Approaches to Promoting Linkage to and Retention in HIV Care in the United States: a Scoping Review.

PURPOSE OF REVIEW: Linkage to and retention in HIV care, as conceptualized in the HIV care continuum, remain critical steps towards achieving and maintaining viral suppression. We evaluated recently published (Jan 2018-Nov 2020) peer-reviewed clinical trials of linkage to and retention in care outcomes in the United States. RECENT FINDINGS: We identified 12 trials evaluating linkage to and retention in care outcomes in the United States. Most trials did not adhere to standardized definitions or metrics for linkage to or retention in HIV care, hindering comparisons between studies. Four interventions indicated improvements on linkage to or retention in HIV care at follow-up, relying on behavioral incentives and/or case management as key intervention strategies. We recommend the adoption standardize metrics across linkage and retention trials, and the future use of implementation science frameworks to identify implementation facilitators and barriers, and evaluate key strategies associated with improvements in linkage to and retention in care.

mHealth to reduce HIV-related stigma among youth in the United States: a scoping review.

Multiple intersecting stigmas and discrimination related to sex, gender, HIV, and race/ethnicity may challenge HIV prevention and treatment service utilization, particularly among youth. This scoping review describes recent and ongoing innovative mobile health (mHealth) interventions among youth in the United States that aim to reduce stigma as an outcome or as part of the intervention model. To identify examples of stigma-mitigation via mHealth, we searched peer-reviewed published literature using keyword strategies related to mHealth, HIV, stigma, and youth (ages 10 to 29). We identified eleven articles that met our inclusion criteria, including three describing data from two randomized controlled trials (RCTs), five describing pilot studies, one describing the process evaluation of an ongoing intervention, one describing formative work for intervention development, and one published study protocol for an ongoing intervention. We review these articles, grouped by HIV prevention and care continuum stages, and describe the mHealth approach used, including telehealth, simulation video games, motion comics, smartphone applications (apps), social media forums, online video campaigns, video vignettes, and a computerized behavioral learning module. Four studies focused on preventing primary acquisition through individual-level behavior change (e.g., reducing condomless anal intercourse), three focused on increasing HIV testing, three focused on linking to prevention services [e.g., pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP)] and one focused on promoting adherence to antiretroviral therapy (ART). Our review did not identify any published studies using mHealth with a primary aim to reduce stigma as a way to improve care engagement and increase viral suppression among youth in the United States. Additional RCTs and implementation studies examining the effectiveness of mHealth stigma-reduction interventions on HIV-related outcomes are needed to end the HIV epidemic among youth. mHealth offers unique advantages to address the complex intersecting stigma barriers along the HIV continuum to improve HIV-related outcomes for youth.

A Scoping Review of HIV Pre-exposure Prophylaxis Stigma and Implications for Stigma-Reduction Interventions for Men and Transwomen Who Have Sex with Men.

HIV remains a public health concern in the United States. Although pre-exposure prophylaxis (PrEP) can be expected to reduce HIV incidence, its uptake, adherence, and persistence remain limited, particularly among highest priority groups such as men who have sex with men and transwomen (MSMTW). Using a socioecological framework, we conducted a scoping review to examine PrEP-related stigma to inform future research, policy, and programmatic planning. Using the PRISMA extension for scoping reviews, we conducted database searches from August 2018 to April 2020 for articles addressing PrEP stigma. Studies were independently screened and coded by three authors, resulting in thematic categorization of several types of PrEP stigma on four socioecological levels. Of 557 references, a final sample of 23 studies was coded, 61% qualitative, and 87% focusing exclusively on MSMTW. Most instances of PrEP-related stigma occurred on the interpersonal level and included associations of PrEP with risk promotion, HIV-related stigma, and promiscuity. Other frequent themes across socioecological levels included provider distrust and discrimination, government and pharmaceutical industry distrust, internalized homonegativity, PrEP efficacy distrust, and anticipated homonegativity. Notably, PrEP was also framed positively as having physical and psychological benefits, and assuming responsibility for protecting one's community via PrEP awareness-raising. PrEP-related stigma persists, demanding interventions to modify its impact. Leveraging PrEP-positive discourses to challenge PrEP stigma is an emerging avenue, alongside efforts to increase provider willingness to promote PrEP routinely by reducing provider bias, aligning with the national strategy to End the HIV Epidemic.

Increasing HIV Testing and Viral Suppression via Stigma Reduction in a Social Networking Mobile Health Intervention Among Black and Latinx Young Men and Transgender Women Who Have Sex With Men (HealthMpowerment): Protocol for a Randomized Controlled Trial.

BACKGROUND: Stigma and discrimination related to sexuality, race, ethnicity, and HIV status negatively impact HIV testing, engagement in care, and consistent viral suppression (VS) among young Black and Latinx men who have sex with men and transgender women who have sex with men (YBLMT). Few interventions address the effects of intersectional stigma among youth living with HIV and those at risk for HIV within the same virtual space. OBJECTIVE: Building on the success of the HealthMpowerment (HMP) mobile health (mHealth) intervention (HMP 1.0) and with the input of a youth advisory board, HMP 2.0 is an app-based intervention that promotes user-generated content and social support to reduce intersectional stigma and improve HIV-related outcomes among YBLMT. The primary objective of this study is to test whether participants randomized to HMP 2.0 report improvement in HIV prevention and care continuum outcomes compared with an information-only control arm. We will also explore whether participant engagement, as measured by paradata (data collected as users interact with an mHealth intervention, eg, time spent using the intervention), mediates stigma- and HIV care-related outcomes. Finally, we will assess whether changes in intersectional stigma and improvements in HIV care continuum outcomes vary across different types of social networks formed within the intervention study arms. METHODS: We will enroll 1050 YBLMT aged 15 to 29 years affected by HIV across the United States. Using an HIV-status stratified, randomized trial design, participants will be randomly assigned to 1 of the 3 app-based conditions (information-only app-based control arm, a researcher-created network arm of HMP 2.0, or a peer-referred network arm of HMP 2.0). Behavioral assessments will occur at baseline, 3, 6, 9, and 12 months. For participants living with HIV, self-collected biomarkers (viral load) are scheduled for baseline, 6, and 12 months. For HIV-negative participants, up to 3 HIV self-testing kits will be available during the study period. RESULTS: Research activities began in September 2018 and are ongoing. The University of Pennsylvania is the central institutional review board for this study (protocol #829805) with institutional reliance agreements with the University of North Carolina at Chapel Hill, Duke University, and SUNY Downstate Health Sciences University. Study recruitment began on July 20, 2020. A total of 205 participants have been enrolled as of November 20, 2020. CONCLUSIONS: Among a large sample of US-based YBLMT, this study will assess whether HMP 2.0, an app-based intervention designed to ameliorate stigma and its negative sequelae, can increase routine HIV testing among HIV-negative participants and consistent VS among participants living with HIV. If efficacious and brought to scale, this intervention has the potential to significantly impact the disproportionate burden of HIV among YBLMT in the United States. TRIAL REGISTRATION: ClinicalTrials.gov NCT03678181; https://clinicaltrials.gov/ct2/show/study/NCT03678181. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/24043.

Online sex partner seeking and HIV testing frequency among young Black sexual minority men.

Dating apps are a novel means of delivering HIV prevention messages. Young black sexual minority men (YBSMM) app users are at high risk for HIV and could benefit from frequent testing. Understanding testing behaviors among YBSMM is critical to inform tailored prevention interventions. We analyzed testing behaviors of 273 YBSMM, comparing typical testing frequency between app users and non-users using odds ratios. Overall, testing rates were high. App users were more likely than non-users to test at least every 12 months. App-using YBSMM exhibit high compliance with testing guidelines, which may indicate future successful uptake of biomedical preventions, such as Pre-Exposure Prophylaxis.

Stigma and Mobile App Use Among Young Black Men Who Have Sex With Men.

Young black men who have sex with men (YBMSM) are disproportionately affected by HIV. Intersectional stigmas are associated with increased HIV vulnerability, and worse outcomes for YBMSM with HIV. YBMSM find sex partners through sexual networking apps, but stigma on apps has been poorly studied. We conducted cross-sectional analysis of 324 YBMSM seeking sex partners through apps to assess stigma experiences in eight dimensions compared to non-users (N = 150). We conducted detailed stratified analyses to identify granular stigma data. App users had higher median scores than non-users in perceived HIV discrimination, perceived HIV stigma, experienced sexual minority stigma, racial discrimination, and perceived homophobia. We demonstrate higher levels of intersectional stigmas among app users than non-users, but did not find an overall increase in stigma with increasing app use. Considering the prominent role of apps in YBMSM sexual networking, interventions that reduce stigma on apps are needed.

Feasibility of using GrindrTM to distribute HIV self-test kits to men who have sex with men in Los Angeles, California.

Background: Our study aimed to determine if Grindr™ is an effective means of reaching high-risk men who have sex with men (MSM) for HIV testing. In Los Angeles (LA), Black and Latino MSM have the highest rate of HIV infection, and Black MSM in LA are four-fold more likely than white MSM to not know they are infected with HIV. Those MSM are also major users of social networking apps. Grindr™ was used to provide access to free HIV self-testing. Methods: Free HIV self-test kits were advertised on Grindr™ from 13 October to 11 November 2014, consisting of 300 000 banner ads and three broadcast messages targeting a high-risk HIV population in LA. Eligible participants, Black or Latino, MSM and who were aged ≥18 years of age, were invited to take a survey 2 weeks after test delivery. Results: The website received 4389 unique visitors and 333 test requests, of which 247 (74%) were requests for mailed tests, 58 (17%) were for vouchers and 28 (8%) were for vending machines. Of the 125 participants, 74% reported at least one episode of condomless anal intercourse in the past 3 months, 29% last tested for HIV over 1 year ago and 9% had never been tested. Conclusions: It was feasible to use Grindr™ to distribute HIV self-test kits. Users are willing to provide personal information in exchange for a free self-test and found self-tests acceptable and easy to use. HIV self-testing promotion through apps has a high potential to reach untested high-risk populations.