired healthcare workers, medical students were considered to support this task. Commitment of medical students in Germany during the COVID-19 pandemic was evaluated using an online survey, with particular focus on their burdens and anxieties. This survey was distributed to students within a 2-week period in April and May 2020. Ultimately, 1241 participants were included in the analysis. During the pandemic, 67.9% (65.3% to 70.5%) of the participants reported that they had volunteered. Furthermore, 88.9% (86.9% to 90.5%) stated that they were against compulsory recruitment in this context. Students who volunteered (committed students) had a significantly lower anxiety index than non-committed students. Additionally, students were more concerned about infecting other patients and relatives than themselves. Higher levels of anxiety were related to lower levels of commitment. A mandatory assignment during the pandemic was rejected by the students and does not seem to be necessary due to the large number of volunteers.
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Affiliation(s)
- Lorenz Mihatsch
- Department of Anaesthesiology and Intensive Care Medicine, Ludwig-Maximilians-Universität München, Munich, Germany
| | | | - Franziska Knolle
- Department of diagnostic and interventional Neuroradiology, Technical University of Munich, Munich, Germany
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Benjamin Luchting
- Department of Pain Medicine, Landsberg am Lech Clinic, Landsberg am Lech, Germany
| | | | - Jens Heyn
- Department of Anaesthesiology and Intensive Care Medicine, Ludwig-Maximilians-Universität München, Munich, Germany
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Karver TS, Atkins K, Fonner VA, Rodriguez-Diaz CE, Sweat MD, Taggart T, Yeh PT, Kennedy CE, Kerrigan D. HIV-Related Intersectional Stigma and Discrimination Measurement: State of the Science. Am J Public Health 2022; 112:S420-S432. [PMID: 35763725 PMCID: PMC9241460 DOI: 10.2105/ajph.2021.306639] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2021] [Indexed: 01/18/2023]
Abstract
Background. Across settings, individuals from populations that are multiply stigmatized are at increased risk of HIV and experience worse HIV treatment outcomes. As evidence expands on how intersecting stigmatized identities and conditions influence HIV outcomes, researchers have used diverse quantitative approaches to measure HIV-related intersectional stigma and discrimination. To date, no clear consensus exists regarding how to best quantitatively measure and analyze intersectional stigma and discrimination. Objectives. To review and document existing quantitative measures of HIV-related intersectional stigma and discrimination to inform research, programmatic, and policy efforts. Search Methods. We searched 5 electronic databases for relevant studies. References of included articles were screened for possible inclusion. Additional articles were screened on the basis of consultations with experts in the field. Selection Criteria. We included peer-reviewed studies published between January 1, 2010, and May 12, 2021, that were HIV related and presented 1 or more quantitative measures of stigma and discrimination using an intersectional lens in measure design or analysis. Data Collection and Analysis. Systematic methods were used to screen citations and abstract data via a standardized coding form. Data were analyzed by coding categories stratified according to 2 subgroups: (1) studies incorporating a single intersectional measure and (2) studies that examined intersectional stigma through analytical approaches combining multiple measures. Main Results. Sixteen articles met the inclusion criteria, 7 of which explicitly referenced intersectionality. Ten studies were from the United States. All of the studies included participants living with HIV. Among the 4 studies incorporating a single intersectional stigma measure, 3 explored race and gender stigma and 1 explored gender and HIV stigma. Studies involving analytic approaches (n = 12) mostly examined intersectional stigma via interaction terms in multivariate regression models. Three studies employed structural equation modeling to examine interactive effects or latent constructs of intersectional stigma. Conclusions. Research on the measurement of HIV-related intersectional stigma and discrimination is currently concentrated in high-income settings and generally focuses on the intersection of 2 identities (e.g., race and gender). Efforts are needed to expand appropriate application of intersectionality in the development, adaptation, and use of measures of HIV-related intersectional stigma and discrimination. The use of context-, identity-, or condition-adaptable measures should be considered. Researchers should also carefully consider how to meaningfully engage communities in the process of measurement development. Public Health Implications. The measures and analytic approaches presented could significantly enhance public health efforts in assessing the impact of HIV-related intersectional stigma and discrimination on critical health outcomes. (Am J Public Health. 2022;112(S4):S420-S432. https://doi.org/10.2105/AJPH.2021.306639).
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Affiliation(s)
- Tahilin Sanchez Karver
- Tahilin Sanchez Karver, Carlos E. Rodriguez-Diaz, Tamara Taggart, and Deanna Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC. Kaitlyn Atkins, Ping Teresa Yeh, and Caitlin E. Kennedy are with the Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Virginia A. Fonner is with the Global Health, Population, and Nutrition Department, FHI 360, Durham, NC. Michael D. Sweat is with the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston
| | - Kaitlyn Atkins
- Tahilin Sanchez Karver, Carlos E. Rodriguez-Diaz, Tamara Taggart, and Deanna Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC. Kaitlyn Atkins, Ping Teresa Yeh, and Caitlin E. Kennedy are with the Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Virginia A. Fonner is with the Global Health, Population, and Nutrition Department, FHI 360, Durham, NC. Michael D. Sweat is with the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston
| | - Virginia A Fonner
- Tahilin Sanchez Karver, Carlos E. Rodriguez-Diaz, Tamara Taggart, and Deanna Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC. Kaitlyn Atkins, Ping Teresa Yeh, and Caitlin E. Kennedy are with the Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Virginia A. Fonner is with the Global Health, Population, and Nutrition Department, FHI 360, Durham, NC. Michael D. Sweat is with the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston
| | - Carlos E Rodriguez-Diaz
- Tahilin Sanchez Karver, Carlos E. Rodriguez-Diaz, Tamara Taggart, and Deanna Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC. Kaitlyn Atkins, Ping Teresa Yeh, and Caitlin E. Kennedy are with the Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Virginia A. Fonner is with the Global Health, Population, and Nutrition Department, FHI 360, Durham, NC. Michael D. Sweat is with the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston
| | - Michael D Sweat
- Tahilin Sanchez Karver, Carlos E. Rodriguez-Diaz, Tamara Taggart, and Deanna Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC. Kaitlyn Atkins, Ping Teresa Yeh, and Caitlin E. Kennedy are with the Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Virginia A. Fonner is with the Global Health, Population, and Nutrition Department, FHI 360, Durham, NC. Michael D. Sweat is with the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston
| | - Tamara Taggart
- Tahilin Sanchez Karver, Carlos E. Rodriguez-Diaz, Tamara Taggart, and Deanna Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC. Kaitlyn Atkins, Ping Teresa Yeh, and Caitlin E. Kennedy are with the Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Virginia A. Fonner is with the Global Health, Population, and Nutrition Department, FHI 360, Durham, NC. Michael D. Sweat is with the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston
| | - Ping Teresa Yeh
- Tahilin Sanchez Karver, Carlos E. Rodriguez-Diaz, Tamara Taggart, and Deanna Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC. Kaitlyn Atkins, Ping Teresa Yeh, and Caitlin E. Kennedy are with the Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Virginia A. Fonner is with the Global Health, Population, and Nutrition Department, FHI 360, Durham, NC. Michael D. Sweat is with the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston
| | - Caitlin E Kennedy
- Tahilin Sanchez Karver, Carlos E. Rodriguez-Diaz, Tamara Taggart, and Deanna Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC. Kaitlyn Atkins, Ping Teresa Yeh, and Caitlin E. Kennedy are with the Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Virginia A. Fonner is with the Global Health, Population, and Nutrition Department, FHI 360, Durham, NC. Michael D. Sweat is with the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston
| | - Deanna Kerrigan
- Tahilin Sanchez Karver, Carlos E. Rodriguez-Diaz, Tamara Taggart, and Deanna Kerrigan are with the Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC. Kaitlyn Atkins, Ping Teresa Yeh, and Caitlin E. Kennedy are with the Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Virginia A. Fonner is with the Global Health, Population, and Nutrition Department, FHI 360, Durham, NC. Michael D. Sweat is with the Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston
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Conocimientos y percepción de estudiantes de psicología sobre el trabajo profesional en personas con VIH. REVISTA DIGITAL INTERNACIONAL DE PSICOLOGÍA Y CIENCIA SOCIAL 2022. [DOI: 10.22402/j.rdipycs.unam.e.8.01.2022.363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Los psicólogos que se dedican a la atención de personas diagnosticadas con VIH es necesario que cuenten con una actitud favorable hacia el trabajo profesional que impacte en una mejor atención; además es necesario que como profesionales de la salud, también tengan un comportamiento sexual saludable, de tal manera que haya congruencia entre lo que hace y lo que transmite como profesional. Con base en lo anterior, se tienen dos objetivos: (1) conocer el nivel de conocimientos sobre VIH/SIDA, creencias y uso del condón en relaciones sexuales estudiantes de psicología; y (2) conocer su percepción sobre VIH y del trabajo profesional con personas diagnosticadas con VIH. Se evaluó a 439 estudiantes de psicología, en términos generales se encontró que tienen un nivel aceptable de conocimientos sobre VIH, pero no sobre el uso del condón; tienen creencias favorables hacia su uso, pero no implica que sean consistentes en su uso; también se encontró una valoración positiva hacia la atención de personas con VIH. Se discute en términos de la importancia de formar a los estudiantes sobre la importancia de su salud sexual y en cómo trabajar con personas con VIH.
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Lacombe-Duncan A, Logie CH, Persad Y, Leblanc G, Nation K, Kia H, Scheim AI, Lyons T, Horemans C, Olawale R, Loutfy M. Implementation and evaluation of the 'Transgender Education for Affirmative and Competent HIV and Healthcare (TEACHH)' provider education pilot. BMC MEDICAL EDUCATION 2021; 21:561. [PMID: 34732178 PMCID: PMC8566115 DOI: 10.1186/s12909-021-02991-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 10/21/2021] [Indexed: 05/14/2023]
Abstract
BACKGROUND Transgender (trans) women face constrained access to gender-affirming HIV prevention and care. This is fueled in part by the convergence of limited trans knowledge and competency with anti-trans and HIV-related stigmas among social and healthcare providers. To advance gender-affirming HIV service delivery we implemented and evaluated 'Transgender Education for Affirmative and Competent HIV and Healthcare (TEACHH)'. This theoretically-informed community-developed intervention aimed to increase providers' gender-affirming HIV prevention and care knowledge and competency and reduce negative attitudes and biases among providers towards trans women living with and/or affected by HIV. METHODS Healthcare and social service providers and providers in-training (e.g., physicians, nurses, social workers) working with trans women living with and/or affected by HIV (n = 78) participated in a non-randomized multi-site pilot study evaluating TEACHH with a pre-post-test design. Pre- and post-intervention surveys assessed participant characteristics, intervention feasibility (e.g., workshop completion rate) and acceptability (e.g., willingness to attend another training). Paired sample t-tests were conducted to assess pre-post intervention differences in perceived competency, attitudes/biases, and knowledge to provide gender-affirming HIV care to trans women living with HIV and trans persons. RESULTS The intervention was feasible (100% workshop completion) and acceptable (91.9% indicated interest in future gender-affirming HIV care trainings). Post-intervention scores indicated significant improvement in: 1) knowledge, attitudes/biases and perceived competency in gender-affirming HIV care (score mean difference (MD) 8.49 (95% CI of MD: 6.12-10.86, p < 0.001, possible score range: 16-96), and 2) knowledge, attitudes/biases and perceived competency in gender-affirming healthcare (MD = 3.21; 95% CI of MD: 1.90-4.90, p < 0.001, possible score range: 9-63). Greater change in outcome measures from pre- to post-intervention was experienced by those with fewer trans and transfeminine clients served in the past year, in indirect service roles, and having received less prior training. CONCLUSIONS This brief healthcare and social service provider intervention showed promise in improving gender-affirming provider knowledge, perceived competency, and attitudes/biases, particularly among those with less trans and HIV experience. Scale-up of TEACHH may increase access to gender-affirming health services and HIV prevention and care, increase healthcare access, and reduce HIV disparities among trans women. TRIAL REGISTRATION ClinicalTrials.gov ( NCT04096053 ).
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Affiliation(s)
- Ashley Lacombe-Duncan
- School of Social Work, University of Michigan, 1080 South University Avenue, Ann Arbor, MI, 48109-1106, USA.
- Center for Sexuality and Health Disparities, University of Michigan, 400 North Ingalls Street, Ann Arbor, MI, 48109-5482, USA.
- Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, Ontario, M5G 1N8, Canada.
| | - Carmen H Logie
- Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, Ontario, M5G 1N8, Canada
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, M5S 1V4, Canada
- Center for Gender & Sexual Health Equity (CGSHE), 1190 Hornby Street, Vancouver, V6Z 2K5, Canada
| | - Yasmeen Persad
- Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, Ontario, M5G 1N8, Canada
| | - Gabrielle Leblanc
- Action Santé Travesti(e)s & Transsexuel(le)s du Québec (ASTT(E)Q), 1300 Sanguinet, Montréal, H2X 3E7, Canada
| | - Kelendria Nation
- Prism Education Series, Vancouver Coastal Health, 1128 Hornby Street, Vancouver, V6Z 2L4, Canada
| | - Hannah Kia
- School of Social Work, University of British Columbia, 2080 West Mall, Vancouver, V6T 1Z2, Canada
| | - Ayden I Scheim
- Epidemiology and Biostatistics, Drexel Dornsife School of Public Health, Drexel University, 3215 Market Street, Philadelphia, PA, 19104, USA
| | - Tara Lyons
- Center for Gender & Sexual Health Equity (CGSHE), 1190 Hornby Street, Vancouver, V6Z 2K5, Canada
- Department of Criminology, Kwantlen Polytechnic University, 12666 72 Avenue, Surrey, V3W 2M8, Canada
| | - Chavisa Horemans
- CIHR Canadian HIV Trials Network, 588-1081 Burrard Street, Vancouver, V6Z 1Y6, Canada
| | - Ronke Olawale
- School of Social Work, University of Michigan, 1080 South University Avenue, Ann Arbor, MI, 48109-1106, USA
| | - Mona Loutfy
- Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, Ontario, M5G 1N8, Canada
- Department of Medicine, University of Toronto, 1 King's College Circle, Toronto, M5S 1A8, Canada
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10
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Logie CH, Earnshaw V, Nyblade L, Turan J, Stangl A, Poteat T, Nelson L, Baral S. A scoping review of the integration of empowerment-based perspectives in quantitative intersectional stigma research. Glob Public Health 2021; 17:1451-1466. [PMID: 34061710 DOI: 10.1080/17441692.2021.1934061] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The genesis of the concept of intersectionality was a call to dismantle interlocking systems of oppression - racial, sexual, heterosexual, and class-based - in order to realise liberation of Black women and other women of colour. Intersectionality holds the radical potential to amplify collective efficacy, community solidarity, and liberation. The extension of intersectionality into stigma research has resulted in an increased focus on intersectional stigma in quantitative research. This raises questions regarding how the radical and liberatory potential of intersectionality is applied in stigma research. Specifically, empowerment-based perspectives may be overlooked in quantitative intersectional stigma research. We conducted a scoping review to document if and how empowerment-based perspectives were included in intersectional stigma quantitative studies. We identified and included 32 studies in this review that examined varied stigmas, most commonly related to race, gender, HIV and sexual orientation. In total 13/32 (40.6%) of these studies reported on empowerment-based factors; most of these examined social support and/or resilience. Taken together, findings suggest that the quantitative intersectional stigma research field would benefit from expansion of concepts studied to include activism and solidarity, as well as methodological approaches to identify the protective roles of empowerment-based factors to inform health and social justice-related programmes and policy.
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Affiliation(s)
- Carmen H Logie
- Factor-Inwentash Faculty of Toronto, University of Toronto, Toronto, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, Canada.,Centre for Gender and Sexual Health Equity, Vancouver, Canada
| | - Valerie Earnshaw
- College of Education & Human Development, University of Delaware, Newark, DE, USA
| | | | - Janet Turan
- Department of Health Care, Organization and Policy, School of Public Health, University of Alabama Birmingham, Birmingham, AL, USA
| | | | - Tonia Poteat
- Department of Social Medicine, UNC-Chapel Hill, Chapel Hill, NC, USA
| | - LaRon Nelson
- Yale School of Nursing, Yale University School of Nursing, New Haven, CT, USA
| | - Stefan Baral
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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11
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Ramos-Pibernus A, Carminelli-Corretjer P, Bermonti-Pérez M, Tollinchi-Natali N, Jiménez-Ricaurte C, Mejías-Serrano D, Silva-Reteguis J, Moreta-Ávila F, Blanco M, Justiz L, Febo M, Rivera-Segarra E. Examining Cervical Cancer Preventive Behaviors for Latinx Transmasculine Individuals among Medical Students. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18030851. [PMID: 33498187 PMCID: PMC7863948 DOI: 10.3390/ijerph18030851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/23/2020] [Accepted: 12/30/2020] [Indexed: 12/02/2022]
Abstract
Latinx transmasculine men (LTM) can be at a particularly high risk for cervical cancer as they lie at the intersection of two health disparity populations (gender and ethnic minorities). Previous research using self-report measures has documented how negative interactions with providers are a key barrier for cervical cancer screening among LTM. However, no research to date has examined, via direct observation, cervical cancer preventive behaviors in clinical interactions with LTM. Thus, the objective of this study was to examine cervical cancer preventive behaviors in clinical interactions between medical students and an LTM. The team implemented standardized patient simulations (simulations of clinical interactions with actors portraying the role of a patient), self-report measures, and observational techniques. A total of 37 medical students participated in the study. The results were mixed with some key behaviors neglected (i.e., asking if the patient preferred to collect the HPV test sample by himself), while others were enacted (i.e., checking family history of cervical cancer). Further research is needed to better understand behaviors in clinical interactions with LTM as well as how to improve them.
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Affiliation(s)
- Alíxida Ramos-Pibernus
- School of Behavioral and Brain Sciences, Ponce Health Sciences University, Ponce 00732, Puerto Rico; (P.C.-C.); (M.B.-P.); (N.T.-N.); (C.J.-R.); (M.B.); (L.J.); (M.F.); (E.R.-S.)
- Correspondence: ; Tel.: +1-787-840-2575
| | - Paola Carminelli-Corretjer
- School of Behavioral and Brain Sciences, Ponce Health Sciences University, Ponce 00732, Puerto Rico; (P.C.-C.); (M.B.-P.); (N.T.-N.); (C.J.-R.); (M.B.); (L.J.); (M.F.); (E.R.-S.)
| | - Mario Bermonti-Pérez
- School of Behavioral and Brain Sciences, Ponce Health Sciences University, Ponce 00732, Puerto Rico; (P.C.-C.); (M.B.-P.); (N.T.-N.); (C.J.-R.); (M.B.); (L.J.); (M.F.); (E.R.-S.)
| | - Nelmit Tollinchi-Natali
- School of Behavioral and Brain Sciences, Ponce Health Sciences University, Ponce 00732, Puerto Rico; (P.C.-C.); (M.B.-P.); (N.T.-N.); (C.J.-R.); (M.B.); (L.J.); (M.F.); (E.R.-S.)
| | - Coral Jiménez-Ricaurte
- School of Behavioral and Brain Sciences, Ponce Health Sciences University, Ponce 00732, Puerto Rico; (P.C.-C.); (M.B.-P.); (N.T.-N.); (C.J.-R.); (M.B.); (L.J.); (M.F.); (E.R.-S.)
| | | | | | | | - Malynie Blanco
- School of Behavioral and Brain Sciences, Ponce Health Sciences University, Ponce 00732, Puerto Rico; (P.C.-C.); (M.B.-P.); (N.T.-N.); (C.J.-R.); (M.B.); (L.J.); (M.F.); (E.R.-S.)
| | - Lellanes Justiz
- School of Behavioral and Brain Sciences, Ponce Health Sciences University, Ponce 00732, Puerto Rico; (P.C.-C.); (M.B.-P.); (N.T.-N.); (C.J.-R.); (M.B.); (L.J.); (M.F.); (E.R.-S.)
| | - Marta Febo
- School of Behavioral and Brain Sciences, Ponce Health Sciences University, Ponce 00732, Puerto Rico; (P.C.-C.); (M.B.-P.); (N.T.-N.); (C.J.-R.); (M.B.); (L.J.); (M.F.); (E.R.-S.)
| | - Eliut Rivera-Segarra
- School of Behavioral and Brain Sciences, Ponce Health Sciences University, Ponce 00732, Puerto Rico; (P.C.-C.); (M.B.-P.); (N.T.-N.); (C.J.-R.); (M.B.); (L.J.); (M.F.); (E.R.-S.)
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12
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Klein V, Brunner F, Grabowski M, Turner D. Stigma Surrounding Sexually Transmitted Infections among Medical Students in Germany. JOURNAL OF SEX RESEARCH 2021; 58:129-136. [PMID: 32500718 DOI: 10.1080/00224499.2020.1763238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Stigmatization by health care professionals leads to decreased help-seeking behaviors in those being stigmatized. Prejudicial attitudes are especially pronounced concerning sexually transmitted infections (STIs), which is crucial in light of rising prevalence rates of STIs in recent years. We aimed to examine stigmatization against patients with sexually versus non-sexually transmitted infections among medical students in Germany. We also assessed how a person's sexual orientation or gender might contribute to stigma. Medical students (N = 332) read about a fictious patient with symptoms of pharyngitis after having had a casual sex encounter. Gender (female/male) and sexual orientation (hetero-/bi-/homosexual) of the patient as well as the pathogen causing the infection (gonococcus/H1N1-virus) were randomly varied. Afterwards, stigma against the patient was assessed. Patients with a gonococcal pharyngitis were perceived as more prone to engage in risky behavior, dumber, and less responsible than patients with a H1N1-virus pharyngitis. Bisexual patients were perceived as more prone to engage in risky behavior than hetero- and homosexual individuals. The predictability of the consequences of the patient's actions was rated higher in bisexual patients. Stigmatizing attitudes toward patients with a STI were frequent, especially against bisexual patients. More education should be dedicated to sexual/LGB health during medical school to reduce existing stigma.
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Affiliation(s)
- Verena Klein
- Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf
| | - Franziska Brunner
- Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf
| | - Max Grabowski
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz
| | - Daniel Turner
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz
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13
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Gu LY, Zhang N, Mayer KH, McMahon JM, Nam S, Conserve DF, Moskow M, Brasch J, Adu-Sarkodie Y, Agyarko-Poku T, Boakye F, Nelson LE. Autonomy-Supportive Healthcare Climate and HIV-Related Stigma Predict Linkage to HIV Care in Men Who Have Sex With Men in Ghana, West Africa. J Int Assoc Provid AIDS Care 2021; 20:2325958220978113. [PMID: 33733909 PMCID: PMC7983411 DOI: 10.1177/2325958220978113] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
In Ghana, the HIV prevalence among MSM is more than 10 times greater than the general population of adults, and rates of engagement in HIV medical care are low among MSM diagnosed with HIV. Using structured surveys, we investigated the impact of HIV-related stigma, same-sex behavior stigma, and gender nonconformity stigma on linkage to HIV care (LTC) in MSM (N = 225) living with HIV in Ghana. Autonomy-supportive healthcare climate (OR = 1.63, p < .01), vicarious HIV stigma (OR = 2.73, p < .01), and age (OR = 1.06, p < .004) predicted LTC. Conversely, felt normative HIV stigma negatively predicted LTC (OR = 0.65, p < .05). Finally, we identified regional disparities, with MSM from Takoradi being 4 times and 5 times more likely to be LTC compared to Kumasi and Accra, respectively. Our findings highlight the nuanced roles of stigmas in shaping the HIV care continuum among MSM living with HIV, while revealing potential gaps in current measures of HIV-related stigma.
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Affiliation(s)
- Lily Y. Gu
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Nanhua Zhang
- Division of Biostatistics and Bioinformatics, Department of Environmental Health, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | | | | | - Soohyun Nam
- School of Nursing, Yale University, New Haven, CT, USA
| | - Donaldson F. Conserve
- Milken Institute School of Public Health, George Washington University, Washington DC, USA
| | - Marian Moskow
- School of Nursing, University of Rochester, Rochester, NY, USA
| | - Judith Brasch
- School of Nursing, University of Rochester, Rochester, NY, USA
| | - Yaw Adu-Sarkodie
- School of Medical Sciences, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
| | - Thomas Agyarko-Poku
- School of Medical Sciences, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
| | | | - LaRon E. Nelson
- School of Nursing, Yale University, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, USA
- Yale Institute of Global Health, Yale University, New Haven, CT, USA
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada
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14
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The People Living with HIV Stigma Index 2.0: generating critical evidence for change worldwide. AIDS 2020; 34 Suppl 1:S5-S18. [PMID: 32881790 DOI: 10.1097/qad.0000000000002602] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE(S) To describe the process of updating the People Living with HIV (PLHIV) Stigma Index (Stigma Index) to reflect current global treatment guidelines and to better measure intersecting stigmas and resilience. DESIGN Through an iterative process driven by PLHIV, the Stigma Index was revised, pretested, and formally evaluated in three cross-sectional studies. METHODS Between March and October 2017, 1153 surveys (n = 377, Cameroon; n = 390, Senegal; n = 391, Uganda) were conducted with PLHIV at least 18 years old who had known their status for at least 1 year. PLHIV interviewers administered the survey on tablet computers or mobile phones to a diverse group of purposively sampled respondents recruited through PLHIV networks, community-based organizations, HIV clinics, and snowball sampling. Sixty respondents participated in cognitive interviews (20 per country) to assess if questions were understood as intended, and eight focus groups (Uganda only) assessed relevance of the survey, overall. RESULTS The Stigma Index 2.0 performed well and was relevant to PLHIV in all three countries. HIV-related stigma was experienced by more than one-third of respondents, including in HIV care settings. High rates of stigma experienced by key populations (such as MSM and sex workers) impeded access to HIV services. Many PLHIV also demonstrated resilience per the new PLHIV Resilience Scale. CONCLUSION The Stigma Index 2.0 is now more relevant to the current context of the HIV/AIDS epidemic and response. Results will be critical for addressing gaps in program design and policies that must be overcome to support PLHIV engaging in services, adhering to antiretroviral therapy, being virally suppressed, and leading healthy, stigma-free lives.
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15
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Rivera-Segarra E, Carminelli-Corretjer P, Varas-Díaz N, Neilands TB, Yang LH, Bernal G. HIV and Depression: Examining Medical Students Clinical Skills. Front Psychiatry 2020; 11:240. [PMID: 32292361 PMCID: PMC7120025 DOI: 10.3389/fpsyt.2020.00240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 03/11/2020] [Indexed: 01/08/2023] Open
Abstract
Major depression is a prevalent psychiatric disorder among people living with HIV (PWH). Major depression symptoms, including suicidal ideation, can hinder clinical care engagement and anti-retroviral treatment adherence. Research suggests that inquiry about major depression symptomatology and suicidal ideation should be standard practice when offering primary care services to PWH. However, studies examining depression and suicidal ideation inquiry are scarce. This study's aim was to describe medical students' clinical skills for dealing with major depression symptomatology and suicidal ideation among PWH in Puerto Rico. A total of 100 4th year medical students participated in a Standardized Patient simulation with a trained actor posing as a PWH and with a previous major depression diagnosis. One-way frequency tables were used to characterize the sample and the percentage of each observed clinical skill. Two key findings stem from these results only 10% of the participants referred the patient to psychological/psychiatric treatment, and only 32% inquired about suicidal ideation. Our findings highlight the need for enhancing medical students' competencies regarding mental health issues, particularly when providing services to at risk populations such as PWH within primary care settings.
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Affiliation(s)
- Eliut Rivera-Segarra
- School of Behavioral and Brain Sciences, Ponce Health Sciences University, Ponce, Puerto Rico
| | | | - Nelson Varas-Díaz
- Department of Global and Sociocultural Studies, Florida International University, Miami, FL, United States
| | - Torsten B. Neilands
- Center for AIDS Prevention Studies, University of California at San Francisco, San Francisco, CA, United States
| | - Lawrence H. Yang
- College of Global Public Health, New York University, New York, NY, United States
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