Barriers to and enablers of the HIV services continuum among gay and bisexual men worldwide: Findings from the Global Men's Health and Rights Study.

OBJECTIVES: To assess ecological, structural, community and individual level correlates of health services utilization along a continuum of HIV care, and sexual health and support services among gay and bisexual men worldwide. METHODS: Using a nonprobability internet sample of 6,135 gay and bisexual men, we assessed correlates of utilization of health services. Chi-Square Tests of Independence were performed to assess drop off along a continuum of HIV care. Multivariable logistic regression analyses using generalized estimating equation models were conducted adjusting for geographic region and clustering by country. In multivariable analyses, we determined the association between utilization outcomes, and ecologic, structural, community and individual correlates by fitting separate generalized estimating equation (GEE) logistic regression models for each of the outcomes, fitted with robust SEs, and accounting for clustering by country. Stratified by sexual identity, analyses adjusted for variables that could influence HIV-related health outcomes including racial/ethnic minority status, participant age, insurance, ability to make ends meet, as well as country-level income (income of country of residence defined by the World Bank). RESULTS: Among men living with HIV (n = 1001), being in HIV care (n = 867) was associated with being on ART (X2 = 191.17, p < .001), and viral load suppression (X2 = 14.03, p < .001); and using ART (n = 840) was associated viral load suppression (X2 = 21.66, p < .001). Overall, the pattern of utilization outcomes were similar for both gay and bisexual men. For example, utilization of PrEP, being in HIV care and utilization of most of the sexual health and support services were negatively associated with sexual stigma. Whereas, utilization of most HIV prevention, and sexual health and support services were positively associated with provider discrimination. Utilization of all HIV prevention and all sexual health services were positively associated with greater community engagement, and receiving services from LGBT-led organizations. Bisexual men had higher odds of reporting provider discrimination when utilizing condom services (gay: AOR = 1.14, [0.95-1.36]; bisexual: 1.58, [1.10-2.28]), PrEP (gay: AOR = 1.06, [0.77-1.45]; bisexual: AOR = 2.14, [1.18-3.89], mental health services (gay: AOR = 1.03, [0.86-1.23]; bisexual: AOR = 1.32, [1.07-1.64]), and community-based support (gay: AOR = 1.23, [1.05-1.45]; bisexual: AOR = 1.49, [1.14-1.93]) than gay men. Bisexual men also reported higher odds of accessing services from LGBT-led organizations when utilizing PrEP (gay: AOR = 5.26, [2.50-11.05]; bisexual: AOR = 7.12, [3.16-16.04]), and community-based support/self-help groups/individual counseling (gay: AOR = 2.63, [1.72-4.01]; bisexual: AOR = 3.35, [2.30-4.88]. CONCLUSIONS: It is essential that barriers to health services utilization be addressed at structural and community levels. Structural interventions should be designed to reduce sexual stigma, as well as train and sensitize healthcare providers; and strengthen community level interventions that bring gay and bisexual men together to lead comprehensive health services.

Enablers and Barriers to HIV Services for Gay and Bisexual Men in the COVID-19 Era: Fusing Data Sets from Two Global Online Surveys Via File Concatenation With Adjusted Weights.

BACKGROUND: Gay and bisexual men are 26 times more likely to acquire HIV than other adult men and represent nearly 1 in 4 new HIV infections worldwide. There is concern that the COVID-19 pandemic may be complicating efforts to prevent new HIV infections, reduce AIDS-related deaths, and expand access to HIV services. The impact of the COVID-19 pandemic on gay and bisexual men's ability to access services is not fully understood. OBJECTIVE: The aim of this study was to understand access to HIV services at the start of the COVID-19 pandemic. METHODS: Our study used data collected from two independent global online surveys conducted with convenience samples of gay and bisexual men. Both data sets had common demographic measurements; however, only the COVID-19 Disparities Survey (n=13,562) collected the outcomes of interest (HIV services access at the height of the first COVID-19 wave) and only the Global Men's Health and Rights Survey 4 (GMHR-4; n=6188) gathered pre-COVID-19 pandemic exposures/covariates of interest (social/structural enablers of and barriers to HIV services access). We used data fusion methods to combine these data sets utilizing overlapping demographic variables and assessed relationships between exposures and outcomes. We hypothesized that engagement with the gay community and comfort with one's health care provider would be positively associated with HIV services access and negatively associated with poorer mental health and economic instability as the COVID-19 outbreaks took hold. Conversely, we hypothesized that sexual stigma and experiences of discrimination by a health care provider would be negatively associated with HIV services access and positively associated with poorer mental health and economic instability. RESULTS: With 19,643 observations after combining data sets, our study confirmed hypothesized associations between enablers of and barriers to HIV prevention, care, and treatment. For example, community engagement was positively associated with access to an HIV provider (regression coefficient=0.81, 95% CI 0.75 to 0.86; P<.001), while sexual stigma was negatively associated with access to HIV treatment (coefficient=-1.39, 95% CI -1.42 to -1.36; P<.001). CONCLUSIONS: HIV services access for gay and bisexual men remained obstructed and perhaps became worse during the first wave of the COVID-19 pandemic. Community-led research that utilizes novel methodological approaches can be helpful in times of crisis to inform urgently needed tailored responses that can be delivered in real time. More research is needed to understand the full impact COVID-19 is having on gay and bisexual men worldwide.

Peer- and community-led responses to HIV: A scoping review.

INTRODUCTION: In June 2021, United Nations (UN) Member States committed to ambitious targets for scaling up community-led responses by 2025 toward meeting the goals of ending the AIDS epidemic by 2030. These targets build on UN Member States 2016 commitments to ensure that 30% of HIV testing and treatment programmes are community-led by 2030. At its current pace, the world is not likely to meet these nor other global HIV targets, as evidenced by current epidemiologic trends. The COVID-19 pandemic threatens to further slow momentum made to date. The purpose of this paper is to review available evidence on the comparative advantages of community-led HIV responses that can better inform policy making towards getting the world back on track. METHODS: We conducted a scoping review to gather available evidence on peer- and community-led HIV responses. Using UNAIDS' definition of 'community-led' and following PRISMA guidelines, we searched peer-reviewed literature published from January 1982 through September 2020. We limited our search to articles reporting findings from randomized controlled trials as well as from quasi-experimental, prospective, pre/post-test evaluation, and cross-sectional study designs. The overall goals of this scoping review were to gather available evidence on community-led responses and their impact on HIV outcomes, and to identify key concepts that can be used to quickly inform policy, practice, and research. FINDINGS: Our initial search yielded 279 records. After screening for relevance and conducting cross-validation, 48 articles were selected. Most studies took place in the global south (n = 27) and a third (n = 17) involved youth. Sixty-five percent of articles (n = 31) described the comparative advantage of peer- and community-led direct services, e.g., prevention and education (n = 23) testing, care, and treatment programs (n = 8). We identified more than 40 beneficial outcomes linked to a range of peer- and community-led HIV activities. They include improved HIV-related knowledge, attitudes, intentions, self-efficacy, risk behaviours, risk appraisals, health literacy, adherence, and viral suppression. Ten studies reported improvements in HIV service access, quality, linkage, utilization, and retention resulting from peer- or community-led programs or initiatives. Three studies reported structural level changes, including positive influences on clinic wait times, treatment stockouts, service coverage, and exclusionary practices. CONCLUSIONS AND RECOMMENDATIONS: Findings from our scoping review underscore the comparative advantage of peer- and community-led HIV responses. Specifically, the evidence from the published literature leads us to recommend, where possible, that prevention programs, especially those intended for people living with and disproportionately affected by HIV, be peer- and community-led. In addition, treatment services should strive to integrate specific peer- and community-led components informed by differentiated care models. Future research is needed and should focus on generating additional quantitative evidence on cost effectiveness and on the synergistic effects of bundling two or more peer- and community-led interventions.

Economic, Mental Health, HIV Prevention and HIV Treatment Impacts of COVID-19 and the COVID-19 Response on a Global Sample of Cisgender Gay Men and Other Men Who Have Sex with Men.

There is an urgent need to measure the impacts of COVID-19 among gay men and other men who have sex with men (MSM). We conducted a cross-sectional survey with a global sample of gay men and other MSM (n = 2732) from April 16, 2020 to May 4, 2020, through a social networking app. We characterized the economic, mental health, HIV prevention and HIV treatment impacts of COVID-19 and the COVID-19 response, and examined whether sub-groups of our study population are disproportionately impacted by COVID-19. Many gay men and other MSM not only reported economic and mental health consequences, but also interruptions to HIV prevention and testing, and HIV care and treatment services. These consequences were significantly greater among people living with HIV, racial/ethnic minorities, immigrants, sex workers, and socio-economically disadvantaged groups. These findings highlight the urgent need to mitigate the negative impacts of COVID-19 among gay men and other MSM.

RESUMEN: Existe una necesidad urgente para medir los impactos de COVID-19 entre hombres gay y otros hombres que tienen sexo con hombres (HSH). Hemos conducido una encuesta multifuncional con una prueba mundial de hombres gay y otros HSH (n = 2732) desde el 16 de Abril hasta el 4 de Mayo del 2020, a través de una aplicación de red social. Nosotros caracterizamos los impactos económicos, de salud mental, prevención del VIH y tratamiento del VIH e impactos a COVID-19 y la respuesta de COVID-19, y examinamos si subgrupos de nuestra población de estudio fueron impactados desproporcionadamente por COVID-19. Muchos hombres no tan solo reportaron consecuencias económicas y de salud mental, sino también interrupciones de prevención y de pruebas de VIH, y cuidado del VIH y servicios de tratamiento. Encontramos consecuencias más significantes entre personas viviendo con VIH, grupos raciales/etnicos, migrantes, sexo servidores, y groupos socioeconomicamente disfavorecidos. Los resultados subrayan la necesidad crucial de mitigar los impactos multifacéticos de COVID-19 entre los hombres homosexuales y otros HSH, especialmente para aquellos con vulnerabilidades entrelazadas.

Blue-Ribbon Boys: factors associated with PrEP use, ART use and undetectable viral load among gay app users across six regions of the world.

INTRODUCTION: Gay social networking apps have grown in popularity among men who have sex with men offering opportunities for rapid and confidential collection of vital data as well as social connection. The goal of our study was to explore factors associated with utilization of pre-exposure prophylaxis (PrEP) and antiretroviral treatment (ART), and self-reported undetectable viral load (UVL) using data collected by the gay social networking app Hornet. METHODS: In 2016, the Global Forum on MSM & HIV (MSMGF) partnered with Hornet, to support an educational initiative called Blue-Ribbon Boys. One aspect of the initiative prompts Hornet users to answer a short series of yes-no questions about their sexual health. Using survey responses, we evaluated factors associated with PrEP and ART use as well as self-reported UVL by fitting separate multivariable generalized estimating equation models. RESULTS: In total, 16,008 unique Hornet users started the survey, of which 12,126 (76%) provided sufficient data for analyses. Of the 10,774 HIV-negative men, 13% reported PrEP use in the past year. PrEP use was associated with a recent sexually transmitted infection (STI) test or treatment (aOR = 2.19, CI = 1.49 to 3.21); and taking steps to protect oneself from HIV (aOR = 1.41, CI = 1.13 to 1.76). Among HIV-positive Hornet users (n = 1243), ART use was associated with older age (each year increase aOR = 1.02, CI = 1.01 to 1.04), a recent STI test or treatment (aOR = 4.54, CI = 2.65 to 7.78); and awareness of unlikely HIV transmission with UVL (aOR = 1.53, CI = 1.03 to 2.26). UVL was associated with older age (each year increase aOR = 1.03, CI = 1.01 to 1.04), a recent STI test or treatment (aOR = 4.84, CI = 2.74 to 8.55), and awareness of unlikely HIV transmission with UVL (aOR = 1.98, CI = 1.37 to 2.85). CONCLUSIONS: Study findings underscore the importance of STI testing and treatment as well as information about HIV transmissibility for encouraging PrEP and ART use. Our findings also reveal age disparities, which can undermine incidence reduction among gay men. Gay social networking apps can be effectively used for rapid data collection and sexual health promotion with men who have sex with men. STI testing and treatment programmes offer important opportunities for encouraging PrEP and ART use. Information about HIV transmissibility with consistent ART use should be incorporated into prevention messaging tailored to various age groups.

Child Sexual Abuse and Adult Mental Health, Sexual Risk Behaviors, and Drinking Patterns Among Latino Men Who Have Sex With Men.

One in five Latino men who have sex with men has experienced child sexual abuse. Although concerning in itself, child sexual abuse may increase an individuals' likelihood of depression and risk-taking in adult life, including engagement in HIV risk behaviors and alcohol and substance use. It is therefore urgent that researchers and practitioners better understand the long-term effects of child sexual abuse. We utilized logistic and linear regression to assess associations between child sexual abuse (operationalized as forced or coerced sexual activity before age 17) and depression, sexual behaviors, and drinking patterns in a sample of 176 adult Latino men who have sex with men from New York City. Over one-fifth (22%) of participants reported child sexual abuse. In multivariable models, participants with histories of child sexual abuse were significantly more likely than participants without such histories to screen for clinically significant depressive symptoms and heavy drinking and reported more anal sex acts, male sexual partners, and incidents of condomless anal intercourse in the previous three months. These findings confirm a high prevalence of child sexual abuse among Latino men who have sex with men and associations between child sexual abuse and adulthood depressive symptoms, high-risk alcohol consumption, and sexual risk behaviors. We recommend that providers who serve Latino men who have sex with men incorporate child sexual abuse screenings into mental health, HIV prevention, and substance use treatment programs, utilizing approaches that are inclusive of resilience.

Depression and Risk for Problem Drinking in Latino Migrant Day Laborers.

BACKGROUND: Given the structural vulnerability of Latino migrant day laborers (LMDLs) to unstable and poorly paying work, harsh living conditions and frequent inability to support or even visit families in country of origin, psychological distress is a common response and one frequently implicated in risky outcomes such as problem drinking. OBJECTIVES: The purpose of this study was to examine the relation of three different forms of psychological distress to problem drinking in LMDLs: depression, anxiety, and desesperación, the latter a popular Latino culture-based idiom of psychological distress. METHODS: A cross sectional survey of 344 LMDLs was conducted in the San Francisco Bay Area from January to June of 2014. Independent contributions of depression, anxiety, and desesperación in explaining problem drinking as measured by a modified version of the AUDIT, were assessed using multiple linear regression analysis. RESULTS: Depression was significantly associated with risk for problem drinking while other forms of psychological distress were not. Conclusion/Importance: Findings provide stronger empirical support for the association between depression and problem drinking, a long suspected but under-demonstrated relationship in the literature on LMDLs. Implications for preventing problem drinking as well as mitigating psychological distress more generally for LMDLs are discussed.

Availability and Use of Substance Abuse Treatment Programs Among Substance-Using Men Who Have Sex With Men Worldwide.

BACKGROUND: Substance use is common among men who have sex with men (MSM) worldwide, and epidemiologic data suggest that alcohol/substance-using MSM are at greater risk for HIV. However, there are scarce data on substance abuse treatment programs (SATPs) for substance-using MSM. OBJECTIVES: We examined proportions of substance use as well as SATP availability and use. We used multivariable regression models, controlling for potential confounders, to examine behavioral and demographic correlates of SATP availability and use. METHODS: This is a cross-sectional study of a multi-region, online sample of substance-using MSM. RESULTS: In this sample, 75% were substance-using MSM of whom 36% reported at-least-weekly use. Substance use was most prevalent among respondents from Eastern Europe/Central Asia (86%) and Latin America (79%). Among substance-using MSM, 96% and 33% reported alcohol intoxication and other substance use, respectively; 11% reported having high SATP availability; and 5% reported using SATPs. Controlling for global region of origin and age, high SATP availability was associated with high access to HIV risk-reduction education (aOR = 3.19; CI = 1.48-6.89), mental health services (aOR = 2.53; CI = 1.32-4.83), and medical care (aOR = 2.32; CI = 1.12-4.80); less than college-level education (aOR = 0.32; CI = 0.18-0.54); and higher comfort levels with providers (aOR = 1.75; CI = 1.30-2.37). Controlling for substance use frequency and personal income additionally, using SATPs was associated with higher levels of connection to the gay community (aOR = 2.76; CI = 1.22-6.22). CONCLUSION: In this global sample of MSM, we found high alcohol intoxication and other substance use proportions. Few substance-using MSM report SATP availability, highlighting the need to develop novel substance use programs outside traditional treatment settings.

Reductions in access to HIV prevention and care services are associated with arrest and convictions in a global survey of men who have sex with men.

OBJECTIVES: Men who have sex with men (MSM) are disproportionately impacted by HIV. Criminalisation of homosexuality may impede access to HIV services. We evaluated the effect of the enforcement of laws criminalising homosexuality on access to services. METHODS: Using data from a 2012 global online survey that was published in a prior paper, we conducted a secondary analysis evaluating differences in perceived accessibility to health services (ie, 'how accessible are ____' services) between MSM who responded 'yes'/'no' to: 'have you ever been arrested or convicted for being gay/MSM?' RESULTS: Of the 4020 participants who completed the study and were included in the analysis, 8% reported ever being arrested or convicted under laws relevant to being MSM. Arrests and convictions were most common in sub-Saharan Africa (23.6% (58/246)), Eastern Europe/Central Asia (18.1% (123/680)), the Caribbean (15% (15/100)), Middle East/North Africa (13.2% (10/76)) and Latin America (9.7% (58/599)). Those arrested or convicted had significantly lower access to sexually transmitted infection treatment (adjusted OR (aOR)=0.81; 95% CI 0.67 to 0.97), condoms (aOR=0.77; 95% CI 0.61 to 0.99) and medical care (aOR=0.70; 95% CI 0.54 to 0.90), compared with other MSM, while accounting for clustering by country and adjusting for age, HIV status, education and country-level income. CONCLUSIONS: Arrests and convictions under laws relevant to being MSM have a strong negative association with access to HIV prevention and care services. Creating an enabling legal and policy environment, and increasing efforts to mitigate antihomosexuality stigma to ensure equitable access to HIV services are needed, along with decriminalisation of homosexuality, to effectively address the public health needs of this population.

Syndemic factors associated with adult sexual HIV risk behaviors in a sample of Latino men who have sex with men in New York City.

OBJECTIVE: Syndemic theory has been proposed as a framework for understanding the role of multiple risk factors driving the HIV epidemic among sexual and gender minority individuals. As yet, the framework has been relatively absent in research on Latinos/as. METHODS: We used logistic regression to assess relationships among cumulative syndemic conditions - including clinically significant depression, high-risk alcohol consumption, discrimination, and childhood sexual abuse - engagement with multiple partners and condomless anal intercourse (CAI) in a sample of 176 Latino men who have sex with men (MSM) in New York City. RESULTS: In bivariate analyses, an increase in the number of syndemic factors experienced was associated with an increased likelihood of reporting multiple partners and CAI. In multivariable analyses, participants with 2, 3, and 4 factors were significantly more likely to report multiple partners than those with 0 (aOR=4.66, 95% CI [1.29, 16.85); aOR=7.28, 95% CI [1.94, 27.28] and aOR=8.25, 95% CI [1.74, 39.24] respectively; p<0.05. Regarding CAI, only participants with 3 and 4 factors differed from those with 0 aOR=7.35, 95% CI [1.64, 32.83] and OR=8.06, 95% CI [1.39, 46.73] respectively. CONCLUSIONS: Comprehensive approaches that address syndemic factors, and capitalize on resiliency, are needed to address the sexual health needs of Latino MSM.

Inequities in access to HIV prevention services for transgender men: results of a global survey of men who have sex with men.

INTRODUCTION: Free or low-cost HIV testing, condoms, and lubricants are foundational HIV prevention strategies, yet are often inaccessible for men who have sex with men (MSM). In the global context of stigma and poor healthcare access, transgender (trans) MSM may face additional barriers to HIV prevention services. Drawing on data from a global survey of MSM, we aimed to describe perceived access to prevention services among trans MSM, examine associations between stigma and access, and compare access between trans MSM and cisgender (non-transgender) MSM. METHODS: The 2014 Global Men's Health and Rights online survey was open to MSM (inclusive of trans MSM) from any country and available in seven languages. Baseline data (n=3857) were collected from July to October 2014. Among trans MSM, correlations were calculated between perceived service accessibility and anti-transgender violence, healthcare provider stigma, and discrimination. Using a nested matched-pair study design, trans MSM were matched 4:1 to cisgender MSM on age group, region, and HIV status, and conditional logistic regression models compared perceived access to prevention services by transgender status. RESULTS: About 3.4% of respondents were trans men, of whom 69 were included in the present analysis. The average trans MSM participant was 26 to 35 years old (56.5%); lived in western Europe, North America, or Oceania (75.4%); and reported being HIV-negative (98.6%). HIV testing, condoms, and lubricants were accessible for 43.5, 53.6, and 26.1% of trans MSM, respectively. Ever having been arrested or convicted due to being trans and higher exposure to healthcare provider stigma in the past six months were associated with less access to some prevention services. Compared to matched cisgender controls, trans MSM reported significantly lower odds of perceived access to HIV testing (OR=0.57, 95% CI=0.33, 0.98) and condom-compatible lubricants (OR=0.54, 95% CI=0.30, 0.98). CONCLUSIONS: This first look at access to HIV prevention services for trans MSM globally found that most reported inadequate access to basic prevention services and that they were less likely than cisgender MSM to have access to HIV testing and lubricants. Results indicate the need to enhance access to basic HIV prevention services for trans MSM, including MSM-specific services.

La desesperación in Latino migrant day laborers and its role in alcohol and substance-related sexual risk.

The purpose of this study was to better understand the relation between psychological distress and alcohol and substance related sexual risk in Latino migrant day laborers (LMDLs). In addition to examining the roles of depression and anxiety, it was also necessary to examine the role of desesperación, a popular Latino idiom of distress frequently expressed by LMDLs in response to the thwarting of major migration related life goals such as traveling to the U.S. in search of work to support families, projects and purchases in country of origin. Given the structural vulnerability of LMDLs to under-employment and frequent unemployment, LMDLs also refer to desesperación as a prelude to problem drinking, substance use, and sexual risk taking. Hence we developed and validated a scale of desesperación for LMDLs to explore this culturally relevant construct of psychological distress in this unique population of Latinos. Based on a cross sectional survey of 344 LMDLs, this study found that the dissatisfaction subscale of desesperación predicted alcohol-related sexual risk taking, while depression predicted substance-related sexual risk taking. These findings are discussed including implications of preventing alcohol and substance related sexual risk taking in LMDLs.

Sexual stigma, criminalization, investment, and access to HIV services among men who have sex with men worldwide.

Globally, HIV disproportionately affects men who have sex with men (MSM). This study explored associations between access to HIV services and (1) individual-level perceived sexual stigma; (2) country-level criminalization of homosexuality; and (3) country-level investment in HIV services for MSM. 3,340 MSM completed an online survey assessing access to HIV services. MSM from over 115 countries were categorized according to criminalization of homosexuality policy and investment in HIV services targeting MSM. Lower access to condoms, lubricants, and HIV testing were each associated with greater perceived sexual stigma, existence of homosexuality criminalization policies, and less investment in HIV services. Lower access to HIV treatment was associated with greater perceived sexual stigma and criminalization. Criminalization of homosexuality and low investment in HIV services were both associated with greater perceived sexual stigma. Efforts to prevent and treat HIV among MSM should be coupled with structural interventions to reduce stigma, overturn homosexuality criminalization policies, and increase investment in MSM-specific HIV services.

Structural vulnerability and problem drinking among Latino migrant day laborers in the San Francisco Bay Area.

Latino migrant day laborers (LMDLs) live under challenging conditions in the San Francisco Bay Area. This study explored day laborer alcohol use guided by a structural vulnerability framework, specifically problem vs. non-problem drinking as perceived by LMDLs and how they cope with or try to avoid problem drinking given their broader environment. The study utilized ethnographic methods including in-depth semi-structured qualitative interviews with 51 LMDLs. Findings revealed the considerable challenge of avoiding problem drinking given socio-environmental factors that influence drinking: impoverished living and working conditions, prolonged separation from home and family, lack of work authorization, consequent distress and negative mood states, and peer pressure to drink. While participants shared strategies to avoid problem drinking, the success of individual-level efforts is limited given the harsh structural environmental factors that define day laborers' daily lives. Discussed are implications for prevention and intervention strategies at the individual, community, national and international levels.

"As Good As It Gets": Undocumented Latino Day Laborers Negotiating Discrimination in San Francisco and Berkeley, California, USA.

Undocumented Latino day laborers in the United States are vulnerable to being arrested and expelled at any time. This social fact shapes their everyday lives in terms of actions taken and strategies deployed to mitigate being confronted, profiled, and possibly incarcerated and deported. While perceptions of threat and bouts of discrimination are routine among undocumented Latino day laborers, their specific nature vary according to multiple social factors and structural forces that differ significantly from locale to locale. The experience of discrimination is often tacitly negotiated through perceptions, decisions, and actions toward avoiding or moderating its ill effects. This essay examines urban undocumented Latino day laborers over a variety of sites in the greater San Francisco Bay Area, which, compared to many metropolitan areas in the U.S. is "as good as it gets" in terms of being socially tolerated and relatively safe from persecution. Nonetheless, tacit negotiations are necessary to withstand or overcome challenges presented by idiosyncratic and ever changing global, national/state, and local dynamics of discrimination. [undocumented Latino laborers, social exclusion, discrimination, tacit negotiation].

Characteristics of people who initiate injection drug use later in life.

BACKGROUND: Studies report that among people who inject drugs (PWID), approximately 1 in 7 initiated injection during their thirties or later (referred to hereafter as "late initiates"). However, little is known about individuals who are late initiates. This study aims to describe characteristics of late initiates to drug injection and to examine how they differ from people who initiated drug injection prior to the age of 30 ("typical initiates"). METHODS: We recruited 696 active PWID in Los Angeles and San Francisco, California between 2011 and 2013, using targeted sampling and street outreach methods. Participants completed personal interviews that covered items on demographics, drug use history and practices, injection initiation episode, HIV injection- and sex-related risk, health care utilization among others. We used bivariate and multivariate analyses to examine factors associated being a late initiate. RESULTS: In our sample, 19% of participants who were 30 years or older were classified as late initiates. In multivariate analysis controlling for city, late initiates had higher odds of being female and African American, having been in treatment prior to initiation, initiating illicit drug use at an older age, and being assisted into injection by someone of the same age or younger. Late initiates had lower odds of frequent recent injection, and having a bipolar disorder diagnosis. CONCLUSION: Late initiates comprise a significant proportion of active PWIDs. More study on the health consequences of late initiation are needed as are interventions to prevent transition to drug injection among at-risk populations.

Internalized homophobia and reduced HIV testing among men who have sex with men in China.

Although previous research has examined barriers and facilitators of HIV testing among men who have sex with men (MSM) in China, few studies have focused on social factors, including homophobia and internalized homophobia. This study utilized data from a global online survey to determine correlates of HIV testing as part of a subanalysis focused on Chinese MSM. Controlling for age, HIV knowledge, number of sexual partners, and other covariates, ever having tested for HIV was significantly correlated with lower internalized homophobia. This study suggests that stigma associated with sexual orientation may serve as a barrier to participation in HIV testing and other health-promoting behaviors.