"I Don't Feel Judged, I Don't Feel Less of a Person" - Engaged and Supportive Providers in the HIV Care Experiences of Black Sexual Minority Men Living with HIV.

Background: Black sexual minority men (BSMM) in the Southern region of the United States experience a disproportionate burden of HIV. Research findings suggest that having supportive patient-provider relationships are critical for sustained HIV care engagement. The present study explores the role of supportive healthcare providers in the care engagement among BSMM living with HIV (BSMM+) in the US South. Methods: Semi-structured qualitative interviews were conducted with BSMM+ in Texas (n=27) to explore perceived barriers and facilitators of sustained care engagement. Interviews lasted 60 minutes on average, were transcribed, coded, and analyzed using applied thematic analysis. Findings: Participants described how important having relationships with engaged and supportive HIV care and service providers is to sustained engagement in care and positive HIV clinical outcomes. Supportive providers were characterized as non-judgmental, meeting patients' needs, and making patients feel "seen". Less supportive providers were described as making their patients "feel like a number" and having lack of follow through on proposed support and resources. Supportive providers were associated with increased care engagement of their patients while less supportive providers often led to patients switching providers, losing touch with services, and getting off track with their care. Discussion: We found that among BSMM+ an important facilitator of sustained care engagement was having positive, affirming, and knowledgeable healthcare providers, while negative and dismissive experiences with providers was a notable barrier to care engagement. This work highlights the need for a scale up of comprehensive, ongoing trainings in patient-centered and person-first communication for providers. Further, manageable provider caseloads can facilitate more thorough patient interactions where tailored HIV care and education can be provided in a safe and non-judgmental environment.

Black sexual minority men in the Southern region of the United States experience a disproportionate burden of HIV. While the role of patient-provider relationships for HIV care engagement has been shown in some contexts, less is known about the specific role of supportive healthcare providers in the care engagement among Black sexual minority men living with HIV in the United States South.Semi-structured qualitative interviews were conducted among Black sexual minority men living with HIV in Texas (n=27) to explore perceived barriers and facilitators of sustained care engagement.We found that supportive providers were associated with increased care engagement of their patients while less supportive providers often led to patients switching providers, losing touch with services, and getting off track with their care. Our findings suggest the need for a scale up of comprehensive, ongoing trainings in patient-centered and person-first communication for providers.

LAI-ART Awareness, Willingness, Barriers and Facilitators among Black Sexual Minority Men Living with HIV in the US South.

Black sexual minority men (BSMM) continue to bear a disproportionate burden of HIV in the United States, with the highest incidence and prevalence in the southern region of the country. In Texas, BSMM living with HIV (BSMM+) have the lowest rates of viral suppression of all SMM and have lower antiretroviral treatment (ART) adherence than white and Hispanic SMM. Long-acting injectable ART (LAI-ART) can potentially overcome several barriers to daily oral ART adherence (e.g., stigma, forgetfulness, pill fatigue). However, little is known about the knowledge, willingness, barriers, and facilitators regarding LAI-ART among BSMM+. From July 2022 to September 2023, we conducted in-depth, semi-structured interviews with 27 BSMM+ from the Houston and Dallas Metropolitan Areas, Texas. Data were analyzed using a thematic analysis approach. Most men knew about LAI-ART, but their understanding varied based on their existing sources of information. Some men were enthusiastic, some were cautious, and some reported no interest in LAI-ART. Barriers to LAI-ART included a lack of public insurance coverage of LAI-ART; fear of needles and side effects; the frequency of injection visits; the requirement of viral suppression before switching from oral ART to LAI-ART; and satisfaction with oral daily ART. Motivators of LAI-ART uptake included the eliminated burden of daily pills and reduced anxiety about possibly missing doses. BSMM+ may be among those who could most benefit from LAI-ART, though more research is needed to understand which factors influence their willingness and how the barriers to LAI-ART might be addressed, particularly among diverse communities of SMM of color.

How Intimate Partner Violence Is Influenced by Social Identity Among Sexual Minority Men.

Purpose: Sexual minority men (SMM) experience intimate partner violence (IPV) at disproportionately high rates. The objective of this article was to identify the experiences of SMM and health care providers on how social identity impacts IPV. Methods: SMM participants (N = 23) were recruited from online community settings and a lesbian, gay, bisexual, transgender, queer, and others (LGBTQ+) organization in Los Angeles; providers (N = 10) were recruited from LGBTQ+ organizations. Semistructured interviews were audio recorded and transcribed verbatim. An applied thematic analysis approach was implemented to create memos, inductively generate a codebook, apply codes to the transcripts, and identify key themes in data. Results: Three main themes were identified. The first theme was weaponizing social identity to control a partner, which had three subthemes: (1) immigration status, race/ethnicity, and skin color, (2) threatening to "out" the partner's sexual orientation, and (3) abusing power inequity. Men who perpetrated IPV often used minority identities or undisclosed sexuality to leverage power over their partner. The second theme was use of IPV to establish masculinity, by exerting power over the more "feminine" partner. The third theme was internalized homophobia as a root cause of IPV, which details how internalized homophobia was often expressed in violent outbursts toward partners. Conclusion: These findings highlight how IPV among SMM can be influenced by social and sexual identity. Future research must consider socially constructed power structures and the multiple identities of SMM when developing interventions to address IPV in this population.

Differential Associations of Depressive Symptomology to HIV Care Engagement Among Young Black Sexual Minority Men with HIV (YBSMM+) in the US South: A Multi-Group Analysis of Mood, Intimate Partner Violence, and Alcohol Use.

Young Black Sexual Minority Men with HIV (YBSMM+) in the US South encounter multiple socio-structural challenges that contribute to disproportionately poor HIV-related outcomes across the care continuum. Depression, anxiety, intimate partner violence (IPV), and alcohol use are prominent factors that negatively impact engagement with HIV care. Syndemic theory posits that these multiple factors interact synergistically to promote poor outcomes; however, depression itself is highly heterogeneous in presentation, which may pose issues when examining associations to HIV care engagement. This study sought to better understand the associations of specific depressive symptomology subtypes, generalized anxiety, experienced IPV, and alcohol use on HIV care engagement for YBSMM+. Results showed that interpersonally oriented depressive symptomatology was associated with increased HIV care engagement among YBSMM + who abstained from alcohol. On the other hand, among YBSMM + who frequently binge drank, combined negative affect and somatic components of depressive symptomatology and frequency of IPV experiences were associated with decreased HIV care engagement while generalized anxiety was associated with increased HIV care engagement. The findings suggest that the negative affect and somatic components of depression may be particularly salient for HIV care engagement among YBSMM + who binge drink frequently. Developing targeted interventions that address these specific conditions while accounting for the nuances of mood-based symptomatology could improve intervention efforts geared towards improving HIV care engagement among YBSMM+.

What's in Your Dataset? Measuring Engagement in HIV Care Using Routinely Administered Items with a Population Disproportionately Burdened by HIV.

We evaluated the psychometric properties of a measure consisting of items that assess current HIV care continuum engagement based on established definitions in the United States. At baseline, participants in this longitudinal study, which included three time points from 2015 to 2020, were 331 young Black sexual minority men ages 18-29 living with HIV in the southern United States residing in two large southern cities. Self-report items reflected four aspects of HIV care continuum engagement as binary variables: seeing a healthcare provider for HIV care, being on antiretroviral treatment, being retained in HIV care, and being virally suppressed. Of these, the following three variables loaded onto a single factor in exploratory factor analysis: being on antiretroviral treatment, being retained in HIV care, and being virally suppressed. A one-dimensional factor structure was confirmed using confirmatory factor analyses at separate time points. Additionally, the three items collectively showed measurement invariance by age, education level, employment status, and income level. The three-item measure also showed reliability based on coefficient omega and convergent validity in its associations with indicators of socioeconomic distress, depression, resilience, and healthcare empowerment. In sum, the items performed well as a single scale. The study demonstrated the potential psychometric strength of simple, feasible, commonly administered items assessing engagement in the HIV care continuum.

Structural Inequities, Syndemics, and Resilience: The Critical Role of Social Support in Overcoming Barriers and Empowering Engagement in HIV Care for Young Black Sexual-Minority Men in the US South.

Young Black sexual minority men (YBSMM) living in the US South are among those most disproportionately impacted by HIV in the USA. This health inequity is, in part, due to lower rates of sustained engagement in the HIV care continuum, resulting in a lower prevalence of viral suppression and higher overall community-level viral load. Social, structural, and economic inequities have previously been linked with poorer HIV care engagement among YBSMM. HIV-related social support, individual-level resilience, and healthcare empowerment have been shown to be independently associated with improved HIV care engagement. The current study sought to assess the relative contribution of individual, structural, and economic factors on engagement in HIV care and to elucidate the potentially mediating role of healthcare empowerment. Data from 224 YBSMM with HIV in the US South indicated that greater levels of socioeconomic distress, intimate partner violence, and depressive symptoms were associated with lower levels of engagement in HIV care, while greater levels of individual-level resilience and healthcare empowerment were associated with higher levels of HIV care engagement. Importantly, healthcare empowerment mediated the association between resilience and engagement in HIV care and the association between social support and engagement in HIV care. Findings emphasize the critical role that HIV-related social support plays in fostering resilience and overcoming syndemic factors to promote empowerment and engagement in HIV care for YBSMM in the USA.

Intimate Partner Violence and the Sexual Health of Sexual Minority Men.

Purpose: This qualitative study explores the pathways by which various forms of intimate partner violence (IPV) impact the sexual health behaviors of cisgender identified sexual minority men (SMM). Methods: Semi-structured interviews were conducted with 23 racially and ethnically diverse SMM who recently experienced IPV and 10 clinical and social service providers focused on how experiences of IPV directly or indirectly influences sexual risk as well as engagement in HIV prevention behaviors (e.g., pre-exposure prophylaxis [PrEP] use). Applied thematic analysis, including cycles of analytic memo writing and coding, aided the identification of patterns across the data. Results: Analyses yielded three overarching themes: use of condoms, use of PrEP, and HIV and sexually transmitted infections (STIs). Participants described different ways condom use or nonuse was a mechanism by which power and/or control might be asserted by one partner over the other partner. A range of responses to questions about PrEP were identified, including partners encouraging PrEP use, as well as avoidance of conversations about PrEP or actual PrEP use, to prevent experiencing aggression or IPV from partners. Responses regarding HIV/STIs included those ranging from a new diagnosis being a potential trigger for violence to the exploitation of status to control partners. Conclusion: These findings suggest that in relationships with IPV, HIV prevention strategies can be sources of relationship control and trigger abuse. Addressing IPV may help to prevent HIV/STI transmission and promote the health of SMM. In addition, long-acting formulations of PrEP may be a promising strategy for SMM experiencing IPV when oral PrEP medications may be a risk factor for violence.

Sources of Resilience as Mediators of the Effect of Minority Stress on Stimulant Use and Sexual Risk Behavior Among Young Black Men who have Sex with Men.

The greatest proportion of new HIV infections among men who have sex with men (MSM) is occurring among young Black MSM (YBMSM) ages 13-24. Consequently, research is needed to understand the psychosocial pathways that influence HIV risk and resilience in YBMSM. Minority Stress Theory proposes that the stigma, prejudice, and discrimination facing sexual and racial minorities are chronic stressors that lead to increased engagement in risk behaviors. The present study examined whether minority stress is associated with stimulant use and sexual risk behaviors by depleting psychosocial resilience. We recruited 1817 YBMSM, ages 18-29, from multiple venues in two major cities in Texas for participation in a brief survey. Results from structural equation modeling indicated that decreased resilience partially mediated the association of minority stress with sexual risk behavior. Resilience was also negatively associated with stimulant use. Interventions focused on cultivating psychosocial resilience could mitigate the deleterious consequences of minority stress and reduce stimulant use in YBMSM.

Approaches to Identify Unknown HIV-Positive Men Who Have Sex with Men in Nairobi, Kenya.

Kenya has been home to one of the most severe HIV/AIDS epidemics in Sub-Saharan Africa. This persistent epidemic requires interventions tailored to affected populations, particularly men who have sex with men (MSM). Given the resource constraints of many clinics and ecological challenges of Kenya, such as the illegality of sex among MSM, interventions to address HIV must strategically engage this population. This quasi-experimental pilot study of N = 497 sought to explore differences in discovering previously unknown HIV-positive MSM in Nairobi, Kenya. The study used four clinical sites to compare a social and sexual network index testing (SSNIT) strategy compared to traditional HIV screening. Clinics using the SSNIT strategy had significantly higher incidence rates of HIV diagnoses than control clinics (IRR = 3.98, p < 0.001). This study found that building upon the social and sexual networks of MSM may be one promising strategy while discovering critical cases of HIV.

"It Is Like Heart Failure. It Is Chronic and It Will Kill You": A Qualitative Analysis of Burnout Among Hospice and Palliative Care Clinicians.

CONTEXT: Although prior surveys have identified rates of self-reported burnout among palliative care clinicians as high as 62%, limited data exist to elucidate the causes, ameliorators, and effects of this phenomenon. OBJECTIVES: We explored burnout among palliative care clinicians, specifically their experiences with burnout, their perceived sources of burnout, and potential individual, interpersonal, organizational, and policy-level solutions to address burnout. METHODS: During the 2014 American Academy of Hospice and Palliative Medicine/Hospice and Palliative Nurses Association Annual Assembly, we conducted three focus groups to examine personal narratives of burnout, how burnout differs within hospice and palliative care, and strategies to mitigate burnout. Two investigators independently analyzed data using template analysis, an inductive/deductive qualitative analytic technique. RESULTS: We interviewed 20 palliative care clinicians (14 physicians, four advanced practice providers, and two social workers). Common sources of burnout included increasing workload, tensions between nonspecialists and palliative care specialists, and regulatory issues. We heard grave concerns about the stability of the palliative care workforce and concerns about providing high-quality palliative care in light of a distressed and overburdened discipline. Participants proposed antiburnout solutions, including promoting the provision of generalist palliative care, frequent rotations on-and-off service, and organizational support for self-care. We observed variability in sources of burnout between clinician type and by practice setting, such as role monotony among full-time clinicians. CONCLUSION: Our results reinforce and expand on the severity and potential ramifications of burnout on the palliative care workforce. Future research is needed to confirm our findings and investigate interventions to address or prevent burnout.

Body Dissatisfaction in a Diverse Sample of Young Men Who Have Sex With Men: The P18 Cohort Study.

Young men who have sex with men (YMSM) may be at greater risk for body dissatisfaction, compared to their heterosexual peers. However, differences within YMSM populations are understudied, precluding the identification of YMSM who are at greatest risk. This study examined body dissatisfaction in a racially/ethnically diverse sample of YMSM ages 18-19 in New York City. Using cross-sectional data from the baseline visit of a longitudinal cohort study of YMSM (N = 591), body dissatisfaction was assessed using the Male Body Attitudes Scale. Three outcomes were modeled using linear regression: (1) overall body dissatisfaction, (2) muscularity dissatisfaction, and (3) body fat dissatisfaction. Covariates in the models included race/ethnicity, sexual orientation, BMI, gay community affiliation, and internalized homonegativity. White YMSM experienced greater body dissatisfaction across the three models. Internalized homonegativity was a statistically significant predictor of dissatisfaction across the three models, though its association with body dissatisfaction was relatively small. The findings point to future avenues of research, particularly qualitative research to explore demographic and cultural nuances in body attitudes among YMSM.

Differences in alcohol use and alcohol-related problems between transgender- and nontransgender-identified young adults.

BACKGROUND: Little is known about differences in alcohol use and alcohol-related problems between transgender- and nontransgender-identified populations. Using data from a large-scale health survey, we compare the drinking patterns and prevalence of alcohol-related problems of transgender-identified individuals to nontransgender-identified males and females. For transgender-identified people, we examine how various forms of victimization relate to heavy episodic drinking (HED). METHODS: Cross-sectional surveys were completed by 75,192 students aged 18-29 years attending 120 post-secondary educational institutions in the United States from 2011 to 2013. Self-reported measures included alcohol use, alcohol-related problems, victimization, and sociodemographics, including 3 gender-identity groups: transgender-identified individuals; nontransgender-identified males; and nontransgender-identified females. RESULTS: Compared to transgender-identified individuals, nontransgender-identified males were more likely to report HED in the past 2 weeks (relative risk=1.42; p=0.006); however, nontransgender-identified males and females reported HED on fewer days than transgender-identified people (incidence-rate ratios [IRRs] ranged from 0.28 to 0.43; p-values<0.001). Compared to transgender-identified people, nontransgender-identified males and females had lower odds of past-year alcohol-related sexual assault and suicidal ideation (odds ratios ranged from 0.24 to 0.45; p-values<0.05). Among transgender-identified people, individuals who were sexually assaulted (IRR=3.21, p=0.011) or verbally threatened (IRR=2.42, p=0.021) in the past year had greater HED days than those who did not experience those forms of victimization. CONCLUSIONS: Compared to transgender-identified people, nontransgender-identified males and females: have fewer HED occasions (despite nontransgender-identified males having greater prevalence of HED); and are at lower risk for alcohol-related sexual assaults and suicidal ideation. Experiences of sexual assault and verbal threats are associated with greater HED occasions for transgender-identified people.

Modeling substance use in emerging adult gay, bisexual, and other YMSM across time: the P18 cohort study.

OBJECTIVE: To examine patterns of substance use over time in a new generation of emerging adult gay, bisexual, and other young men who have sex with men (YMSM). METHODS: Data were drawn from the first four waves of on ongoing prospective cohort study of YMSM who were ages 18 to 19 at baseline and were assessed each 6 months for substance use via calendar based methods. Latent growth curve modeling was utilized to assess changes over time for four drug use categories: alcohol, marijuana, inhalant nitrates, and other drugs (e.g., cocaine, ecstasy) and between groups (race/ethnicity, perceived familial socioeconomic status; SES). RESULTS: Use of all substances increased steadily across the follow-up period. White YMSM demonstrated higher levels of alcohol use at the 18-mo follow-up visit compared to other racial/ethnic groups, while rates of change across groups were similar. Marijuana use at 18 months was highest for Hispanics who also indicated the highest rate of change. Finally, YMSM who reported higher perceived SES reported the lowest use and lowest rates of change for other drug use. Controlling for perceived SES, differences in patterns of drug use by race/ethnicity were evident but differences were not as large. CONCLUSIONS: Increases in substance use in the emerging adulthood of YMSM indicate the need for structural and behavioral interventions tailored to address substance use in these young men before chronic patterns of use develop. Differences in patterns of drug use across racial/ethnic and SES groups suggest that interventions need to consider person-level differences.

Sociodemographic Factors Contribute to Mental Health Disparities and Access to Services Among Young Men Who Have Sex with Men in New York City.

Young men who have sex with men (YMSM) may be at increased risk for mental health problems including depression, post-traumatic stress (PTSD), and suicidality. The overriding goal of the current investigation was to examine mental health and mental health services in a diverse sample of YMSM. We analyzed cross-sectional data from a cohort study of 598 YMSM, including sociodemographics, mental health, and mental health care. We then tested for bivariate associations, and used multivariable modeling to predict depression, PTSD, suicidality and mental health care utilization. Lower socioeconomic status, unstable housing, and school non-enrollment predicted depression and PTSD scores, while unstable housing and school non-enrollment predicted recent suicide attempt(s). These recent suicide attempt(s) also predicted current utilization of counseling or treatment, any history of psychiatric hospitalization, and any history of psychiatric diagnosis. Black and API men were less likely to have ever accessed mental health counseling or treatment. There were significant class-based differences with regard to mental health outcomes, but not mental health services. Further, recent crises (i.e., suicide attempt, hospitalization) were strong predictors of accessing mental health services. Improving the mental health of YMSM requires addressing the underlying structural factors that influence mental health outcomes and service access.

When the emotions really started kicking in, which ended up being a problem: sex, HIV, and emotions among young gay and bisexual men.

Interviews from 10 young gay and bisexual men aged 18 to 29 were examined to explore how young gay and bisexual men make decisions regarding sexual behaviors in the age of AIDS. Three main themes emerged: (a) disconnections between what an individual knows about HIV, their motivations to remain HIV-negative, and their sexual behaviors; (b) a struggle to connect emotionally and intimately with another man; and (c) a power dynamic whereby the individual acts as an autonomous decider in the decision-making process. Participants indicated high levels of HIV knowledge, and were engaged in a struggle to balance emotional experiences with sexual partners in a complex gendered dynamic. Findings from this analysis indicate a need to reexamine the social-cognitive theoretical frameworks that have guided gay men's HIV-prevention efforts, as these frameworks have failed to account for the psychologically complex emotional experiences and gender dynamics that are part of sexual decision making.

Individual, psychosocial, and social correlates of unprotected anal intercourse in a new generation of young men who have sex with men in New York City.

OBJECTIVES: We examined associations of individual, psychosocial, and social factors with unprotected anal intercourse (UAI) among young men who have sex with men in New York City. METHODS: Using baseline assessment data from 592 young men who have sex with men participating in an ongoing prospective cohort study, we conducted multivariable logistic regression analyses to examine the associations between covariates and likelihood of recently engaging in UAI with same-sex partners. RESULTS: Nineteen percent reported recent UAI with a same-sex partner. In multivariable models, being in a current relationship with another man (adjusted odds ratio [AOR] = 4.87), an arrest history (AOR = 2.01), greater residential instability (AOR = 1.75), and unstable housing or homelessness (AOR = 3.10) was associated with recent UAI. Although high levels of gay community affinity and low internalized homophobia were associated with engaging in UAI in bivariate analyses, these associations did not persist in multivariable analyses. CONCLUSIONS: Associations of psychosocial and socially produced conditions with UAI among a new generation of young men who have sex with men warrant that HIV prevention programs and policies address structural factors that predispose sexual risk behaviors.

Psychosocial and demographic correlates of drug use in a sample of HIV-positive adults ages 50 and older.

The prevalence of HIV among adults 50 and older in the USA is increasing as a result of improvements in treatment and detection of HIV infection. Substance use by this population has implications for physical and mental health outcomes. We examined patterns of demographics, mental health, and recent substance use in a diverse sample of heterosexual, bisexual, and gay adults 50 and older living with HIV/AIDS (PLWHA) in New York City. The most commonly used substances were cigarettes or alcohol; however, the majority of the sample did not report recent use of marijuana, poppers, or hard drugs (crystal methamphetamine, cocaine, crack, heroin, ecstasy, GHB, ketamine, and LSD or PCP). Statistically significant associations between substance use and psychological states (well-being and loneliness) were generally weak, and depression scores were not significantly related to use; instead, drug use was associated with gender/sexual orientation. The study observations support addressing substance use specific to subpopulations within PLWHA.

Sexual health screening among racially/ethnically diverse young gay, bisexual, and other men who have sex with men.

PURPOSE: Screening for sexually transmitted infections (STIs) is a crucial element of improving health and reducing disparities, and young men who have sex with men (YMSM) face high rates of both STIs and human immunodeficiency virus. We examined sexual health screening among a diverse sample of adolescent YMSM living in New York City. METHODS: Between 2009 and 2011, cross-sectional data were collected from 590 YMSM in New York City. Separate multivariable logistic regression models were used to assess the relationship between sociodemographic, psychosocial, and health and healthcare related factors and two main outcomes: having sought a recent sexual health screening (past 6 months) and having a rectal sexual health screening (lifetime). RESULTS: Overall, 46% reported a sexual health screening in the prior 6 months, but only 16% reported ever having a rectal screening for STIs. Rates were higher among ethnic minority YMSM and men who accessed care at clinics. Multivariable results indicated that gay community affiliation, recent unprotected anal sex, and number of lifetime male partners were also associated with seeking a recent screening. CONCLUSIONS: Though half of the sample reported recent general screening, rates of lifetime rectal screening are low. Efforts to increase screening may focus on improving provider knowledge and guideline adherence, and educating and encouraging YMSM to access sexual health check-ups.

Sexual risk taking in relation to sexual identification, age, and education in a diverse sample of African American men who have sex with men (MSM) in New York City.

HIV disproportionately affects African American men who have sex with men (MSM) in the United States. To inform this epidemiological pattern, we examined cross-sectional sexual behavior data in 509 African American MSM. Bivariate logistic regression analyses were conducted to examine the extent to which age, education,and sexual identity explain the likelihood of engaging in sex with a partner of a specific gender and the likelihood of engaging in unprotected sexual behaviors based on partner gender. Across all partner gender types,unprotected sexual behaviors were more likely to be reported by men with lower education. Younger, non-gay identified men were more likely to engage in unprotected sexual behaviors with transgender partners, while older, non-gay identified men were more likely to engage in unprotected sexual behaviors with women. African American MSM do not represent a monolithic group in their sexual behaviors, highlighting the need to target HIV prevention efforts to different subsets of African American MSM communities as appropriate.