Integrating Intersectional and Syndemic Frameworks for Ending the US HIV Epidemic

Increasing Urban African American Women's Readiness for Pre-exposure Prophylaxis: A Pilot Study of the Women Prepping for PrEp Plus Program (WP3+)

BACKGROUND

African American women are disproportionately at risk for HIV infection. To increase women's readiness to consider taking pre-exposure prophylaxis (PrEP), we conducted a pilot study of Women Prepping for PrEP Plus (WP3+). Adapted from an evidence-based HIV risk reduction intervention for African American couples who are HIV-serodiscordant, WP3+ is a group-based culturally congruent program designed for African American women without HIV.

METHODS

Women were screened for eligibility; if eligible, they were invited to participate in the four-session WP3+ group. Participants completed surveys at baseline (n = 47) and post-implementation (n = 28); surveys assessed demographics, HIV and PrEP knowledge, depression and posttraumatic stress (PTS) symptoms, substance use, sexual risk behaviors, health care-related discrimination, and social support. In a process evaluation, a subset of women completed qualitative interviews at baseline (n = 35) and post-implementation (n = 18); the interviews were designed to converge with (e.g., on HIV and PrEP knowledge) and expand upon (e.g., unmeasured perceived impacts of WP3+) quantitative measures. To triangulate with the quantitative data, deductive qualitative analysis concentrated on women's knowledge and awareness of PrEP and HIV, their relationship dynamics and challenges, and their considerations (e.g., barriers, facilitators) related to taking PrEP; inductive analysis focused on women's experiences in the intervention.

RESULTS

Participants in the WP3+ intervention reported: improved proportion of condom use in the past 90 days (p < .01) and in a typical week (p < .05); reduced PTS symptoms (p < .05); increased HIV knowledge (p < .0001) and awareness of PrEP (p < .001); and greater consideration of using PrEP (p < .001). In interviews, participants expressed not only increased knowledge but also appreciation for learning how to protect themselves against HIV, communicate with their partners, and take charge of their health, and they expressed greater receptiveness to using PrEP as a result of the knowledge and skills they gained.

CONCLUSIONS

The WP3+ pilot study demonstrated preliminary efficacy and acceptability as an HIV-prevention program for African American women. A controlled trial is needed to confirm its efficacy for increasing PrEP use among African American women.

Structural and Psychosocial Syndemic Conditions and Condomless Anal Intercourse Among Transgender Women - National HIV Behavioral Surveillance Among Transgender Women, Seven Urban Areas, United States, 2019-2020

Psychosocial and structural syndemic conditions, including polydrug use and experiencing homelessness, frequently co-occur and might jointly increase HIV risk. Limited studies have assessed racial and ethnic differences in exposure to syndemic conditions and behaviors associated with HIV transmission among transgender women. This report examines the relation between syndemic conditions and condomless anal intercourse (CAI) among transgender women in seven urban areas in the United States to develop HIV prevention interventions for transgender women. During 2019-2020, transgender women in seven urban areas were recruited using respondent-driven sampling for a biobehavioral survey. Reported syndemic conditions (psychosocial: polydrug use, sexual violence, and psychological distress; structural: homelessness, incarceration, and exchange sex) were summed to create a syndemic score. Using modified Poisson regression to account for RDS, the study assessed whether the strength of the association between syndemic score and CAI differed by race and ethnicity. To assess additive interaction, the relative excess prevalence owing to interaction (REPI) and 95% CIs for selected pairs of syndemic conditions on CAI prevalence stratified by race and ethnicity were estimated. Of 1,348 transgender women (Black = 546, White = 176, and Hispanic = 626), 55% reported CAI; and 24% reported ≥3 syndemic conditions. Reporting additional syndemic conditions was associated with CAI for White, Hispanic, and Black participants. The association was significantly stronger for White than Black and Hispanic participants. Limited significant superadditive interactions were found, although the majority were between structural syndemic conditions. Racial and ethnic differences in REPI estimates were observed. Reporting more syndemic conditions was associated with increased CAI across racial and ethnic groups, demonstrating that HIV prevention efforts for transgender women should address structural and psychosocial syndemic conditions. Results differed by race and ethnicity, indicating that syndemic-focused interventions for transgender women should be tailored to racial and ethnic groups.

A Systematic Review of Implementation Research on Determinants and Strategies of Effective HIV Interventions for Men Who Have Sex with Men in the United States

Men who have sex with men (MSM) are disproportionately affected by HIV, accounting for two-thirds of HIV cases in the United States despite representing ∼5% of the adult population. Delivery and use of existing and highly effective HIV prevention and treatment strategies remain suboptimal among MSM. To summarize the state of the science, we systematically review implementation determinants and strategies of HIV-related health interventions using implementation science frameworks. Research on implementation barriers has focused predominantly on characteristics of individual recipients (e.g., ethnicity, age, drug use) and less so on deliverers (e.g., nurses, physicians), with little focus on system-level factors. Similarly, most strategies target recipients to influence their uptake and adherence, rather than improving and supporting implementation systems. HIV implementation research is burgeoning; future research is needed to broaden the examination of barriers at the provider and system levels, as well as expand knowledge on how to match strategies to barriers-particularly to address stigma. Collaboration and coordination among federal, state, and local public health agencies; community-based organizations; health care providers; and scientists are important for successful implementation of HIV-related health innovations.

Informing Acceptability and Feasibility of Digital Phenotyping for Personalized HIV Prevention among Marginalized Populations Presenting to the Emergency Department

For marginalized populations with ongoing HIV epidemics, alternative methods are needed for understanding the complexities of HIV risk and delivering prevention interventions. Due to lack of engagement in ambulatory care, such groups have high utilization of drop-in care. Therefore, emergency departments represent a location with those at highest risk for HIV and in highest need of novel prevention methods. Digital phenotyping via data collected from smartphones and other wearable sensors could provide the innovative vehicle for examining complex HIV risk and assist in delivering personalized prevention interventions. However, there is paucity in exploring if such methods are an option. This study aimed to fill this gap via a cross-sectional psychosocial assessment with a sample of N=85 emergency department patients with HIV risk. Findings demonstrate that although potentially feasible, acceptability of digital phenotyping is questionable. Technology-assisted HIV prevention needs to be designed with the target community and address key ethical considerations.

Sexual Health and Drug Use Prevention for Black Girls (The Dreamer Girls Project): Protocol for an Intervention Development

BACKGROUND

Substance use among adolescent girls is associated with numerous risk characteristics, including engaging in sexual risk behaviors, which can lead to HIV and sexually transmitted infection (STI) diagnoses. This is an important phenomenon to target as there is a significant race-gendered paradox that occurs when Black girls use and misuse drugs. When misuse occurs among this group, they are more likely to face harsher consequences and worse health outcomes than boys and other ethnic-minority girls. Therefore, there is a need to understand the risk and protective factors of drug use and sexual risk behaviors among Black girls and develop a robust intervention that can cater for this group.

OBJECTIVE

We propose the development of a strengths-based prevention education intervention for Black girls between the ages of 13 and 18 years to promote protective factors.

METHODS

A sequential, mixed methods study will be conducted, and we will use the first 3 steps of the ADAPT-ITT (assessment, decision, adaptation, production, topical experts, integration, training, testing) framework to begin the development of the intervention. Three aims will be described in this protocol. First, aim 1 is to explore sociocultural risk and protective factors among Black girls between the ages 13 and 18 years in drug use and HIV/STI prevention using focus group methodology and surveys. We will conduct at least 10 focus groups to include up to 75 Black girls or until we reach saturation. Our target sample size for the quantitative portion of the study will be 200 participants. Aim 2 will focus on deciding upon an intervention based on findings from aim 1 and forming a youth advisory board to guide intervention development. Aim 3 will be to conduct a pretest of the intervention with the youth advisory board to determine if the intervention is feasible and will be accepted by Black girls.

RESULTS

The study is part of a 2-year research pilot study award from the National Institutes of Mental Health. Data collection for this study began in October 2021. For aim 1, data collection is 95% complete. We expect to complete all data collection for aim 1 on or before May 30, 2023. Study activities for aim 2 are occurring simultaneously as data are being collected and analyzed and will be completed in the summer of 2023. Study activities for aim 3 will begin in the fall of 2023.

CONCLUSIONS

This study will be one of the few interventions that address both sexual health and drug use together and cater to Black girls. We anticipate that the intervention will be beneficial for Black girls across the nation to work on building culturally appropriate prevention education and building peer social supports, resulting in reduction or delayed substance use and improved sexual health.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05014074; https://clinicaltrials.gov/ct2/show/NCT05014074.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45007.

Associations of past-year stigma and psychosocial syndemic conditions: Considerations for intersectional stigma measures among Black Sexual Minority Men

This secondary analysis of a mixed serostatus sample of Black sexual minority men (BSMM) used conditional inference tree methods to explore associations of past-year experienced stigma and psychosocial syndemic conditions. Experienced stigmas were attributed to race, sexuality, socioeconomic status, HIV status or some "other" reason. Psychosocial syndemic conditions studied included physical assault, intimate partner violence, polysubstance use, and depression symptomology. Data are from Promoting Our Worth, Equality and Resilience (POWER), a serial, cross-sectional study conducted between 2014-2017 (N=4430). Experiences of multiple stigmas were reported by n=938 (22.1%) of BSMM. Conditional inference tree results revealed that HIV-related stigma and its intersection with "other" stigma showed the greatest variance in psychosocial condition prevalence. Our findings suggest that when developing intercategorical intersectional analyses with BSMM, there are important stigmas for BSMM beyond those attributed to race, sexuality, and SES, particularly intersecting with HIV-related stigma. Conditional inference tree analysis shows promise in quantitative explorations of intersectional stigma with BSMM, but will benefit from the inclusion of additional forms of stigma, which should be considered by the field moving forward.

A Review of Serious Gaming as an Intervention for HIV Prevention

PURPOSEOF REVIEW

Young people face the highest number of new HIV infections globally. With today's increasing access to smartphones, serious games have been viewed as an effective means of improving knowledge and behavioral outcomes. This systematic review describes current HIV prevention serious games and their relationship with HIV-related knowledge and behavioral outcomes.

RECENT FINDINGS

A search of HIV prevention serious games was conducted using PubMed, CINAL, IEEE, Web of Science, and Google Scholar. A total of 31 papers were identified, which consist of 20 studies and 11 protocols. Results for knowledge, attitudes, intentions, and behaviors were mixed. Two interventions reported improvement in PrEP usage and optimal dosing. Gaming appears to be a viable and engaging method to improve knowledge, attitudes, and behavioral outcomes to promote HIV prevention among diverse groups of adolescents and young adults globally. However, additional research is needed to understand how to implement this modality effectively.

Racial, gender, and psychosocial disparities in viral suppression trends among people receiving coordinated HIV care in Los Angeles County

OBJECTIVE

To longitudinally evaluate differences in HIV viral suppression (<200 copies/ml) by intersections of race/ethnicity, gender, and psychosocial issues in people with HIV in the Los Angeles County Medical Care Coordination Program.

DESIGN

We analyzed 74 649 viral load measurements over 10 184 people with HIV enrolled in the Medical Care Coordination Program between January 1, 2013 and March 1, 2020.Methods: We fit Bayesian logistic hierarchical random effects models to test interactions between gender, race/ethnicity, and a psychosocial acuity score on viral suppression over time from 1 year prior to program enrollment to 24 months after enrollment.

RESULTS

The probability of viral suppression declined prior to enrollment, then increased and stabilized by 6 months after enrollment. Black/African American patients with low and moderate psychosocial acuity scores did not achieve the same increase in percentage of viral suppression as those in other racial/ethnic groups. Transgender women with high psychosocial acuity scores took longer (about 1 year) to achieve the same percentage of viral suppression as clients of other gender identities.

CONCLUSIONS

Some racial/ethnic and gender disparities in viral suppression persisted after enrollment in the Los Angeles County Medical Care Coordination Program while accounting for psychosocial acuity score, which may be explained by factors not assessed in the program.

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

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

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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