The pervasive effects of childhood sexual abuse: challenges for improving HIV prevention and treatment interventions

A Longitudinal Examination of HIV Risk Perception Accuracy among Sexual Minority Men with History of Childhood Sexual Abuse

Men who have sex with men (MSM) with history of childhood sexual abuse (CSA) are at high risk for HIV acquisition. One reason is posttraumatic responses compromise ability to accurately appraise risk for danger/vulnerability. Health behavior change models and related interventions assume risk perception can be changed in an enduring manner. Given paucity of studies examining how risk perception changes or sustains over time post-intervention, this underlying assumption is not confirmed. Among this particularly high-risk group who struggle with perceiving risk due to trauma-related cognitions, it may be accuracy of risk perception is fluid. The study primarily aimed to examine accuracy of HIV risk perception over time post-HIV prevention behavioral intervention. Leveraging data from a larger RCT, N = 190 MSM in Boston, MA and Miami, FL USA completed a psychosocial baseline assessment, an intervention aimed to increase awareness of personal HIV risk level, then four follow-up assessments three months apart for a year. Linear mixed effect models were used to examine the degree to which accuracy of HIV risk perception (vs. traditional construct of risk perception with no information about accuracy) predicts sex risk behavior over time delineated by between-person (trait level) and within-person (state level) effects. Majority (92%) of participants fluctuated in HIV risk accuracy over time post-intervention. Within-person risk accuracy (one's accuracy at any given timepoint) predicted sex risk behavior (condomless sex not protected by adherent PrEP) over time, but not between-person (one's average of accuracy). Findings have implications for intervention and counseling related to specific HIV prevention strategies.

Posttraumatic Cognitions and Condomless Sex Among Men Who Have Sex with Men (MSM) with a History of Childhood Sexual Abuse: The Role of Avoidance Coping

This study explicated associations between trauma-related cognitions and condomless sex, examining avoidance coping style and behavior (i.e., substance use) as intermediate variables, among a group disproportionately affected by both trauma and HIV. Two hundred and ninety HIV-negative MSM with a history of childhood sexual abuse (CSA) completed a cross-sectional psychosocial battery. Trauma-related cognitions were positively associated with more acts of condomless sex. Indirect associations on condomless sex were driven by avoidance coping, but not substance use. Findings indicate a need to address trauma-related cognitions and avoidance coping within interventions for reducing HIV risk among MSM with a history of CSA.

The importance of assessing and addressing mental health barriers to PrEP use during pregnancy and postpartum in sub-Saharan Africa: state of the science and research priorities

Introduction

Pregnant and postpartum women (PPW) in sub‐Saharan Africa are at disproportionately high risk of HIV infection compared to non‐pregnant women. When used consistently, pre‐exposure prophylaxis (PrEP) can prevent HIV acquisition and transmission to the foetus or infant during these critical periods. Recent studies have demonstrated associations between mental health challenges (e.g. depression and traumatic stress associated with intimate partner violence) and decreased PrEP adherence and persistence, particularly among adolescents, younger women and women in the postpartum period. However, mental health is not currently a major focus of PrEP implementation research and programme planning for PPW.

Discussion

PrEP implementation programmes for PPW need to assess and address mental health barriers to consistent PrEP use to ensure effectiveness and sustainability in routine care. We highlight three key research priorities that will support PrEP adherence and persistence: (1) include mental health screening tools in PrEP implementation research with PPW, both to assess the feasibility of integrating these tools into routine antenatal and postpartum care and to ensure that limited resources are directed towards women whose symptoms may interfere most with PrEP use; (2) identify cross‐cutting, transdiagnostic psychological mechanisms that affect consistent PrEP use during these periods and can realistically be targeted with intervention in resource‐limited settings; and (3) develop/adapt and test interventions that target those underlying mechanisms, leveraging strategies from existing interventions that have successfully mitigated mental health barriers to antiretroviral therapy use among people with HIV.

Conclusions

For PPW, implementation of PrEP should be guided by a robust understanding of the unique psychological difficulties that may act as barriers to uptake, adherence and persistence (i.e. sustained adherence over time). We strongly encourage PrEP implementation research in PPW to incorporate validated mental health screening tools and ultimately treatment in routine antenatal and postnatal care, and we stress the potential public health benefits of identifying women who face mental health barriers to PrEP use.

Indirect effects of dissociation on the relationship between lifetime PTSD symptoms and condomless sex among men who have sex with men with a history of childhood sexual abuse

Posttraumatic stress disorder (PTSD) symptoms may interfere with gay, bisexual and other men who have sex with men's (MSM) ability to engage in safe sex practices. An indirect relationship with dissociation may help to elucidate the relationship between PTSD symptom severity and condomless sex among MSM with childhood sexual abuse (CSA) histories. These relationships have not previously been examined in this group, which has a unique vulnerability for HIV acquisition. A cross-sectional sample of MSM with histories of CSA (N=290) was recruited at study sites in Boston, MA, and Miami, FL. Participants had a mean age of 37.95 years (SD=11.68), 22% were African American and 29.4% identified as Latino. The sample reported a mean of 10.47 (SD=4.38) lifetime PTSD symptoms and 26.4% met the clinical threshold for dissociation. Logistic regression models (adjusted for age, education, and substance use disorder) were used to assess indirect effects of dissociation on the relationship between lifetime PTSD symptoms and condomless anal/vaginal sex episodes with serodiscordant or unknown status partners in the past 3 months. Dissociation accounted for the association between lifetime PTSD symptom severity and condomless sex episodes. The Sobel test (Sobel = 2.04, p= .042; CI 95% bias-corrected bootstrap) suggested significant indirect effects for dissociation. Dissociation among MSM with CSA histories may compromise accurate appraisals of sexual risk and safety and increase vulnerability for HIV acquisition. Further research is warranted to address HIV prevention in the context of PTSD symptom severity to improve the mental health of MSM and increase the effectiveness of HIV prevention interventions.

Association of positive psychobehavioral factors and structural disadvantage with condomless sex in men who have sex men with childhood sexual abuse histories

Previous research has highlighted both psychological and structural risk factors as correlates of condomless anal sex, a key pathway to HIV acquisition in men who have sex with men (MSM). Fewer studies have focused on positive psychobehavioral factors, which may be associated with more consistent condom use. This study hypothesized that positive psychobehavioral factors would be associated with more frequent condom use over and above psychological and structural risk factors. MSM with histories of childhood sexual abuse in Boston, MA and Miami, FL (N = 108) completed cross-sectional assessments of psychosocial, structural, and positive psychobehavioral factors. These factors were entered simultaneously in a linear regression model to examine their association with frequency of condomless sex. More recent seroadaptive behavior (B = 0.323, 95% CI = 0.055-0.590, p = .019) and receipt of government benefits to supplement income (B = 0.892, 95% CI = 0.171-1.612, p = .016) were independently associated with higher frequency of condomless sex over and above all other psychosocial, structural, and positive psychobehavioral factors. R² for the final model was 0.270. Ancillary analyses including participants taking and adherent to biomedical HIV prevention suggested an association between higher distress tolerance and lower frequency of condomless sex. Positive psychobehavioral factors may potentially lower risk for HIV in high-risk MSM; however, left unaddressed, structural disadvantage is a potent influence which may limit potential benefits.

Longitudinal associations between childhood sexual abuse-related PTSD symptoms and passive and active suicidal ideation among sexual minority men

BACKGROUND

Sexual minority men report high rates of childhood sexual abuse (CSA) and adulthood suicidality. However, mechanisms (e.g., PTSD symptoms) through which CSA might drive suicidality remain unknown.

OBJECTIVE

In a prospective cohort of sexual minority men, we examined: (1) associations between CSA and suicidal thoughts and behaviors; (2) prospective associations between CSA-related PTSD symptoms and suicidal ideation; and (3) interpersonal moderators of these associations.

PARTICIPANTS AND SETTING

Participants included 6305 sexual minority men (M_age = 33.2, SD = 11.5; 82.0% gay; 53.5% White) who completed baseline and one-year follow-up at-home online surveys.

METHODS

Bivariate analyses were used to assess baseline demographic and suicidality differences between CSA-exposed participants and non-CSA-exposed participants. Among CSA-exposed participants, multivariable logistic regression analyses were used to regress passive and active suicidal ideation at one-year follow-up on CSA-related PTSD symptoms at baseline. Interactions were examined between CSA-related PTSD symptoms and interpersonal difficulties.

RESULTS

CSA-exposed sexual minority men reported two-and-a-half times the odds of suicide attempt history compared to non-CSA-exposed men (95% CI = 2.15-2.88; p < 0.001). Among CSA-exposed sexual minority men, CSA-related PTSD symptoms were prospectively associated with passive suicidal ideation (adjusted odds ratio [aOR] = 1.38; 95% CI = 1.19; 1.61). Regardless of CSA-related PTSD symptom severity, those with lower social support and greater loneliness were at elevated risk of active suicidal ideation at one-year follow-up.

CONCLUSIONS

CSA-related PTSD symptom severity represents a psychological mechanism contributing to CSA-exposed sexual minority men's elevated suicide risk, particularly among those who lack social support and report loneliness.

Psychiatric, Substance Use, and Structural Disparities Between Gay and Bisexual Men with Histories of Childhood Sexual Abuse and Recent Sexual Risk Behavior

Sexual minority men disproportionately experience childhood sexual abuse (CSA) compared to heterosexual men, resulting in greater risk of psychiatric and substance use diagnoses, sexual risk taking, and HIV acquisition later in life. However, little is known about psychiatric and substance use disparities between gay and bisexual men who have experienced CSA. We recruited a purposive convenience sample in Boston and Miami, involving self-report and clinical interview data from 290 sexual minority men (M age = 38.0 years) who reported CSA, defined as unwanted sexual contact before 13 years of age with an adult or person five years older, or unwanted sexual contact between 13 and 16 years of age with a person 10 years older (or any age with the threat of force or harm). We compared those who self-identified as gay (n = 199) versus bisexual (n = 64) on demographic and structural variables (i.e., government benefits, unstable housing, and neighborhood crime) as well as psychiatric and substance use diagnoses. Across 15 unique diagnoses, three were more common in bisexual men than gay men in unadjusted models: bipolar disorder (OR = 2.90, 95% CI: 1.01-8.34), obsessive compulsive disorder (OR = 2.22, 95% CI: 1.01-4.88), and alcohol use disorder (OR = 1.86, 95% CI: 1.03-3.38). Bisexual men were also more likely to meet criteria for "any substance use disorder" than were gay men (OR = 1.99, 95% CI: 1.10-3.59). However, when race, education, and income were included as covariates, the odds ratios reduced significantly (bipolar disorder: aOR = 1.98, 95% CI: 0.59-6.61; obsessive compulsive disorder: aOR = 1.56, 95% CI: 0.64-3.77; alcohol use disorder, aOR = 1.54, 95% CI: 0.80-2.98; any substance use disorder, aOR = 1.79, 95% CI: 0.93-3.45, respectively). Our results highlight the mental health needs, including problematic substance use, of bisexual men with histories of CSA, as well as the importance of accounting for potential confounding demographic variables that may influence disparities in mental health and substance use.

Posttraumatic cognitions, childhood sexual abuse characteristics, and posttraumatic stress disorder in men who have sex with men

BACKGROUND

High rates of experience of childhood sexual abuse (CSA) among in men who have sex with men (MSM) place this population at increased risk for posttraumatic stress disorder (PTSD).

OBJECTIVE

This study explores how specific characteristics of CSA relate to posttraumatic cognitions (PTCs) and explores the role that specific PTCs play in the relationship between CSA and PTSD in MSM.

METHODS

Two-hundred and ninety MSM completed a CSA interview, the Davidson Trauma Scale, and the Posttraumatic Cognitions Inventory.

RESULTS

Controlling for sociodemographic factors, CSA involving physical injury and CSA with intense fear were associated with higher levels of PTCs about the self and world, but not with self-blame. We did not find significant associations for CSA involving a family member, CSA with penetration, or duration or frequency of CSA with any subscale on the PTCI. Experiencing CSA for the first time during adolescence was associated with higher self-blame. Analyses revealed that physical injury and intense fear each had indirect effects on PTSD symptoms through negative cognitions about the self and world. First CSA episode during adolescence had an indirect effect on PTSD symptoms through self-blame. CSAs accounted for 16.7% and PTCs accounted for 31.7% of the variance in PTSD, underlining the importance of PTCs.

CONCLUSIONS

Assessing for physical injury, intense fear, and age at first CSA are particularly relevant to PTCs and of critical importance to advancing assessment and treatment strategies for PTSD in MSM.

Cognitive Behavioral Therapy for Trauma and Self-Care (CBT-TSC) in Men Who have Sex with Men with a History of Childhood Sexual Abuse: A Randomized Controlled Trial

To address childhood sexual abuse (CSA) related distress and HIV risk in men who have sex with men (MSM) using cognitive-behavioral therapy for trauma and self-care (CBT-TSC), which is a novel intervention integrating HIV risk reduction with modified cognitive and behavioral therapy strategies for post-traumatic stress. We compared CBT-TSC to HIV voluntary counseling and testing (VCT)-only in an initial 2-arm RCT in 43 HIV-negative MSM at with a history of CSA and HIV risk. Serodiscordant condomless anal/vaginal sex (CAS; CAS with HIV-postive or HIV unknown status partners) and posttraumatic stress disorder (PTSD) symptoms (Davidson Trauma Scale: total score and avoidance, intrusions, hyperarousal subscales) were outcomes immediately post-treatment, and at 6- and 9-month follow-up. At post-treatment, CBT-TSC had decreased odds (approximately 60%) of any CAS and greater reductions in CAS compared to VCT-only. Additionally, the CBT-TSC condition experienced greater reductions in total PTSD and avoidance symptoms. At the follow-up visits, CBT-TSC condition had significant reductions in the odds of any CAS and reductions in CAS. However, for PTSD symptoms, only the avoidance subscale remained significantly different compared to VCT-only. CBT-TSC is a potentially efficacious approach to address HIV risk in MSM with a CSA history, with replication and extension in a larger trial needed. This proof-of-concept trial is the first to integrate the treatment of a commonly occurring mental-health syndemic problem in MSM with a health psychology approach to self-care in MSM.Trial Registration Clinicaltrials.gov NCT01266122.

The Indirect Effect of Posttraumatic Stress Disorder Symptoms on Current Alcohol Use Through Negative Cognitions in Sexual Minority Men

Self-medication theory posits that some trauma survivors use alcohol to cope with posttraumatic stress disorder (PTSD) symptoms, but the role of negative posttraumatic cognitions in this relationship is not well defined. We examined associations among PTSD symptoms, posttraumatic cognitions, and alcohol intoxication frequency in 290 men who have sex with men (MSM), who reported a history of childhood sexual abuse (CSA). Using a bootstrap approach, we examined the indirect effects of PTSD symptoms on alcohol intoxication frequency through posttraumatic cognitions regarding the self, world, and self-blame. In separate regression models, higher levels of PTSD symptoms and posttraumatic cognitions were each associated with more frequent intoxication, accounting for 2.6% and 5.2% of the variance above demographics, respectively. When examined simultaneously, posttraumatic cognitions remained significantly correlated with intoxication frequency whereas PTSD symptoms did not. Men reporting elevated posttraumatic cognitions faced increased odds for current alcohol dependence, odds ratio (OR) = 2.19, 95% CI [1.13, 4.22], compared with men reporting low posttraumatic cognitions, independent of current PTSD diagnosis. A higher level of PTSD symptom severity was indirectly associated with more frequent alcohol intoxication through cognitions about the self and world; the indirect to total effect ratios were 0.74 and 0.35, respectively. Negative posttraumatic cognitions pertaining to individuals' self-perceptions and appraisals of the world as dangerous may play a role in self-medication with alcohol among MSM with a history of CSA. Interventions targeting these cognitions may offer potential for reducing alcohol misuse in this population, with possible broader implications for HIV-infection risk.

Methamphetamine-associated dysregulation of the hypothalamic-pituitary-thyroid axis

Methamphetamine and HIV impair thyroid function, but few studies have investigated their combined effects on thyroid dysregulation. This study examined the associations of methamphetamine use alone and in combination with HIV on thyroid function among men in South Florida. Measures of thyroid function in methamphetamine-using, HIV-infected (METH+HIV+; n = 127) and HIV-negative (METH+HIV-; n = 46) men who have sex with men (MSM) were compared to non-methamphetamine-using, HIV-negative men (METH-HIV-; n = 136). Thyroid function was dysregulated in methamphetamine-using MSM, irrespective of HIV status. Both meth-using groups had greater odds of abnormal thyroid stimulating hormone levels and significantly higher mean free triiodothyronine (T3) levels. Elevated free T3 was associated with greater depressive symptoms. Overall, outcomes have important implications for assessment of thyroid function in methamphetamine users, particularly among those presenting with depression.

Applying network analysis to psychological comorbidity and health behavior: Depression, PTSD, and sexual risk in sexual minority men with trauma histories

OBJECTIVE

High rates of depression and posttraumatic stress disorder (PTSD) contribute to sexual risk, particularly in men who have sex with men (MSM) who have experienced childhood sexual abuse. The comorbidity between depression and PTSD and mechanisms by which they contribute to sexual risk in MSM remain unclear. This study sought to demonstrate the feasibility and utility of a network approach to (a) characterize symptom interconnections between depression and PTSD in MSM, (b) identify specific symptoms related to sexual risk behavior, and (c) compare symptom networks across groups at different levels of risk.

METHOD

Cross-sectional baseline data were collected from 296 HIV-negative urban MSM as part of a multisite randomized intervention trial. Symptoms of depression and PTSD were self-reported along with sexual risk behavior. Analyses were performed in R using regularized partial correlation network modeling.

RESULTS

Network analyses revealed complex associations between depression and PTSD symptoms and in relation to sexual risk behavior. While symptoms clustered within their respective disorders, depression and PTSD were connected at key symptom nodes (e.g., sleep, concentration). Specific symptoms (e.g., avoiding thoughts and feelings) were linked to sexual risk behavior. Network comparisons across risk groups suggested avoidant processes could be more readily activated in higher-risk individuals, whereas hyperarousal symptoms may be more salient and protective for lower-risk individuals.

CONCLUSIONS

This study is one of the earliest network analyses of depression and PTSD, and first to extend this inquiry to health behavior. Symptom-level investigations may clarify mechanisms underlying psychological comorbidity and behavioral risk in MSM and refine targets for intervention/prevention. (PsycINFO Database Record

Evaluating a novel intervention to reduce trauma symptoms and sexual risk taking: qualitative exit interviews with sexual minority men with childhood sexual abuse

Childhood sexual abuse (CSA) continues to affect sexual minority men (SMM) at disproportionate levels and contributes to multiple negative health outcomes, including sexual-risk taking and HIV acquisition. This paper presents qualitative evaluative feedback from SMM (N = 9) who participated in a 10-session Cognitive Behavioral Therapy-Trauma and Sexual Health (CBT-TSH) intervention to reduce CSA-related posttraumatic stress reaction and distress. The treatment was designed to increase accurate sexual risk appraisals and to improve self-care health behaviors related to HIV/STI acquisition. The researchers identified four emerging themes: (1) motivation to participate, (2) response to cognitive therapy, (3) process of change, and (4) considerations for intervention improvement. These qualitative findings provide useful feedback on the acceptability of an innovative program that integrates CBT for trauma related to CSA with sexual risk-reduction counseling.

Syndemic conditions and HIV transmission risk behavior among HIV-negative gay and bisexual men in a U.S. national sample

OBJECTIVE

The syndemics framework has been used to explain the high rates of HIV infection among gay and bisexual men. However, most studies have relied primarily on urban or otherwise limited (e.g., single location) samples. We evaluated the prevalence of syndemics-here, depression, polydrug use, childhood sexual abuse, intimate partner violence, and sexual compulsivity-among gay and bisexual men from across the United States, including nonurban areas.

METHOD

Using data from a national sample of 1,033 HIV-negative gay and bisexual men, demographic differences in the prevalence of each syndemic condition and associations with HIV transmission risk behavior were examined.

RESULTS

More than 62% of men reported at least 1 syndemic condition. Prevalence did not vary by U.S. region-however, a larger proportion of nonurban men and those with lower income and education levels were above the median number of syndemic conditions. In bivariate analyses, HIV transmission risk behavior was associated with each syndemic condition except for childhood sexual abuse, whereas in multivariate analyses, it was associated with polydrug use, sexual compulsivity, being Latino, and being single and was highest among those reporting 3 or more syndemic conditions.

CONCLUSIONS

Rates of syndemic conditions among this national sample of gay and bisexual men were generally comparable to previous studies, however elevated rates in nonurban men suggest the need for targeted intervention and support. Links observed between syndemics and HIV transmission risk behavior highlight the ongoing need to address psychosocial concerns among gay and bisexual men in order to reduce their disproportionately high rates of HIV infection. (PsycINFO Database Record

Psychological and behavioral moderators of the relationship between trauma severity and HIV transmission risk behavior among MSM with a history of childhood sexual abuse

Childhood sexual abuse (CSA) is associated with post-traumatic stress disorder (PTSD), which can be associated with condomless sex among men who have sex with men (MSM). However, the impact of moderating factors on the relationship between PTSD symptom severity and condomless sex is poorly understood. We examined whether PTSD symptom severity was associated with condomless sex among MSM with CSA histories, and whether substance dependence, self-esteem, and distress tolerance moderated that relationship (n = 288). Notably, no direct relationship between PTSD symptom severity and condomless sex was found. Adjusted models indicated that condomless sex was differentially impacted by PTSD symptom severity among those without substance dependence (ΔR² = 0.03, p = 0.034) and, counterintuitively, those with high self-esteem (ΔR² = 0.07, p = 0.005). PTSD symptom severity was associated with condomless sex across levels of distress tolerance. Findings indicate that substance use, self-esteem, and distress tolerance should be targeted in high-risk MSM with CSA even if they do not have PTSD.

Mental health in 2020 for men who have sex with men in the United States

Despite continued advances in HIV prevention and treatment, gay and bisexual men and other men who have sex with men (MSM) remain the population most impacted by HIV/AIDS in the US and many other Western countries. Additionally, MSM are disproportionately affected by various psychological problems, including depression, distress, trauma and substance use. These challenges frequently co-occur, and are associated with higher rates of behaviours related to HIV acquisition and transmission, HIV infection, and, for those living with HIV/AIDS, lower levels of treatment engagement. Moreover, racial disparities exist among MSM in the US; for example, young African American MSM bear a disproportionate burden of the continuing HIV epidemic, likely related to disparate HIV prevalence in partner pools as well as long-standing structural inequities. In this review, the mental health challenges facing MSM primarily in the US, related to HIV and STI prevention and across the HIV care cascade, including HIV diagnosis, engagement and retention in care, and antiretroviral adherence, are illustrated. Disparities among MSM including racial and ethnic, age-related and structural barriers associated with HIV prevention and treatment, as well as current interventions, are also described. Moving forward towards 2020, resources will be needed to assess and implement scalable intervention strategies to address psychological and social barriers to HIV and STI risk reduction and treatment for MSM, with a particular focus on the most vulnerable subpopulations. As access to prevention and treatment strategies expand, and new breakthroughs continue to emerge, behavioural strategies will continue to be needed to reduce risk and increase uptake and engagement among MSM most at risk through 2020 and beyond.

High Levels of Concomitant Behavioral Health Disorders Among Patients Presenting for HIV Non-occupational Post-exposure Prophylaxis at a Boston Community Health Center Between 1997 and 2013

A paucity of information regarding mental health exists for patients presenting for HIV non-occupational post-exposure prophylaxis (nPEP). We reviewed electronic medical records of 894 adult nPEP patients seen at a large Boston community health center between 1997 and 2013. Of 821 patients with consensual sexual exposures, 88.3 % were men who have sex with men, and 40.0 % had a mental health diagnosis. Diagnoses included: depression (24.4 %), anxiety (21.9 %), attention deficit disorder (7.8 %), post-traumatic stress disorder (3.3 %), and psychotic disorders (3.3 %). Of 129 patients with substance use disorders, alcohol dependence (65.9 %) and crystal methamphetamine (43.4 %) predominated. Unprotected receptive anal intercourse was associated with psychotic disorders (aOR = 4.86; 95 %CI:1.76-13.5) and substance use disorders (aOR = 1.89; 95 %CI:1.28-2.80). Substance use at the time of exposure was associated with: depression (aOR = 1.95; 95 %CI:1.36-2.80), anxiety (aOR = 2.22; 95 %CI:1.51-3.25), attention deficit disorder (aOR = 1.96; 95 %CI:1.18-3.27), and substance use disorder (aOR = 4.78; 95 %CI:3.30-6.93). Mental illness should be screened for and addressed at nPEP visits to optimize HIV risk-reduction.

Childhood sexual abuse and depression in Latino men who have sex with men: Does resilience protect against nonadherence to antiretroviral therapy?

This study tested depression as a mediator between childhood sexual abuse and adherence to antiretroviral therapy, an effect moderated by resilience. In total, 149 HIV+ Latino men who have sex with men were recruited for this study. Using a regression-based bootstrap approach, depression mediated the relationship between childhood sexual abuse and antiretroviral therapy adherence, with worse adherence for participants at lowest percentiles of the resilience index. The prevalence of childhood sexual abuse and depression in HIV+ men who have sex with men is high and must be addressed to better prevent disease progression and reduce transmission, especially in expanding Latino populations.

Resilience among gay/bisexual young men in Western Kenya: psychosocial and sexual health outcomes

OBJECTIVE

To explore associations between intrapersonal and interpersonal factors and both sexual and psychosocial resilient outcomes among young gay, bisexual, and other men who have sex with men (GBMSM) in Western Kenya.

DESIGN

Cross-sectional observational study.

METHODS

Five hundred and eleven GBMSM ages 18-29 were recruited from nine communities in Western Kenya using community-based mobilization strategies. Participants completed an audio computer-assisted self-interview survey in English or Duhluo. We estimated four three-step hierarchical linear regression models to examine associations between predictors (intrapersonal and interpersonal factors) and four resilient outcomes (psychological well-being, self-esteem, condom use, HIV testing).

RESULTS

Psychosocial well-being model (modeled conversely as depression/anxiety) was significant (F(13,424) = 106.41, P < 0.001, R = 0.765) with loneliness, lesbian/gay/bisexual (LGB) difficult process, LGB identity superiority, and reactions to trauma as predictors. Self-esteem model was significant (F(12,425) = 6.40, P < 0.001, R = 0.153) with known HIV-seropositivity, perceived social support, internalized homonegativity, and LGB difficult process as predictors. Condom use model was significant (F(13,379) = 4.30, P < 0.001, R = 0.128) with perceived social support, self-esteem, and reactions to trauma as predictors. HIV testing model was significant (F(12,377) = 4.75, P < 0.001, R = 0.131) with loneliness, LGB identity uncertainty, LGB difficult process, and LGB identity superiority as predictors.

CONCLUSION

This study demonstrates the variety of ways in which intrapersonal and interpersonal factors are associated with HIV-related resilient outcomes for young GBMSM in Western Kenya. HIV prevention programs for this population should be developed in collaboration with GBMSM and include intervention components that promote resilience.

Complexity of childhood sexual abuse: predictors of current post-traumatic stress disorder, mood disorders, substance use, and sexual risk behavior among adult men who have sex with men

Men who have sex with men (MSM) are the group most at risk for HIV and represent the majority of new infections in the United States. Rates of childhood sexual abuse (CSA) among MSM have been estimated as high as 46 %. CSA is associated with increased risk of HIV and greater likelihood of HIV sexual risk behavior. The purpose of this study was to identify the relationships between CSA complexity indicators and mental health, substance use, sexually transmitted infections, and HIV sexual risk among MSM. MSM with CSA histories (n = 162) who were screened for an HIV prevention efficacy trial completed comprehensive psychosocial assessments. Five indicators of complex CSA experiences were created: CSA by family member, CSA with penetration, CSA with physical injury, CSA with intense fear, and first CSA in adolescence. Adjusted regression models were used to identify relationships between CSA complexity and outcomes. Participants reporting CSA by family member were at 2.6 odds of current alcohol use disorder (OR 2.64: CI 1.24-5.63), two times higher odds of substance use disorder (OR 2.1: CI 1.02-2.36), and 2.7 times higher odds of reporting an STI in the past year (OR 2.7: CI 1.04-7.1). CSA with penetration was associated with increased likelihood of current PTSD (OR 3.17: CI 1.56-6.43), recent HIV sexual risk behavior (OR 2.7: CI 1.16-6.36), and a greater number of casual sexual partners (p = 0.02). Both CSA with Physical Injury (OR 4.05: CI 1.9-8.7) and CSA with Intense Fear (OR 5.16: CI 2.5-10.7) were related to increased odds for current PTSD. First CSA in adolescence was related to increased odds of major depressive disorder. These findings suggest that CSA, with one or more complexities, creates patterns of vulnerabilities for MSM, including post-traumatic stress disorder, substance use, and sexual risk taking, and suggests the need for detailed assessment of CSA and the development of integrated HIV prevention programs that address mental health and substance use comorbidities.

Retrospective reports of developmental stressors, syndemics, and their association with sexual risk outcomes among gay men

Gay and bisexual men (GBM) continue to have a disproportionately higher HIV incidence than any other group in Canada and the United States. This study examined how multiple co-occurring psychosocial problems, also known as a syndemic, contribute to high-risk sexual behavior among GBM. It also examined the impact of early life adversity on high-risk sexual behavior as mediated by syndemic severity. A sample of 239 GBM completed self-report questionnaires at baseline and 6-month follow-up. Syndemic variables included depression, polysubstance use, and intimate partner violence. Early life adversity variables measured retrospectively included physical and verbal bullying by peers and physical and sexual abuse by adults. A Cochran-Armitage trend test revealed a proportionate increase between number of syndemic problems and engagement in high-risk sex (p < .0001), thereby supporting syndemic theory. All early life adversity variables were positively correlated with number of syndemic problems. A bootstrap mediation analysis revealed indirect effects of two types of early life adversity on high-risk sex via syndemic severity: verbal bullying by peers and physical abuse by adults. There was also an overall effect of physical bullying by peers on high-risk sexual behavior, but no specific direct or indirect effects were observed. Consistent with syndemic theory, results provide evidence that certain types of early life adversity impact high-risk sex later in life via syndemic problems. Behavioral interventions to reduce sexual risk among GBM should address anti-gay discrimination experienced before adulthood as well as adult psychological problems.

Sexual minority specific and related traumatic experiences are associated with increased risk for smoking among gay and bisexual men

OBJECTIVE

This study examined the hypothesis that sexual minority specific stress and trauma histories may explain some of the risk for smoking among gay/bisexual men.

METHODS

Patients at a Boston community health center were invited to complete a 25-item questionnaire assessing demographics, general health, trauma history, and substance use. Of the 3103 who responded, 1309 identified as male and gay or bisexual (82.8% White and mean age of 38.55 [sd = 9.76]).

RESULTS

A multinomial logistic regression with never smoked as referent group and covariates of age, education, employment, HIV status, and race, showed that the number of sexual minority stressors/traumas were significantly related to the odds of both current and former smoking. In comparison to participants with no trauma history, those who reported 1, 2, 3, and 4 traumas had respectively 1.70 (OR = 1.70: 95% CI: 1.24-2.34), 2.19 (OR = 2.19: 95% CI: 1.48-3.23), 2.88 (OR = 2.88: 95% CI: 1.71-4.85), and 6.94 (OR = 6.94: 95% CI: 2.62-18.38) the odds of identifying as a current smoker. Adjusted logistic regression analysis revealed a significant dose effect of number of sexual minority stressors/traumas with odds of ever smoking. Experiencing intimate partner violence, anti-gay verbal attack, anti-gay physical attack, and childhood sexual abuse were each independently associated with increased odds of the smoking outcomes.

CONCLUSION

A sexual minority specific trauma history may represent a vulnerability for smoking among gay/bisexual men. Interventions that address trauma may enhance the efficacy of smoking cessation programs and improve the mental health of gay/bisexual men.

Youth violence and connectedness in adolescence: what are the implications for later sexually transmitted infections?

PURPOSE

To examine associations between (1) youth violence victimization and perpetration and later sexually transmitted infections (STI) and (2) parent-family and school connectedness and later STI, and to explore the moderating role of connectedness on the associations between youth violence victimization and perpetration and later STI.

METHODS

We used data from Waves I and IV of the National Longitudinal Study of Adolescent Health, which provided a baseline weighted sample of 14,800 respondents. We used logistic regression to examine associations between youth violence and connectedness with self-reported ever STI diagnosis, including gonorrhea, chlamydia, syphilis, genital herpes, genital warts or human papillomavirus, or human immunodeficiency virus. If participants reported having an STI at Wave I they were excluded from the analysis.

RESULTS

Controlling for biological sex, race/ethnicity, age, parent's highest education level, and parent's marital status, both youth violence victimization and perpetration were associated with an increased risk of later STI (adjusted odds ratio [AOR], 1.27, 95% confidence interval [CI], 1.07-1.52; and AOR, 1.21, 95% CI, 1.04-1.41, respectively). Parent-family and school connectedness in adolescence were associated with a decreased risk for later STI (AOR, .96, 95% CI, .95-.98; and AOR, .97, 95% CI, .95-.99, respectively); however, connectedness did not moderate the associations between nonsexual violence involvement and later STI.

CONCLUSIONS

These results indicate that youth violence victimization and perpetration may be risk factors for STI later in life. Conversely, parent-family and school connectedness in adolescence appear to protect against subsequent STI. The findings suggest that provider efforts to address youth violence and connectedness in adolescence can promote positive sexual health outcomes in adulthood.

Mediation effects of problem drinking and marijuana use on HIV sexual risk behaviors among childhood sexually abused South African heterosexual men

HIV/AIDS prevalence in South Africa is one of the highest in the world with heterosexual, transmission predominantly promoting the epidemic. The goal of this study is to examine whether, marijuana use and problem drinking mediate the relationship between histories of childhood sexual, abuse (CSA) and HIV risk behaviors among heterosexual men. Participants were 1181 Black men aged, 18-45 from randomly selected neighborhoods in Eastern Cape Province, South Africa. Audio computer assisted, self-interviewing was used to assess self-reported childhood sexual abuse, problem drinking, and marijuana (dagga) use, and HIV sexual transmission behavior with steady and casual partners. Data were analyzed using multiple meditational modeling. There was more support for problem, drinking than marijuana use as a mediator. Findings suggest that problem drinking and marijuana use, mediate HIV sexual risk behaviors in men with histories of CSA. Focusing on men with histories of CSA, and their use of marijuana and alcohol may be particularly useful for designing strategies to reduce, HIV sexual transmission in South Africa.

Factors associated with change in sexual transmission risk behavior over 3 years among HIV-infected patients in Tanzania

Background

The reduction of HIV transmission risk behaviors among those infected with HIV remains a major global health priority. Psychosocial characteristics have proven to be important correlates of sexual transmission risk behaviors in high-income countries, but little attention has focused on the influence of psychosocial and psychological factors on sexual transmission risk behaviors in African cohorts.

Methodology and Principal Findings

The CHAT Study enrolled a representative sample of 499 HIV-infected patients in established HIV care and 267 newly diagnosed HIV-infected individuals from the Kilimanjaro Region of Tanzania. Participants completed in-person interviews every 6 months for 3 years. Using logistic random effects models to account for repeated observations, we assessed sociodemographic, physical health, and psychosocial predictors of self-reported unprotected sexual intercourse. Among established patients, the proportion reporting any recent unprotected sex was stable, ranging between 6–13% over 3 years. Among newly diagnosed patients, the proportion reporting any unprotected sex dropped from 43% at baseline to 11–21% at 6–36 months. In multivariable models, higher odds of reported unprotected sex was associated with female gender, younger age, being married, better physical health, and greater post-traumatic stress symptoms. In addition, within-individual changes in post-traumatic stress over time coincided with increases in unprotected sex.

Conclusions and Significance

Changes in post-traumatic stress symptomatology were associated with changes in sexual transmission risk behaviors in this sample of HIV-infected adults in Tanzania, suggesting the importance of investing in appropriate mental health screening and intervention services for HIV-infected patients, both to improve mental health and to support secondary prevention efforts.