ABSTRACT
People who inject drugs (PWID) are at an increased risk of multimorbid mental health and chronic diseases, which are frequently underdiagnosed and under-treated due to systemic barriers and ongoing substance use. Healthcare engagement is essential to address these conditions and prevent excess morbidity and mortality. The goal of this study was to understand how PWID engage in care for their chronic health conditions and substance use treatment given the known historic and pervasive barriers. We conducted 24 semistructured qualitative interviews informed by the Behavioral Model for Vulnerable Populations between July-September 2019. Participants were sampled across a range of comorbidities, including co-occurring mental health disorders. Thematic analysis was conducted to explore experiences of healthcare engagement for multimorbid chronic diseases, mental health, and treatment for substance use disorder. Mean age for participants was 58 years; 63% reported male sex and 83% reported Black race. Interviews yielded themes regarding healthcare access and wraparound services, positive patient-provider relationships, service integration for substance use treatment and mental health, healthcare needs alignment, medication of opioid use disorder stigma, and acceptance of healthcare. Taken together, participants described how these themes enabled healthcare engagement. Engagement in care is crucial to support health and recovery. Clinical implications include the importance of strengthening patient-provider relationships, encouraging integration of medical and mental health services, and counseling on substance use treatment options in a non- stigmatizing manner. Additionally, policy to reimburse wrap-around support for substance use recovery can improve care engagement and outcomes related to chronic diseases, mental health, and substance use among PWID. No Patient or Public Contribution: While we acknowledge and thank ALIVE participants for their time for data collection and sharing their perspectives, no ALIVE participants, other people who use drugs, and service users were involved in data collection, analysis or interpretation of data, or in preparation of the manuscript.
Subject(s)
Drug Users , Substance Abuse, Intravenous , Humans , Male , Middle Aged , Substance Abuse, Intravenous/psychology , Drug Users/psychology , Patient Acceptance of Health Care/psychology , Health Services Accessibility , Chronic DiseaseABSTRACT
AIM: To identify attitudes towards HIV/STI screening guidelines and explore the acceptability of assessing sexual positioning practices among Black sexual minority men (SMM). BACKGROUND: Risks for HIV/STIs vary by sexual positioning practices. However, clinicians and Black SMM do not always discuss sexuality with each other. Therefore, HIV/STI screening and testing remain suboptimal. DESIGN: Qualitative study using focus groups. METHODS: Data were obtained from 12 focus groups and one in-depth interview conducted in Baltimore, MD among HIV-negative Black SMM between October 2019 and May 2020 (N = 39). Groups were stratified into three age categories: 18-24, 25-34 and 35+. Participants were given the "5 P's" from the CDC's 2015 Sexual History Screening Guidelines and asked to discuss attitudes towards existing questions regarding sexual positioning practices. Themes were identified using an electronic pile sorting approach. RESULTS: Most identified as homosexual/gay/same gender-loving (68%), were employed (69%) and single (66%). Additionally, 34% had ever been diagnosed with an STI, of whom 38% had a history of repeated STI acquisition in their lifetime. Participants across age groups said clinicians should use the words "top" and "bottom" to demonstrate cultural familiarity and build trust. Some said that screening for sexual positioning was unnecessary and intrusive; others said that questions should be justified. Younger men wanted clinicians to ask questions in ways that make them feel cared for. DISCUSSION: Guidelines should include language for clinicians to use culturally specific language and better ways to prepare Black SMM patients for screening. IMPACT TO NURSING PRACTICE: Some Black SMM will not discuss sexual positioning practices without clinicians' demonstration of cultural understanding and respect. Screening should incorporate culturally responsive language, justification and convey care. REPORTING METHOD: Consolidated criteria for reporting qualitative research (COREQ). NO PATIENT OR PUBLIC CONTRIBUTION: There was no patient or public involvement in the design or drafting of this discursive paper.
Subject(s)
Black or African American , Focus Groups , Sexual and Gender Minorities , Sexually Transmitted Diseases , Adolescent , Adult , Humans , Male , Young Adult , Baltimore , Black or African American/psychology , Black or African American/statistics & numerical data , Mass Screening/methods , Patient Acceptance of Health Care/psychology , Patient Acceptance of Health Care/ethnology , Practice Guidelines as Topic , Qualitative Research , Sexual and Gender Minorities/psychology , Sexual Behavior/psychology , Sexually Transmitted Diseases/diagnosis , Sexually Transmitted Diseases/prevention & controlABSTRACT
PURPOSE: Adjuvant endocrine therapy (AET) increases sexual health challenges for women with early-stage breast cancer. Black women are more likely than women of other racial/ethnic groups to report adverse symptoms and least likely to initiate and maintain AET. Little is known about how sexual health challenges influence patient-clinician communication and treatment adherence. This study explores facilitators of and barriers to patient-clinician communication about sexual health and how those factors might affect AET adherence among Black women with early-stage breast cancer. METHODS: We conducted 32 semi-structured, in-depth interviews among Black women with early-stage breast cancer in the U.S. Mid-South region. Participants completed an online questionnaire prior to interviews. Data were analyzed using thematic analysis. RESULTS: Participants' median age was 59 (range 40-78 years, SD = 9.0). Adverse sexual symptoms hindered participants' AET adherence. Facilitators of patient-clinician communication about sexual health included female clinicians and peer support. Barriers included perceptions of male oncologists' disinterest in Black women's sexual health, perceptions of male oncologists' biased beliefs about sexual activity among older Black women, cultural norms of sexual silence among Southern Black women, and medical mistrust. CONCLUSIONS: Adverse sexual symptoms and poor patient-clinician communication about sexual health contribute to lower AET adherence among Black women with early-stage breast cancer. New interventions using peer support models and female clinicians trained to discuss sexual health could ameliorate communication barriers and improve treatment adherence. IMPLICATIONS FOR CANCER SURVIVORS: Black women with early-stage breast cancer in the U.S. Mid-South may require additional resources to address sociocultural and psychosocial implications of cancer survivorship to enable candid discussions with oncologists.
ABSTRACT
Despite evidence that pre-exposure prophylaxis (PrEP) reduces HIV risk, initiation and adherence remain low among vulnerable communities. Motivational interviewing (MI) can improve HIV prevention behaviors. However, limited research identifies how MI impacts PrEP uptake and adherence. This scoping review examines essential components of MI-based interventions that aimed to improve PrEP use, including the number and duration of sessions, counselor characteristics, and interview content. We searched four databases, PubMed, CINAHL Plus, Embase, and Web of Science, and reviewed 379 articles. Studies were considered if they (a) were published between 2012 and 2023, (b) used MI independently or part of a multi-component intervention strategy, and (c) focused on improving PrEP initiation or adherence. Seven articles met inclusion criteria. Regarding intervention components, the number of MI sessions varied and duration ranged between 15 and 60 min. MI counselors varied in credentialing and demographic characteristics. MI content included PrEP education, identifying initiation and adherence barriers, and strategizing ways to overcome barriers. MI is an important component of interventions that aim to improve PrEP initiation and adherence. However, the variability and limited details across studies hinder our ability to assess MI efficacy on PrEP initiation and adherence or replicate these approaches in future interventions.
Subject(s)
Acquired Immunodeficiency Syndrome , HIV Infections , Motivational Interviewing , Pre-Exposure Prophylaxis , Humans , Male , HIV Infections/prevention & control , Cognition , Homosexuality, MaleABSTRACT
HIV pre-exposure prophylaxis (PrEP) use remains suboptimal among Black gay and bisexual men (GBM). Multilevel factors such as medication costs, intersectional stigma, patient-clinician communication, medical mistrust, side effect concerns, and low perceived HIV risk (PHR) are well-established PrEP initiation barriers for this group. Peer change agents (PCAs) are culturally congruent interventionists who can circumvent multilevel PrEP barriers among Black GBM. I led an intervention as a PrEP-using PCA to improve PHR and PrEP willingness among 69 Black GBM from 2019-2022 and conducted an autoethnography to better understand multilevel barriers and identify the personal/professional challenges of being an in-group HIV interventionist serving Black SMM. Findings provide novel perspectives regarding PrEP barriers, the role of cultural homophily in behavior change interventions, and how interpersonal dynamics can impact staff fatigue, protocol fidelity, and research participation. Recommendations to prepare and support culturally congruent research staff are also provided.
Subject(s)
HIV Infections , Pre-Exposure Prophylaxis , Sexual and Gender Minorities , Male , Humans , Homosexuality, Male , Trust , HIV Infections/prevention & control , Bisexuality , Pre-Exposure Prophylaxis/methodsABSTRACT
Racial and sexuality-based discrimination can induce depressive symptoms among Black sexual minority men and transgender women (BSMM/BTW). BSMM and BTW who disclose their sexuality to parents may be better prepared to cope with discrimination. We explored the relationship between discrimination and depression among BSMM and BTW and whether parental disclosure modified this relationship. Secondary analysis of The MARI Study was used to test the relationship between discrimination and depression modified by level of disclosure of sexuality to parents among 580 BSMM and BTW in Jackson, Mississippi, and Atlanta, Georgia. Bivariate tests and linear regression models were stratified by sexuality disclosure to parents. Discrimination was associated with greater depression, with significant dose-response modification across levels of disclosure. After adjustment, maximum discrimination scores were associated with depression scores 10.7 units higher among participants with very open disclosure (95% CI, 10.4-11.8), 15.3 units higher among participants with somewhat open disclosure (95% CI, 3.7-26.9), and 19.5 units higher among participants with no disclosure (95% CI, 10.2-26.8). Disclosure of sexuality to supportive parents can substantially benefit the mental health of BSMM and BTW. Future studies should explore intervention approaches to providing social support for BSMM and BTW in unsupportive families.
Subject(s)
Depression , Sexual and Gender Minorities , Transgender Persons , Female , Humans , Male , Black or African American , Depression/epidemiology , Parents , Sexual and Gender Minorities/psychology , Sexuality , Transgender Persons/psychology , Self Disclosure , Social Discrimination , Family SupportABSTRACT
This study qualitatively explores HIV-related gossip as both a manifestation and driver of HIV-related stigma, which is a known barrier to HIV testing and treatment in Botswana. Data were elicited from 5 focus group discussions and 46 semi-structured in-depth interviews with individuals living with HIV and community members with undisclosed serostatus in Gaborone, Botswana in 2017 (n = 84). Directed content analysis using the 'What Matters Most' theoretical framework identified culturally salient manifestations of HIV-related stigma; simultaneous use of Modified Labeling Theory allowed interpretation and stepwise organization of how the social phenomenon of gossip leads to adverse HIV outcomes. Results indicated that HIV-related gossip can diminish community standing through culturally influenced mechanisms, in turn precipitating poor psychosocial well-being and worsened HIV-related outcomes. These harms may be offset by protective factors, such as appearing healthy, accepting one's HIV status, and community education about the harms of gossip.
Subject(s)
HIV Infections , Stereotyping , Humans , HIV Infections/psychology , Botswana , Social Stigma , HospitalsABSTRACT
Mental health problems (e.g., anxiety, depression) are frequently experienced by adolescents living with HIV (ALWH) and can worsen HIV-related outcomes. This scoping review synthesizes the existing research on ALWHs' mental health problems at multiple steps along the HIV care continuum in sub-Saharan Africa. Searching PubMed, CINAHL, EMBASE, and PsycINFO identified 34 peer-reviewed studies that met inclusion criteria. Most studies assessed ALWHs' mental health problems at the "Engaged or Retained in Care" continuum step, are cross-sectional, focus on depression and anxiety, and used measures developed in high-income countries. Studies identify mental health problems among ALWH as prevalent and barriers to care. Significant gaps remain in understanding how mental health problems and their relationships with HIV-related health outcomes shift across the continuum. Additional attention is needed, especially at the HIV testing and viral suppression steps, to generate a more comprehensive understanding of mental health needs and priority timepoints for intervention for ALWH.
Subject(s)
HIV Infections , Humans , Adolescent , HIV Infections/epidemiology , HIV Infections/psychology , Mental Health , Cross-Sectional Studies , Africa South of the Sahara/epidemiology , Continuity of Patient CareABSTRACT
INTRODUCTION: People who inject drugs (PWID) have a greater burden of multimorbid chronic diseases than the general population. However, little attention has been paid to the engagement in primary care for services related specifically to injection drug use and management of underlying chronic comorbid diseases for this population. This systematic review identified facilitators and barriers to healthcare engagement in the primary care setting among PWID. DESIGN AND METHODS: Studies were identified by a literature search of PubMed, CINAHL, and EMBASE, and by searching the references of retrieved articles. Studies were included if they measured active injection drug use, and outcomes related to primary care engagement characterized by: diagnosis of a health condition, linkage or retention in care, health condition-related outcomes, and reported patient-provider relationship. RESULTS: Twenty-three articles were included. Using the behavioral model, factors within predisposing, enabling, need, and health behavior domains were identified. Having co-located services and a positive patient-provider relationship were among the strongest factors associated with healthcare utilization and engagement while active injection drug use was associated with decreased engagement. CONCLUSIONS: To our knowledge, this is the only review of evidence that has examined factors related to primary care engagement for people who inject drugs. Most articles were observational studies utilizing descriptive designs. Although the assessment of the evidence was primarily rated 'Good', this review identifies a significant need to improve our understanding of primary care engagement for PWID. Future research and intervention strategies should consider these findings to better integrate the holistic care needs of PWID into primary care to reduce morbidity and mortality associated with injection drug use and chronic disease. CLINICAL RELEVANCE: Primary care engagement is important for preventative care, early diagnosis of disease, and management of chronic diseases, including addressing problems of substance use. This review highlights factors nurses can utilize to facilitate primary care engagement of PWID.
Subject(s)
Drug Users , HIV Infections , Substance Abuse, Intravenous , Humans , Substance Abuse, Intravenous/complications , Substance Abuse, Intravenous/epidemiology , Delivery of Health Care , Primary Health Care , Chronic DiseaseABSTRACT
This special edition of JLME centers on a novel proposal for a national PrEP access program with the potential to break through a failed status quo.
Subject(s)
HIV Infections , Pre-Exposure Prophylaxis , HIV Infections/prevention & control , HumansABSTRACT
Inequities in HIV pre-exposure prophylaxis (PrEP) use persist in the United States. Although scientific advancement in delivery options and social acceptance of PrEP has occurred in the past decade, gaps remain in ensuring that this sexual health program is available to all. Components of what a national PrEP program for all would look like are discussed.
Subject(s)
Anti-HIV Agents , HIV Infections , Pre-Exposure Prophylaxis , Anti-HIV Agents/therapeutic use , HIV Infections/prevention & control , Humans , Sexual Behavior , United StatesABSTRACT
The U.S. has the tools to end the HIV epidemic, but progress has stagnated. A major gap in U.S. efforts to address HIV is the under-utilization of medications that can virtually eliminate acquisition of the virus, known as pre-exposure prophylaxis (PrEP). This document proposes a financing and delivery system to unlock broad access to PrEP for those most vulnerable to HIV acquisition and bring an end to the HIV epidemic.
Subject(s)
Epidemics , HIV Infections , Pre-Exposure Prophylaxis , HIV Infections/epidemiology , HIV Infections/prevention & control , HumansABSTRACT
PURPOSE: Few studies have captured the multidimensionality of pregnancy intentions for adolescents on a national level, particularly missing the perspectives of male adolescents. Therefore, this study aimed to identify and describe pregnancy intention profiles among U.S. adolescents. METHODS: Latent class analysis was conducted using data from two cycles of the National Survey of Family Growth (2015-2017 and 2017-2019) among U.S. adolescents 15-19 years old (N = 3,812). Stratified by sex, six National Survey of Family Growth indicators around desires, feeling, timing, and social acceptability were included. Multinomial logistic regression was used to identify the correlates of class membership. RESULTS: Three latent classes of pregnancy intention were identified for each sex, which were distinguished by immediate and future desires, feelings, timing, and social acceptability. For both females and males, Delayed Pro-pregnancy (53% vs. 82%) and Near Pro-pregnancy (28% vs. 8%) were identified. Ambivalent-pregnancy (14%) and Anti-pregnancy (10%) were specific to females and males, respectively. Near Pro-pregnancy females and Anti-pregnancy males were more likely to be sexually active, older, of Hispanic descent, report receiving public assistance, and have a teen mother than adolescents classified as Delayed Pro-pregnancy. Females with a pregnancy history were more likely to be classified as Ambivalent than Delayed Pro-pregnancy. DISCUSSION: While most adolescents intend to delay or avoid childbearing, there are subsets of adolescents whose pregnancy intentions are in favor of early childbearing, which is often dismissed in adolescent sexual and reproductive health. Current efforts can use these distinct pregnancy intention classes to tailor sexual and reproductive health services specifically for diverse adolescent populations.
Subject(s)
Adolescent Behavior , Reproductive Health Services , Adolescent , Adult , Female , Hispanic or Latino , Humans , Intention , Male , Sexual Behavior , Young AdultABSTRACT
BACKGROUND: Aging people who inject drugs (PWID) have complex health needs. Health care management could be complicated by persistent substance use, multiple health challenges, and inconsistent access to care. However, we know little about the relationship between chronic multimorbidity and health care engagement in this population. The purpose of this study is to characterize patterns and correlates of chronic disease multimorbidity among PWID. METHODS: We conducted a latent class analysis (LCA) using data from the AIDS Linked to the IntraVenous Experience (ALIVE) Study, a community-based observational cohort, to determine classes of multimorbid chronic diseases. We then conducted regressions to determine factors associated with class membership and the impact of each multimorbid class on health events and utilization. RESULTS: Of 1387 individuals included, the majority were male (67%) and Black (81%), with a mean age of 53 years. We identified four classes of multimorbidity: Low Multimorbidity (54%), and Low Multimorbidity Including Psychiatric Comorbidity (26%), Multimorbidity (12%), and Multimorbidity Including Psychiatric Comorbidity (7%). Female sex, baseline age, and receipt of disability were factors significantly associated with membership in all three classes compared to the Low Multimorbidity class. Additionally, PWID in these three classes were significantly more likely to utilize emergency room and outpatient health care. Membership in both classes with psychiatric comorbidity was associated with significantly higher adjusted odds of receiving medication for opioid use disorder. DISCUSSION: Holistic health care systems can best address the needs of aging PWID with integrated care that provides harm reduction, substance use and mental health treatment together, and wrap around services.
Subject(s)
Drug Users , Opioid-Related Disorders , Substance Abuse, Intravenous , Chronic Disease , Delivery of Health Care , Female , Humans , Male , Middle Aged , Multimorbidity , Substance Abuse, Intravenous/epidemiology , Substance Abuse, Intravenous/psychologyABSTRACT
Black sexual minority men (BSMM) are substantially less likely than White SMM to accept a clinician's recommendation to initiate HIV pre-exposure prophylaxis (PrEP). The purpose of this study is to identify PrEP messaging preferences among BSMM. Data were obtained from 12 focus groups and one in-depth interview among BSMM in Baltimore, MD (N = 39). Focus groups were stratified (18-24, 25-34, and 35 and older), and facilitators probed on ways clinicians could discuss PrEP with BSMM. An adapted pile sorting approach was used to identify themes. Most identified as homosexual, gay, or same-gender-loving (68%), were employed (69%), and single (66%). Thematic analysis revealed that BSMM wanted clinicians to explain PrEP efficacy and side effects, tailor messaging, provide prevention messaging with care, and disclose PrEP use. Clinicians could increase uptake and adherence among BSMM by implementing PrEP communication preferences. Discussing PrEP efficacy and safety is also necessary. When possible, clinicians should disclose PrEP use history to build trust.
Subject(s)
Anti-HIV Agents , HIV Infections , Pre-Exposure Prophylaxis , Sexual and Gender Minorities , Anti-HIV Agents/therapeutic use , Communication , HIV Infections/prevention & control , Homosexuality, Male , Humans , Male , MenSubject(s)
Diketopiperazines/therapeutic use , HIV Infections/prevention & control , HIV Integrase Inhibitors/therapeutic use , Pyridones/therapeutic use , Costs and Cost Analysis , Diketopiperazines/economics , HIV Integrase Inhibitors/economics , Health Equity , Health Services Accessibility , Humans , Pyridones/economicsABSTRACT
PURPOSE: This study explored potentially underreported healthcare contexts, clinical experiences, and motivations for adherence in care among virally suppressed Black sexual minority men (BSMM) living with HIV (LWHIV) in Baltimore, MD. METHODS: Go-alongs with two virally suppressed BSMM LWHIV supplemented 27 in-depth interviews of a larger qualitative study guided by Positive Deviance and Life Course Theory. The go-alongs involved accompanying participants' follow-up HIV care visit to obtain a better account of contextual healthcare factors. Observations focused on (1) clinic location and resources, (2) sources of HIV and sexuality stigma or support in the clinic, and (3) patient-provider interactions. RESULTS: We found that facilitators and barriers to viral suppression for BSMM LWHIV included structural factors (i.e., healthcare setting, facility, and services), quality of patient-provider interactions, and personal motivations to achieve viral suppression. CONCLUSION: Clinic accessibility, co-located clinical services, and rapport with clinicians and healthcare staff could be key contextual conditions that facilitate retention in care among BSMM LWHIV.
Subject(s)
HIV Infections , Sexual and Gender Minorities , Follow-Up Studies , Humans , Male , Sexual Behavior , Social StigmaABSTRACT
ABSTRACT: The goals and strategies of Black sexual minority men living with HIV (BSMMLWH) who achieve viral suppression require further investigation. This study explored treatment adherence strategies among BSMMLWH with sustained viral suppression. We conducted 27 in-depth qualitative interviews with BSMMLWH in Baltimore, Maryland, and Los Angeles, California, between December 2018 and May 2019. Interviews included questions guided by Positive Deviance and Life Course theoretical frameworks regarding multilevel factors and explicit strategies for antiretroviral therapy adherence. Themes regarding intentional, age group-specific strategies such as using technology (among younger men) and taking HIV medications with other daily pills (among older men) were identified. Participants also reported symbiotic goals and values that encouraged adherence, such as having a desire to live, strong familial relationships with clinicians, and support networks. Identifying personal goals and having supportive clinical and social relationships could be key to improving treatment adherence and viral suppression among BSMMLWH.
Subject(s)
HIV Infections , Sexual and Gender Minorities , Aged , Baltimore , HIV Infections/drug therapy , Humans , Los Angeles , Male , Medication Adherence , Treatment Adherence and ComplianceABSTRACT
HIV pre-exposure prophylaxis (PrEP) remains underutilized in the U.S. Since greater than 85% of PrEP prescriptions are filled at commercial pharmacies, pharmacists are uniquely positioned to increase PrEP use. This scoping review explores pharmacy-based initiatives to increase PrEP use. We searched PubMed, PsycINFO, CINAHL, and Scopus for peer-reviewed studies on pharmacist-led interventions to increase PrEP use or pharmacy-based PrEP initiatives. Forty-nine articles were included in this review. Overall, studies demonstrated that patients expressed strong support for pharmacist prescription of PrEP. Three intervention designs compared changes in PrEP initiation or knowledge pre- and post-intervention. Commentary/review studies recommended PrEP training for pharmacists, policy changes to support pharmacist screening for HIV and PrEP prescription, and telemedicine to increase prescriptions. Pharmacists could play key roles in improving PrEP use in the U.S. Studies that assess improvements in PrEP use after interventions such as PrEP prescription, PrEP-specific training, and adherence monitoring by pharmacists are needed.
Subject(s)
Anti-HIV Agents , HIV Infections , Pharmacies , Pharmacy , Pre-Exposure Prophylaxis , Anti-HIV Agents/therapeutic use , HIV Infections/drug therapy , HIV Infections/prevention & control , Humans , Pharmacists , United States/epidemiologyABSTRACT
Black gay, bisexual, and other Black sexual minority men (BSMM) continue to experience some of the largest sexual health disparities in the U.S. Engaging BSMM in PrEP is crucial to improving sexual health outcomes and reducing disparities. However, knowledge of the profiles of sexual risk and PrEP initiation among this group is limited. This study used latent class analysis toâ¯identify HIV risk andâ¯PrEPâ¯initiation patterns among BSMM in the HPTN 073 Study (n = 226). Guided by current Centers for Disease Control screening guidelines, latent class indicators included relationship status, condom use, number of sexual partners, substance use, sexually transmitted infection (STI) history, and partner HIV status. Age and PrEP initiation were used in a multinomial regression to identify correlates of class membership. Three latent classes were identified: Single, Condomless Partners, Single, Multiple Partners, and Serodiscordant Partners. Single, Condomless Partners had the highest conditional probabilities of having greater than three male partners, substance use before sex, and receiving an STI diagnosis. Serodiscordant Partners had a 100% conditional probability of condomless sex and having a male partner living with HIV. BSMM who initiated PrEP were less likely to be classified as Single, Condomless Partners than Serodiscordant Partners (AOR = 0.07, 95% CI = 0.02, 0.66). Findings support the need for culturally relevant tailored and targeted messaging for BSMM with multiple sexual risk indicators.