Associations Between Multiple Forms of Discrimination and Tobacco Use Among People Living With HIV: The Mediating Role of Avoidance Coping

Race/ethnicity-based discrimination, depressive symptoms, and smoking-related variables among people with HIV participating in a randomized clinical trial for cigarette smoking cessation

People with HIV smoke cigarettes at a high prevalence, and it is important to identify modifiable variables related to smoking in this population. Race/ethnicity-based discrimination is common among people with HIV from minoritized racial and ethnic groups and results in significant adverse effects. The goal of this study was to examine the relationship between race/ethnicity-based discrimination, depression, and smoking-related variables among people with HIV who smoke. This was a secondary analysis of data from a prospective, randomized controlled smoking cessation trial for people with HIV. Participants were recruited from three HIV clinical care sites and randomly assigned to an HIV-tailored group therapy intervention or a control condition. Participants completed measures of demographics, smoking-related variables, race/ethnicity-based discrimination, and depressive symptoms at baseline and were followed up 3- and 6-months after study completion. Depressive symptoms had an indirect effect on the relationship between race/ethnicity-based discrimination and self-efficacy to quit smoking at 3-month follow-up. Depressive symptoms mediated the relationship between race/ethnicity-based discrimination and both nicotine dependence and self-efficacy to quit smoking at 6-month follow-up. Findings highlight the importance of considering race/ethnicity-based discrimination and depressive symptoms in the development and implementation of smoking cessation treatment interventions for people with HIV.

An Integrated mHealth App for Smoking Cessation in Black Smokers With HIV: Protocol for a Randomized Controlled Trial

BACKGROUND

Black adults who smoke and have HIV experience immense stressors (eg, racial discrimination and HIV stigma) that impede smoking cessation success and perpetuate smoking-related health disparities. These stressors also place Black adults who smoke and have HIV at an increased risk of elevated interoceptive stress (eg, anxiety and uncomfortable bodily sensations) and smoking to manage symptoms. In turn, this population is more likely to smoke to manage interoceptive stress, which contributes to worse HIV-related outcomes in this group. However, no specialized treatment exists to address smoking cessation, interoceptive stress, and HIV management for Black smokers with HIV.

OBJECTIVE

This study aims to test a culturally adapted and novel mobile intervention that targets combustible cigarette smoking, HIV treatment engagement and adherence, and anxiety sensitivity (a proxy for difficulty and responsivity to interoceptive stress) among Black smokers with HIV (ie, Mobile Anxiety Sensitivity Program for Smoking and HIV [MASP+]). Various culturally tailored components of the app are being evaluated for their ability to help users quit smoking, manage physiological stress, and improve health care management.

METHODS

This study is a pilot randomized controlled trial in which Black combustible cigarette smokers with HIV (N=72) are being recruited and randomly assigned to use either (1) the National Cancer Institute's QuitGuide app or (2) MASP+. Study procedures include a web-based prescreener; active intervention period for 6 weeks; smartphone-based assessments, including daily app-based ecological momentary assessments for 6 weeks (4 ecological momentary assessments each day); a video-based qualitative interview using Zoom Video Communications software at week 6 for participants in all study conditions; and smartphone-based follow-up assessments at 0, 1, 2 (quit date), 3, 4, 5, 6, and 28 weeks postbaseline (26 weeks postquitting date).

RESULTS

Primary outcomes include biochemically verified 7-day point prevalence of abstinence, HIV-related quality of life, use of antiretroviral therapy, and HIV care appointment adherence at 26 weeks postquitting date. Qualitative data are also being collected and assessed to obtain feedback that will guide further tailoring of app content and evaluation of efficacy.

CONCLUSIONS

The results of this study will determine whether the MASP+ app serves as a successful aid for combustible cigarette smoking cessation, HIV treatment engagement, and physiological stress outcomes among Black people with HIV infection. If successful, this study will provide evidence for the efficacy of a new means of addressing major mental and physical health difficulties for this high-risk population. If the results are promising, the data from this study will be used to update and tailor the MASP+ app for testing in a fully powered randomized controlled trial that will evaluate its efficacy in real-world behavioral health and social service settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05709002; https://clinicaltrials.gov/study/NCT05709002.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/52090.

Perceived racial/ethnic discrimination and cigarette smoking behaviors among a sample of people with HIV

This study was a secondary analysis of baseline data from a clinical trial of an intensive group-based smoking cessation treatment for people with HIV (PWH) who smoke. It examined the cross-sectional relationship between perceived ethnic discrimination (PED) and cigarette smoking variables (i.e., nicotine dependence, motivation to quit smoking, self-efficacy to quit smoking) among PWH and explored whether depressive symptoms mediated the relationship between PED and smoking variables. Participants (N = 442; Mage = 50.6; 52.8% Male; 56.3% Black, non-Hispanic; 6.3% White, non-Hispanic; 13.3% Hispanic; 87.7% unemployed; 81.6% single) completed measures of demographics, cigarette smoking, depressive symptoms, and PED. Greater PED was related to lower self-efficacy to quit smoking, greater perceived stress, and greater depressive symptoms. In addition, depressive symptoms mediated the relationship between PED and two cigarette smoking variables (i.e., nicotine dependence, self-efficacy to quit smoking). Findings highlight the need for smoking interventions to target PED, self-efficacy, and depressive symptoms to improve smoking cessation variables among PWH.

Significant Others and Not Family or Friend Support Mediate Between Stigma and Discrimination Among People Living With HIV in Lagos State, Nigeria: A Cross-sectional Study

ABSTRACT

Approximately 70% of the 37.7 million people living with HIV (PLWH) globally reside in sub-Saharan Africa and 10% of the global HIV burden is in Nigeria. PLWH encounter stigma and discrimination. Limited support from family, friends, and significant others increases stigma and discrimination among PLWH. This study sought to understand how support from family, friends, and significant others mediates stigma and discrimination in the Nigerian context. This descriptive cross-sectional study enrolled 396 PLWH from six health facilities between June and July 2021 in Lagos State, Nigeria. Stigma, discrimination, and social support were assessed. On average, participants were 32 years of age and female. Increased social support was associated with reduced stigma and discrimination. Support from participants' significant others was found to mediate the relationship between stigma and discrimination.

Internalized HIV-Related Stigma and Neurocognitive Functioning Among Women Living with HIV

The prevalence of HIV-associated neurocognitive impairment persists despite highly effective antiretroviral therapy (ART). In this study we explore the role of internalized stigma, acceptance of negative societal characterizations, and perceptions about people living with HIV (PLWH) on neurocognitive functioning (executive function, learning, memory, attention/working memory, psychomotor speed, fluency, motor skills) in a national cohort of women living with HIV (WLWH) in the United States. We utilized observational data from a multicenter study of WLWH who are mostly African American living in low-resource settings. Neurocognitive function was measured using an eight-test battery. A multiple linear regression model was constructed to investigate the relationship between internalized stigma and overall neurocognitive functioning (mean of all neurocognitive domain standardized T-scores), adjusting for age, education, race, previous neuropsychological battery scores, illicit drug use, viral load, and years on ART. Our analysis revealed that internalized HIV-related stigma is significantly associated with worse performance on individual domain tests and overall neurocognitive performance (B = 0.27, t = 2.50, p = 0.01). This suggests HIV-related internalized stigma may be negatively associated with neurocognitive functioning for WLWH. This finding highlights a specific psychosocial factor associated with poor neurocognitive function that may be targeted to better promote the health of PLWH. Future research on the longitudinal relationship between these variables and the effects of other stigma dimensions on poor neurocognitive function would provide further insights into the pathways explaining the relationship between internalized stigma and neurocognition.

Practices, attitudes, and confidence related to tobacco treatment interventions in HIV clinics: a multisite cross-sectional survey

Tobacco use disorder (TUD) is a major threat to health among people with HIV (PWH), but it is often untreated. Among HIV clinicians and staff, we sought to characterize practices, attitudes, and confidence addressing TUD among PWH to identify potential opportunities to enhance provision of care. Cross-sectional deidentified, web-based surveys were administered from November 4, 2020 through December 15, 2020 in HIV clinics in three health systems in the United States Northeast. Surveys assessed provider characteristics and experience, reported practices addressing tobacco use, and knowledge and attitudes regarding medications for TUD. Chi-square tests or Fisher's exact tests were used to examine differences in responses between clinicians and staff who were prescribers versus nonprescribers and to examine factors associated with frequency of prescribing TUD medications. Among 118 survey respondents (56% prescribers), only 50% reported receiving prior training on brief smoking cessation interventions. Examining reported practices identified gaps in the delivery of TUD care, including counseling patients on the impact of smoking on HIV, knowledge of clinical practice guidelines, and implementation of assessment and brief interventions for smoking. Among prescribers, first-line medications for TUD were infrequently prescribed and concerns about medication side effects and interaction with antiretroviral treatments were associated with low frequency of prescribing. HIV clinicians and staff reported addressable gaps in their knowledge, understanding, and practices related to tobacco treatment. Additional work is needed to identify ways to ensure adequate training for providers to enhance the delivery of TUD treatment in HIV clinic settings.

Views and preferences of people living with HIV about smoking, quitting and use of nicotine products

AIMS AND BACKGROUND

People living with HIV (PLHIV) have a higher rate of smoking and experience a greater burden of tobacco-related disease than the general population. This study aimed to understand the role smoking plays in the lives of PLHIV, participants' views of traditionally available nicotine products (e.g., nicotine replacement therapy or NRT) and novel nicotine products (e.g., nicotine vaping products or NVPs) as both short-term quit aids and long-term substitutes for cigarettes.

METHODS

Semi-structured focus groups were conducted with PLHIV who smoked. Focus groups were transcribed and analysed using a combination of deductive and inductive thematic analysis. A brief questionnaire of nicotine product use and interest was also completed and the quantitative data presented using descriptive statistics.

RESULTS

Fifty-four participants took part in 11 focus groups. Participants' views of smoking, quitting and nicotine products were diverse. Commitment to smoking and interest in quitting were categorised into three groups across a smoking-quitting continuum: committed to smoking, ambivalent about smoking and reluctantly smoking. NRT was criticised for a range of side effects and primarily considered as a short-term cessation aid. NVPs generated debate. NVPs that closely resembled cigarettes were viewed as the most acceptable product and were considered to be more suitable than NRT for long-term use.

DISCUSSION AND CONCLUSIONS

Understanding the unique needs, goals and views of PLHIV related to smoking, quitting smoking and using nicotine products could inform development of novel and tailored smoking interventions for PLHIV. NVPs should be further examined as potential long-term substitutes for PLHIV who are ambivalent about smoking. However, traditional smoking cessation assistance (approved cessation aids and counselling) is likely to be most appropriate for PLHIV who are reluctantly smoking.

A pilot randomized controlled trial of a tailored smoking cessation program for people living with HIV in the Washington, D.C. metropolitan area

OBJECTIVE

Morbidity and mortality from smoking-related diseases among people living with HIV (PLWH) in the U.S. surpasses that due to HIV itself. Conventional smoking cessation treatments have not demonstrated strong efficacy among PLWH. We conducted a pilot randomized controlled trial (RCT) to evaluate a tailored smoking cessation intervention based on the minority stress model. We compared standard of care counseling (SOC) to a tailored intervention (TI) including one face-to-face counseling session incorporating cognitive behavioral therapy to build resilience, and 30 days of 2-way text messaging.

RESULTS

The primary outcome was smoking cessation. Secondary outcomes included cigarettes per day (CPD), exhaled carbon monoxide (CO), and cessation self-efficacy. A total of 25 participants were enrolled (TI:11, SOC:14), and 2 were lost to follow-up. There were no significant differences in quit rates between study groups. However, there was a significantly greater decrease in CPD in the TI versus SOC (13.5 vs. 0.0, p-value:0.036). Additionally, self-efficacy increased in both groups (TI p-value:0.012, SOC p-value:0.049) and CO decreased in both groups (TI p-value: < 0.001, SOC p-value:0.049). This intervention shows promise to support smoking cessation among PLWH. A larger study is needed to fully evaluate the efficacy of this approach.

CLINICAL TRIAL

Trial Registration: Retrospectively registered (10/20/2020) NCT04594109.

"Being downcast by society… adds to the stress levels and would explain why [we] smoke more.": Smoking among HIV-Positive Black Men Who Have Sex with Men

Smoking causes more deaths among people living with HIV than HIV infection itself. Few smoking cessation interventions and studies of sexual minority communities have considered the lived experiences of Black men who have sex with men (BMSM) living with HIV. Before developing interventions for these men, we need to answer: How do experiences of discrimination and stigma influence their perceptions of smoking? This phenomenological study was led by a community-based organization. We conducted six focus groups with 53 BMSM living with HIV in Los Angeles. We used minority stress theory in the analysis and interpretation of the data. We identified two themes: (1) co-occurrence of race and sexual orientation stressors and smoking (e.g., "I feel like I'd be discriminated against sometimes because I'm gay and because I'm Black.") and (2) smoking as a reaction to HIV-positive status (e.g., "I know more people that started smoking after they found out they [had] HIV."). Participants smoked to cope with stressors around race, sexual orientation, and living with HIV. These findings challenge us to ensure that smoking cessation interventions address the personal and social concerns of BMSM living with HIV and help them identify healthier ways to cope with stressors.

A Mixed Methods Study of Anticipated and Experienced Stigma in Health Care Settings Among Women Living with HIV in the United States

Among places where people living with HIV experience and anticipate HIV-related stigma, stigma in health care settings may be particularly harmful. Utilizing an exploratory sequential mixed methods approach, we conducted interviews (n = 76) and questionnaires (N = 460) with older adult women living with HIV enrolled in the Women's Interagency HIV Study in Birmingham, AL; Jackson, MS; Atlanta, GA; and San Francisco, CA. Interviews addressed facilitators and barriers to HIV treatment adherence, including HIV-related stigma. Qualitative data were coded using thematic analysis. Questionnaires assessed self-reported antiretroviral therapy (ART) adherence and experienced and anticipated HIV-related stigma from various sources (i.e., health care personnel, family, partner, and community). Covariate-adjusted logistic regression analyses examined total and mediated effects of stigma on ART adherence. Interviewees described fears and experiences of stigma in health care settings; including privacy violations, disrespect for patient autonomy, and reproductive coercion; and how these influenced their adherence to HIV treatment recommendations. Experienced and anticipated HIV-related stigma in health care settings were associated with suboptimal (or <95%) ART adherence in separate models controlling for experienced or anticipated stigma, respectively, from other sources. When entered together, only anticipated stigma in health care settings was associated with suboptimal ART adherence, controlling for anticipated and experienced stigma from other sources. The effect of anticipated stigma in health care settings on suboptimal ART adherence may work through the pathways of lower adherence self-efficacy, higher depressive symptoms, and higher coping by substance use. These findings indicate that interventions should promote cultures of acceptance within health care settings and resilience-based strategies for women to combat stigma and promote life-sustaining behaviors.

"You Come Back to the Same Ole Shit:" A Qualitative Study of Smoking Cessation Barriers among Women Living with HIV: Implications for Intervention Development

Although tobacco use among women living with HIV (WLWH) is decreasing, the prevalence is more than double that of women in the general population and remains an important health behavior to target among WLWH. Few smoking cessation interventions specifically focus on the unique social and medical needs of WLWH. Thus, the investigative team engaged WLWH (N=18) in qualitative focus groups to: 1) understand barriers and facilitators to smoking cessation; and 2) inform intervention structure and content priorities. Participants identified salient reasons for smoking and barriers to smoking cessation, which included coping with multiple life stressors, HIV-related stress, HIV-related stigma and social isolation. Further, WLWH highlighted the importance of long-term smoking cessation support, peer support, mental health content, religion/spirituality, and targeted risk messaging in smoking cessation intervention development. Study findings provide concrete, operational strategies for future use in a theory-based smoking cessation intervention, and underscore the importance of formative research to inform smoking cessation interventions for WLWH.