Chronic pain and substance use disorders among older sexual minority men living with HIV: Implications for HIV disease management across the HIV care continuum.

HIV continues to be a critical health issue for sexual minority men (SMM) in the USA. Chronic pain is common in individuals with HIV, including older SMM, and is associated with substance use behaviors. This cross-sectional study sought to address a gap in the literature by characterizing interrelationships among chronic pain, substance use disorders (SUDs), medication adherence, and engagement in HIV care among older (≥50) SMM living with HIV and chronic pain (N = 63). The unadjusted relationship between an opioid use disorder and pain indicated that participants with an opioid use disorder reported higher pain ratings than those without. Presence of alcohol use disorder was significantly associated with missed HIV-care appointments due to chronic pain or substance use, showing that individuals with an alcohol use disorder reported more missed appointments in the past year. Higher pain was significantly associated with the same missed appointments variable, such that those reporting higher pain ratings also reported more missed appointments in the past year. These findings provide preliminary evidence of the interrelationships among chronic pain, SUDs, and engagement in HIV care among older SMM living with HIV and suggest that pain management in this population might support fuller engagement in HIV care.

Perspectives on Pain, Engagement in HIV Care, and Behavioral Interventions for Chronic Pain Among Older Sexual Minority Men Living with HIV and Chronic Pain: A Qualitative Analysis.

OBJECTIVE AND METHODS: The transition of HIV from an acute, fatal illness to a chronic health condition has shifted the treatment needs of people living with HIV (PLWH). PLWH, including sexual minority men (SMM), are living longer and are subject to health concerns often associated with aging. A major health concern of older SMM living with HIV who report problematic substance use is chronic pain. This qualitative analysis of 15 one-on-one interviews with older SMM living with HIV and chronic pain aimed to characterize this population's experiences with pain, engagement in HIV care, and problematic substance use. This study was conducted in a community health center in Boston, MA. We also solicited suggestions for preferred intervention strategies. RESULTS: Three main themes emerged from the interview transcripts: 1) the impact of chronic pain and pain treatment on engagement in HIV clinical care; 2) the impact of substance use on chronic pain; and 3) response to interventions to address chronic pain and substance use. CONCLUSIONS: These findings underscore the need for interventions that address the structural, physical, and psychological barriers to engagement in medical and self-care that affect older SMM living with HIV and chronic pain.

Cognitive Behavioral Therapy for Trauma and Self-Care (CBT-TSC) in Men Who have Sex with Men with a History of Childhood Sexual Abuse: A Randomized Controlled Trial.

To address childhood sexual abuse (CSA) related distress and HIV risk in men who have sex with men (MSM) using cognitive-behavioral therapy for trauma and self-care (CBT-TSC), which is a novel intervention integrating HIV risk reduction with modified cognitive and behavioral therapy strategies for post-traumatic stress. We compared CBT-TSC to HIV voluntary counseling and testing (VCT)-only in an initial 2-arm RCT in 43 HIV-negative MSM at with a history of CSA and HIV risk. Serodiscordant condomless anal/vaginal sex (CAS; CAS with HIV-postive or HIV unknown status partners) and posttraumatic stress disorder (PTSD) symptoms (Davidson Trauma Scale: total score and avoidance, intrusions, hyperarousal subscales) were outcomes immediately post-treatment, and at 6- and 9-month follow-up. At post-treatment, CBT-TSC had decreased odds (approximately 60%) of any CAS and greater reductions in CAS compared to VCT-only. Additionally, the CBT-TSC condition experienced greater reductions in total PTSD and avoidance symptoms. At the follow-up visits, CBT-TSC condition had significant reductions in the odds of any CAS and reductions in CAS. However, for PTSD symptoms, only the avoidance subscale remained significantly different compared to VCT-only. CBT-TSC is a potentially efficacious approach to address HIV risk in MSM with a CSA history, with replication and extension in a larger trial needed. This proof-of-concept trial is the first to integrate the treatment of a commonly occurring mental-health syndemic problem in MSM with a health psychology approach to self-care in MSM.Trial Registration Clinicaltrials.gov NCT01266122.

The Feasibility and Acceptability of a Smartphone-Based Music Intervention for Acute Pain.

Pain is an unpleasant experience the neurobiology of which is influenced by psychosocial factors including negative affect. Music is a ubiquitous experience that can improve affect, potentially decreasing anxiety and catastrophizing, both of which are associated with greater pain severity. We hypothesized that a machine-learning generative music intervention in the form of a smartphone web app (Unwind) could be used to modulate the experience of pain. In this pilot study, we recruited 15 individuals with acute pain who were admitted to an observation unit in the emergency department, and were being treated with opioids. Participants used the music intervention (Unwind) during this brief hospitalization, after which we assessed their response to its use through a semi-structured qualitative interview. Overall, participants responded positively to Unwind. While some reported some technical challenges, participants were willing to continue using it at home. In particular, participants reported using Unwind to address their anxiety, and many used it to facilitate sleep in the presence of pain. This study demonstrates that individuals with acute pain will accept and use a smartphone-based music protocol.

Personality Traits and Adaptive HIV Disease Management: Relationships with Engagement in Care and Condomless Anal Intercourse Among Highly Sexually Active Sexual Minority Men Living with HIV.

PURPOSE: The purpose of this study was to identify systematic relationships between personality domains and engagement in HIV care and secondary HIV prevention among sexual minority men living with HIV. METHODS: This cross-sectional study examined the relationships between general personality traits of the Five-Factor Model of personality (e.g., Neuroticism and Conscientiousness) and engagement in medical care and condomless anal intercourse among a sample of highly sexually active sexual minority men living with HIV (N = 60). RESULTS: Conscientiousness (B = -0.01, P < 0.05), Openness (B = -0.03, P < 0.05), and Extraversion (B = -0.03, P < 0.001) were each associated with engaging in fewer episodes of condomless anal intercourse and Conscientiousness alone was significantly related to having fewer sexual partners (B = -0.04, P < 0.001). Conscientiousness (odds ratio [OR] = 1.07, confidence interval [CI]: 1.01-1.13) and Extraversion (OR = 1.13, CI: 1.04-1.22) were both associated significantly with prevention service use. Conscientiousness alone was related to engagement in HIV medical case management (B = -0.11, P < 0.05), whereas both Conscientiousness (B = 0.41, P < 0.0001) and Neuroticism (B = -0.64, P < 0.001) were associated with perceived health. Furthermore, compared with the normative sample for the NEO-Personality Inventory-Revised, men in our sample scored significantly higher on Neuroticism and significantly lower on Conscientiousness (Ps < 0.05). CONCLUSION: These findings suggest that enduring individual differences may account, in part, for some of the high levels of condomless anal intercourse reported by this group, as well as engagement in and use of prevention services. We suggest strategies for engaging this group in secondary HIV prevention programs and initiatives.

Evaluating a novel intervention to reduce trauma symptoms and sexual risk taking: qualitative exit interviews with sexual minority men with childhood sexual abuse.

Childhood sexual abuse (CSA) continues to affect sexual minority men (SMM) at disproportionate levels and contributes to multiple negative health outcomes, including sexual-risk taking and HIV acquisition. This paper presents qualitative evaluative feedback from SMM (N = 9) who participated in a 10-session Cognitive Behavioral Therapy-Trauma and Sexual Health (CBT-TSH) intervention to reduce CSA-related posttraumatic stress reaction and distress. The treatment was designed to increase accurate sexual risk appraisals and to improve self-care health behaviors related to HIV/STI acquisition. The researchers identified four emerging themes: (1) motivation to participate, (2) response to cognitive therapy, (3) process of change, and (4) considerations for intervention improvement. These qualitative findings provide useful feedback on the acceptability of an innovative program that integrates CBT for trauma related to CSA with sexual risk-reduction counseling.

Cognitive behavioral therapy for body image and self-care (CBT-BISC) in sexual minority men living with HIV: A randomized controlled trial.

OBJECTIVE: Body image disturbance is a distressing and interfering problem among many sexual minority men living with HIV, and is associated with elevated depressive symptoms and poor HIV self-care (e.g., antiretroviral therapy [ART] nonadherence). The current study tested the preliminary efficacy of a newly created intervention: cognitive-behavioral therapy for body image and self-care (CBT-BISC) for this population. METHOD: The current study entailed a 2-arm randomized controlled trial (N = 44) comparing CBT-BISC to an enhanced treatment as usual (ETAU) condition. Analyses were conducted at 3 and 6 months after baseline. The primary outcome was body image disturbance (BDD-YBOCS), and secondary outcomes were ART adherence (electronically monitored via Wisepill), depressive symptoms (MADRS), and global functioning (GAF). RESULTS: At 3 months, the CBT-BISC condition showed substantial improvement in BDD-YBOCS (b = -13.6, SE = 2.7, 95% CI [-19.0, -8.3], p < .001; dppc2 = 2.39); MADRS (b = -4.9, SE = 2.8, 95% CI [-10.6, .70], p = .086; dppc2 = .87); ART adherence (b = 8.8, SE = 3.3, 95% CI [2.0, 15.6], p = .01; dppc2 = .94); and GAF (b = 12.3, SE = 3.2, 95% CI [6.1, 18.6], p < .001; dppc2 = 2.91) compared with the ETAU condition. Results were generally maintained, or improved, at 6 months; although, adherence findings were mixed depending on the calculation method. CONCLUSIONS: CBT-BISC shows preliminary efficacy in the integrated treatment of body image disturbance and HIV self-care behaviors among sexual minority men living with HIV. (PsycINFO Database Record

"Life-Steps" for PrEP Adherence: Demonstration of a CBT-Based Intervention to Increase Adherence to Preexposure Prophylaxis (PrEP) Medication Among Sexual-Minority Men at High Risk for HIV Acquisition.

One dramatic advance in human immunodeficiency virus (HIV) prevention efforts has been the prescription of medications typically used for HIV treatment as prophylaxis against acquiring HIV. As a preventative agent, this practice is referred to as "preexposure prophylaxis" (PrEP). The U.S. Federal Drug Administration approved daily PrEP for adults at risk for HIV who do not consistently use condoms during sex with HIV-infected or unknown-status partners. In this paper, we describe a cognitive-behavioral therapy (CBT) PrEP adherence intervention developed for use in high-risk sexual-minority men in the United States, adapted from "Life-Steps," an evidence-based CBT intervention to promote adherence to HIV treatment. Modules include creating a PrEP dosing schedule, adhering to daily PrEP, problem solving barriers to adherence, and sexual risk-reduction techniques. Supplemented with practical video vignettes, this novel intervention may help to enhance the clinical practice of health care providers in outpatient settings to increase PrEP adherence in sexual-minority men.

Stigma, medical mistrust, and perceived racism may affect PrEP awareness and uptake in black compared to white gay and bisexual men in Jackson, Mississippi and Boston, Massachusetts.

Gay and bisexual men and other men who have sex with men (MSM) account for more than two thirds of new HIV infections in the U.S., with Black MSM experiencing the greatest burden. Antiretroviral pre-exposure prophylaxis (PrEP) can reduce MSM's vulnerability to HIV infection. Uptake of PrEP has been limited, particularly among racial and ethnic minority MSM. Four semi-structured focus groups with gay and bisexual men and other MSM at risk for HIV infection were convened in Boston and Jackson in late 2013. The analysis plan utilized a within-case, across-case approach to code and analyze emerging themes, and to compare results across the two cities. Participants recruited in Jackson were primarily Black gay men, while Boston participants were mostly non-Hispanic White gay men. Participants in both sites shared concerns about medication side effects and culturally insensitive health care for gay men. Jackson participants described stronger medical mistrust, and more frequently described experiences of anti-gay and HIV related stigma. Multiple addressable barriers to PrEP uptake were described. Information about side effects should be explicitly addressed in PrEP education campaigns. Providers and health departments should address medical mistrust, especially among Black gay and bisexual men and other MSM, in part by training providers in how to provide affirming, culturally competent care. Medicaid should be expanded in Mississippi to cover low-income young Black gay and bisexual men and other MSM.

Behavioral Health.

In this chapter, we will describe the state of the literature on behavioral health, which includes mental health and substance use problems, and the available treatment interventions to ameliorate these problems, for older adults living with HIV (OALH). The scientific literature on the behavioral health of OALH is highly underdeveloped, especially in terms of the creation of empirically supported interventions to alleviate psychological distress. From the literature that does exist, there are a number of salient factors that emerge, including stereotypes (i.e., older adults are not sexually active), stigmatization (of those who are HIV-positive), social isolation, unique psychosocial needs for newly-infected OALH, and elevated rates of emotional distress and concomitant disorders - especially, depression. These factors persist alongside findings that OALH have fewer sources of social or institutional support, fewer surviving peers, and a lack of family to care for them. Additionally, many OALH report problems with substance use, both as a function of their 'baby-boomer' generational status (i.e., people born between 1946 and 1964) and in terms of the life experiences associated with their HIV-positive status. Overall, it is unclear how mental health and substance use problems affect combination antiretroviral therapy adherence, multimorbidity, polypharmacy, or treatment outcomes in this population, and further study is needed.

Complexity of childhood sexual abuse: predictors of current post-traumatic stress disorder, mood disorders, substance use, and sexual risk behavior among adult men who have sex with men.

Men who have sex with men (MSM) are the group most at risk for HIV and represent the majority of new infections in the United States. Rates of childhood sexual abuse (CSA) among MSM have been estimated as high as 46 %. CSA is associated with increased risk of HIV and greater likelihood of HIV sexual risk behavior. The purpose of this study was to identify the relationships between CSA complexity indicators and mental health, substance use, sexually transmitted infections, and HIV sexual risk among MSM. MSM with CSA histories (n = 162) who were screened for an HIV prevention efficacy trial completed comprehensive psychosocial assessments. Five indicators of complex CSA experiences were created: CSA by family member, CSA with penetration, CSA with physical injury, CSA with intense fear, and first CSA in adolescence. Adjusted regression models were used to identify relationships between CSA complexity and outcomes. Participants reporting CSA by family member were at 2.6 odds of current alcohol use disorder (OR 2.64: CI 1.24-5.63), two times higher odds of substance use disorder (OR 2.1: CI 1.02-2.36), and 2.7 times higher odds of reporting an STI in the past year (OR 2.7: CI 1.04-7.1). CSA with penetration was associated with increased likelihood of current PTSD (OR 3.17: CI 1.56-6.43), recent HIV sexual risk behavior (OR 2.7: CI 1.16-6.36), and a greater number of casual sexual partners (p = 0.02). Both CSA with Physical Injury (OR 4.05: CI 1.9-8.7) and CSA with Intense Fear (OR 5.16: CI 2.5-10.7) were related to increased odds for current PTSD. First CSA in adolescence was related to increased odds of major depressive disorder. These findings suggest that CSA, with one or more complexities, creates patterns of vulnerabilities for MSM, including post-traumatic stress disorder, substance use, and sexual risk taking, and suggests the need for detailed assessment of CSA and the development of integrated HIV prevention programs that address mental health and substance use comorbidities.