Development and Validation of Two Abbreviated Intraminority Gay Community Stress Scales.

Social stressors stemming from within the gay community might render gay and bisexual men vulnerable to mental health problems. The 20-item intraminority Gay Community Stress Scale (GCSS) is a reliable measure of gay community stress, but the scale's length limits its widespread use in sexual minority mental health research. Using three independent samples of gay and bisexual men, the present research developed two abbreviated versions of the GCSS using nonparametric item response modeling and validated them. Results indicated that eight items provided maximal information about the gay community stress construct; these items were selected to form the eight-item GCSS. The eight-item GCSS reproduced the factor structure of the parent scale, and gay community stress scores obtained from it correlated with other identity-specific social stress constructs and mental health symptoms. Associations between gay community stress and mental health symptoms remained significant even after controlling for related identity-specific stressors, general life stress, and relevant demographics. A four-item version was also developed and assessed, showing good structural, convergent, criterion, and incremental validity and adequate reliability. The eight- and four-item versions of the GCSS offer efficient measures of gay community stress, an increasingly recognized source of stress for gay and bisexual men.

Individual, Interpersonal, and Structural Factors That Influence Intentions to Use Pre-exposure Prophylaxis Among Sexual Minority Men in Miami.

Pre-exposure prophylaxis for HIV or "PrEP" holds great promise for reducing HIV incidence. However, in certain geographic settings, like Miami, a US HIV epicenter, uptake of PrEP has been paradoxically very low compared to other areas of the country. The goal of the current study was to examine factors associated with low uptake of PrEP in young sexual minority men in Miami. Qualitative data were extracted from conversations during voluntary HIV/STI counseling and testing sessions with 24 young sexual minority men, most of whom identified as racial/ethnic minorities. These sessions were completed as part of a baseline visit for a combined mental and sexual health intervention trial. Thematic analysis of transcripts revealed barriers and facilitators associated with PrEP uptake at multiple levels (individual, interpersonal, and economic and healthcare systems barriers). Individual-level themes included concerns about the safety of PrEP, risk compensation, and taking daily oral medication; and potential benefits of PrEP as a backup plan to condom use to reassure and reduce worry about HIV. Interpersonal-level themes included lack of knowledgeable and affirming medical providers, changing norms within the community around "safe sex," and PrEP use in serodiscordant partnerships. Economic and healthcare systems barriers included challenges to accessing PrEP because of a lack of insurance and high out-of-pocket cost. These data can be used to inform the development of interventions aligned with Ending the HIV Epidemic priorities to increase PrEP use among young sexual minority men living in an HIV epicenter.

Longitudinal Associations of Syndemic Conditions with Antiretroviral Therapy Adherence and HIV Viral Suppression Among HIV-Infected Patients in Primary Care.

Psychosocial syndemic conditions have received more attention regarding their deleterious effects on HIV acquisition risk than for their potential impact on HIV treatment and viral suppression. To examine syndemic conditions' impact on the HIV care continuum, we analyzed data collected from people living with HIV (N = 14,261) receiving care through The Centers for AIDS Research Network of Integrated Clinical Systems at seven sites from 2007 to 2017 who provided patient-reported outcomes ∼4-6 months apart. Syndemic condition count (depression, anxiety, substance use, and hazardous drinking), sexual risk group, and time in care were modeled to predict antiretroviral therapy (ART) adherence and viral suppression (HIV RNA <400 copies/mL) using multilevel logistic regression. Comparing patients with each other, odds of ART adherence were 61.6% lower per between-patient syndemic condition [adjusted odds ratio (AOR) = 0.384; 95% confidence interval (CI), 0.362-0.408]; comparing patients with themselves, odds of ART adherence were 36.4% lower per within-patient syndemic condition (AOR = 0.636 95% CI, 0.606-0.667). Odds of viral suppression were 29.3% lower per between-patient syndemic condition (AOR = 0.707; 95% CI, 0.644-0.778) and 27.7% lower per within-patient syndemic condition (AOR = 0.723; 95% CI, 0.671-0.780). Controlling for the effects of adherence (AOR = 5.522; 95% CI, 4.67-6.53), each additional clinic visit was associated with 1.296 times higher odds of viral suppression (AOR = 1.296; 95% CI, 1.22-1.38), but syndemic conditions were not significant. Deploying effective interventions within clinics to identify and treat syndemic conditions and bolster ART adherence and continued engagement in care can help control the HIV epidemic, even within academic medical settings in the era of increasingly potent ART.

Scaling Up and Out HIV Prevention and Behavioral Health Services to Latino Sexual Minority Men in South Florida: Multi-Level Implementation Barriers, Facilitators, and Strategies.

Latino sexual minority men (LSMM) are disproportionately affected by HIV in the United States. Concurrently, behavioral health disparities, including mental health and substance use concerns, worsen HIV disparities affecting LSMM. Yet, evidence-based HIV prevention and behavioral health services are insufficiently scaled up and out to this population, perpetuating health disparities, thwarting efforts to control the HIV epidemic, and highlighting the need for culturally relevant evidence-based implementation strategies that address these disparities. Participants included 28 LSMM with varying degrees of engagement in HIV prevention and behavioral health services, and 10 stakeholders with experience delivering HIV prevention and behavioral health services to LSMM in South Florida, an HIV epicenter in general and in particular for LSMM. Participants completed semistructured interviews (English/Spanish) regarding LSMM's barriers and facilitators to engaging in HIV prevention and behavioral health services. Interviews were audio recorded and analyzed using thematic analysis. The 16 themes that emerged from the qualitative analysis were consistent with the consolidated framework for implementation research, an implementation research framework that articulates barriers and facilitators to implementing clinical interventions. Findings suggested the need for implementation strategies that simplify and reduce costs of HIV prevention and behavioral health services, address syndemic challenges impacting service use among LSMM, reduce stigma about service utilization, leverage peer networks, increase provider and community knowledge about services, and build LSMM's readiness and motivation to engage in services. Such strategies may ultimately address HIV and behavioral health disparities among LSMM and facilitate achievement of ending the HIV epidemic goals in this disproportionally affected population.

Estimating HIV transmissions in a large U.S. clinic-based sample: effects of time and syndemic conditions.

INTRODUCTION: Little is known about onward HIV transmissions from people living with HIV (PLWH) in care. Antiretroviral therapy (ART) has increased in potency, and treatment as prevention (TasP) is an important component of ending the epidemic. Syndemic theory has informed modelling of HIV risk but has yet to inform modelling of HIV transmissions. METHODS: Data were from 61,198 primary HIV care visits for 14,261 PLWH receiving care through the Centers for AIDS Research (CFAR) Network of Integrated Clinical Systems (CNICS) at seven United States (U.S.) sites from 2007 to 2017. Patient-reported outcomes and measures (PROs) of syndemic conditions - depressive symptoms, anxiety symptoms, drug use (opiates, amphetamines, crack/cocaine) and alcohol use - were collected approximately four to six months apart along with sexual behaviours (mean = 4.3 observations). Counts of syndemic conditions, HIV sexual risk group and time in care were modelled to predict estimated HIV transmissions resulting from sexual behaviour and viral suppression status (HIV RNA < 400/mL) using hierarchical linear modelling. RESULTS: Patients averaged 0.38 estimated HIV transmissions/100 patients/year for all visits with syndemic conditions measured (down from 0.83, first visit). The final multivariate model showed that per 100 patients, each care visit predicted 0.05 fewer estimated transmissions annually (95% confidence interval (CI): 0.03 to 0.06; p < 0.0005). Cisgender women, cisgender heterosexual men and cisgender men of undisclosed sexual orientation had, respectively, 0.47 (95% CI: 0.35 to 0.59; p < 0.0005), 0.34 (95% CI: 0.20 to 0.49; p < 0.0005) and 0.22 (95% CI: 0.09 to 0.35; p < 0.005) fewer estimated HIV transmissions/100 patients/year than cisgender men who have sex with men (MSM). Each within-patient syndemic condition predicted 0.18 estimated transmissions/100 patients/year (95% CI: 0.12 to 0.24; p < 0.0005). Each between-syndemic condition predicted 0.23 estimated HIV transmissions/100 patients/year (95% CI: 0.17 to 0.28; p < 0.0005). CONCLUSIONS: Estimated HIV transmissions among PLWH receiving care in well-resourced U.S. clinical settings varied by HIV sexual risk group and decreased with time in care, highlighting the importance of TasP efforts. Syndemic conditions remained a significant predictor of estimated HIV transmissions notwithstanding the effects of HIV sexual risk group and time in care.

Quantifying Sexual Orientation Among Homeless and Unstably Housed Women in a Longitudinal Study: Identity, Behavior, and Fluctuations Over a Three-Year Period.

Sexual orientation has been linked to certain health conditions, and yet quantifying sexual orientation in longitudinal studies is challenging. This study examined different methods of accounting for sexual orientation in a cohort study of 300 homeless and unstably housed women followed every 6 months over 3 years. Altogether, 39.7% (n = 119) could be considered sexual minority at one or more time points based on identity and/or behavior; 16.3% (n = 49) reported shifts in sexual identity. Only 24.0% (n = 72) were identified as sexual minority through a single measure of sexual identity, 27.0% (n = 81) were identified with a single measure of identity and behavior, 33.0% (n = 99) were identified through annual measures of identity and behavior, and 22.0%-22.3% (n = 66-67) were identified through latent class analysis including all identity/behavior measures. This study found that sexual fluidity is common in unstably housed women, and many sexual minority women would be missed in longitudinal studies with different methods of accounting for sexual orientation.

Abnormal sleep duration associated with hastened depressive recurrence in bipolar disorder.

BACKGROUND: Abnormal sleep duration (ASD, <6 or ≥9h) is common in bipolar disorder (BD), and often persists beyond acute mood episodes. Few longitudinal studies have examined the ASD's impact upon BD illness course. The current study examined the longitudinal impact of ASD upon bipolar depressive recurrence/recovery. METHODS: Outpatients referred to the Stanford BD Clinic during 2000-2011 were assessed with the Systematic Treatment Enhancement Program for BD (STEP-BD) Affective Disorders Evaluation at baseline, and with the Clinical Monitoring Form at monthly follow-ups for up to two years of naturalistic treatment. Prevalence and clinical correlates of ASD in 93 recovered (euthymic ≥8 weeks) and 153 depressed BD patients were assessed. Kaplan-Meier analyses (Log-Rank tests) assessed relationships between baseline ASD and longitudinal depressive severity, with Cox Proportional Hazard analyses assessing potential mediators. RESULTS: ASD was only half as common among recovered versus depressed BD outpatients, but was significantly associated with hastened depressive recurrence (Log-Rank p=0.007), mediated by lifetime anxiety disorder and attenuated by lifetime history of psychosis, and had only a non-significant tendency towards association with delayed depressive recovery (Log-Rank p=0.07). In both recovered and depressed BD outpatients, baseline ASD did not have significant association with any baseline BD illness characteristic. LIMITATIONS: Self-reported sleep duration. Limited generalizability beyond our predominately white, female, educated, insured American BD specialty clinic sample. CONCLUSIONS: Baseline ASD among recovered BD patients may be a risk marker for hastened depressive recurrence, suggesting it could be an important therapeutic target between mood episodes.