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Transgender and gender-diverse (TGD) people are disproportionately impacted by incarceration, interpersonal violence, HIV and other sexually transmitted infections, substance use disorders, and suicidality. Little is known about successful approaches to improve health outcomes for TGD individuals impacted by incarceration. We review the barriers to providing gender-affirming clinical care in correctional systems in the United States, identify key knowledge gaps regarding the provision of gender-affirming care to incarcerated TGD populations, and highlight necessary steps to improve the health and safety of this highly vulnerable population. We also describe the components of a gender-affirming care model implemented in a state correctional facility, including support from correctional administrators, identifying a gender-affirming care provider, standardizing clinical care protocols, and adapting clinical services to TGD population needs. Similar models should be employed elsewhere to improve health outcomes for TGD populations during incarceration and on release.

HIV incidence among African American (AA) young men who have sex with men (YMSM) has remained stable even though they made up the largest number of new HIV diagnoses among men who have sex with men (MSM) in 2017. HIV spreads at increased rates in dense sexual networks. Identifying the location of risk behaviors "activity spaces" could inform geographically circumscribed HIV prevention interventions. Utilizing the modified social ecological model we completed five semi-structured focus groups incorporating a modified social mapping technique, based on Singer et al.'s approach. Participants included 27 AA YMSM. Focus groups explored how and where HIV transmission happens in Jackson, Mississippi. Result themes included: 1) location of sexual behaviors, 2) knowledge of geographic hotspots of HIV infection in Jackson, and 3) traveling to meet partners: at home and away. HIV transmission or "activity spaces" may be occurring outside identified HIV hot spots. Mixed geospatial and qualitative methods offered a comprehensive assessment of where HIV transmission occurs, and suggests that geographically circumscribed interventions may need to focus on where individuals living with HIV reside and in specific geographic locations where they engage in behaviors that raise their HIV acquisition risks.

More than 2 million people are incarcerated in the United States with many millions more processed through correctional facilities annually. Communities impacted by incarceration are also disproportionately impacted by the HIV and sexually transmitted infection (STI) epidemics. However, relatively little is known about the behaviors that place individuals with a history of incarceration at risk for HIV/STI acquisition. We utilized clinical data from patients presenting to an STI clinic located in Providence, Rhode Island. A latent class analysis was conducted on reported HIV acquisition risk behavior and STI testing results on a total of 1129 encounters where a history of incarceration was reported. A total of three classes were identified. Class 1 (

Latino sexual minority men (LSMM) experience sexual and behavioral health disparities. Yet, LSMM are underrepresented in sexual and behavioral health research, creating scientific inequity. There is, therefore, a need to identify the barriers and facilitators to LSMM's participation in sexual and behavioral health research, which is the gap that the current study sought to fill. We interviewed LSMM (n = 28; age 18-40, 57% US born) and key informants (n = 10) regarding LSMM's barriers and facilitators to participating in sexual and behavioral health research and suggestions for increasing participation. The research team coded the data via thematic analysis. We found that relational factors are central to understanding LSMM's participation in sexual and behavioral health research. Some relational experiences (e.g., interpersonal stigma) interfered with participation, whereas others (e.g., altruistic desires to contribute to community well-being) facilitated participation. The findings are consolidated within a new relational framework for understanding LSMM's participation in sexual and behavioral health research. Study findings highlight the centrality of relational factors in influencing LSMM's participation in sexual and behavioral health research. Relational factors can be used to inform the development of culturally relevant recruitment strategies to improve representation of LSMM in sexual and behavioral health research. Implementing these recommendations may address scientific inequity, whereby LSMM are disproportionately impacted by sexual and behavioral health concerns yet underrepresented in related research.

Research suggests sex-related substance use can be conceptualized within the disinhibited externalizing spectrum of psychopathology. However, this research has generally excluded sexual-minority samples. In the current study, we examined the associations between the disinhibited externalizing spectrum and several sex-related substance use domains (i.e., heavy drinking and poppers [alkyl nitrite], cannabis, cocaine, and methamphetamine use) in a clinical sample ( N = 254) of sexual-minority men. Disinhibited externalizing was significantly associated with reporting sex-related cannabis and methamphetamine use versus not and with frequency of sex-related alcohol and cocaine use. These results suggest few and generally weak associations—except for methamphetamine use—between the disinhibited externalizing spectrum and sex-related substance use. Implications for the applicability of dimensional models of psychopathology for sexual-minority populations, future directions for research on sexual behavior and substance use grounded in the specific sociocultural context in which sexual-minority men exist, and transdiagnostic interventions for sex-related substance use are discussed.

Despite the efficacy of HIV pre-exposure prophylaxis (PrEP), retention in care in the United States remains suboptimal. The goal of this study was to explore factors that lead to suboptimal retention in PrEP care for men who have sex with men (MSM) in real-world clinical settings in the United States. Trained interviewers conducted semi-structured interviews with MSM (N = 49) from three clinics who had been engaged in PrEP care in the Midwest (n = 15), South (n = 15), and Northeast (n = 19) geographic regions and had experienced a lapse in PrEP use. Factors that emerged as related to suboptimal retention in PrEP care included structural factors such as transportation and out-of-pocket costs; social factors such as misinformation on media and in personal networks; clinical factors such as frequency and timing of appointments; and behavioral factors such as changes in sexual behavior and low perceived risk for HIV. Participants suggested reducing the out-of-pocket costs of medications and lab visits, having flexible appointment times, culturally responsive services, and comprehensive patient navigation to help retention in care. These findings leveraged real-world experiences and opinions of patients to inform gaps in current services and how to make changes to optimize PrEP care.

The purpose of this study was to evaluate the impact of the Coronavirus Disease 2019 (COVID-19) pandemic on sexual behavior, mental health, and substance use among men who have sex with men (MSM) engaged in pre-exposure prophylaxis (PrEP) care. Generalized linear mixed models and logistic mixed-effect models examined change over time for number of sexual partners, mood, and alcohol consumption. From February 29, 2020 to July 31, 2020, 177 MSM actively engaged in PrEP care were evaluated. The median age was 37 [interquartile range (IQR 30, 51]. Patients in the sample were largely representative of the clinic population and identified as White (73.0%), Black/African American (9.2%), and other race (17.2%), and 11.8% identified as Hispanic/Latino ethnicity. Men reported an average of 2.60 fewer sexual partners (95% CI -4.04, -1.40) during the pandemic compared to pre-COVID-19. Rates of depressive symptoms and alcohol use remained stable and few patients reported substance use. The reduced number of sexual partners may be explained by patients' efforts to reduce risk of exposure to COVID-19 and low rates of psychosocial symptoms may be indicative of only the highest functioning patients continuing to engage in care. Reductions in sexual partners may offset reduced engagement in care and help mitigate risk of HIV and other sexually transmitted infections (STIs).El propósito de este estudio fue evaluar el impacto que tuvo la pandemia causada por la enfermedad del coronavirus 2019 (COVID-19) en el comportamiento sexual, la salud mental y el uso de sustancias en hombres que tienen sexo con hombres (HSH) que reciben profilaxis previa a la exposición (PrEP). Los modelos lineales mixtos generalizados y los modelos logísticos de efectos mixtos examinaron el cambio a través del tiempo en el número de parejas sexuales, el estado de ánimo y el consumo de alcohol. Desde el 29 de febrero de 2020 hasta el 31 de julio de 2020, se evaluaron 177 HSH que recibían los servicios de la PrEP. La mediana de edad fue de 37 (rango intercuartílico (IQR: 30, 51). Los pacientes de la muestra eran en gran parte representativos de la población de la clínica y se identificaban como Blancos (73.0%), Negros/Afroamericanos (9.2%) y de Otra raza (17.2%) y el 11.8% se identificó de origen Hispano/Latino. Los hombres reportaron un promedio de 2.60 parejas sexuales menos (IC del 95%: -4.04, -1.40) durante la pandemia en comparación con antes de COVID-19. Las tasas de síntomas depresivos y el uso de alcohol se mantuvieron estables y pocos pacientes reportaron uso de sustancias. El número reducido de parejas sexuales puede explicarse por los esfuerzos de los pacientes para reducir su riesgo de exposición al COVID-19 y las bajas tasas de síntomas psicosociales pueden ser indicativos de que solo los pacientes con mayor funcionamiento continúan participando. La reducción en el número de parejas sexuales puede contrarrestar la baja participación en la atención medica de la PrEP y ayudar a mitigar el riesgo de contraer el VIH y otras infecciones de transmisión sexual (ITS).

COVID-19 is a public health crisis that has fundamentally altered health care provision. The purpose of this study was to examine the impact of COVID-19 on pre-exposure prophylaxis (PrEP) care. We reviewed all patient records for those who presented for PrEP care at a PrEP program in Providence, Rhode Island from September 1st, 2019 to May 29th, 2020. The number of PrEP encounters decreased but was not significantly different over time (ps .05). Patients were still able to access PrEP clinical services during the COVID-19 pandemic. Implementing flexible and timely PrEP delivery approaches in this setting likely minimized the disruption of PrEP care during COVID-19.COVID-19 es una crisis de salud pública que ha alterado fundamentalmente la prestación de servicios de salud. El propósito de este estudio fue examinar el impacto de COVID-19 en los servicios de la profilaxis preexposición (PrEP). Revisamos todos los registros de pacientes que se presentaron para recibir atención de PrEP en un programa de PrEP en Providence, Rhode Island desde el 1 de septiembre de 2019 hasta el 29 de mayo de 2020. El número de encuentros de PrEP disminuyó pero no fue significativamente diferente con el paso del tiempo (ps .05). Los pacientes aún pudieron acceder a los servicios clínicos de PrEP durante la pandemia de COVID-19. La implementación de enfoques de entrega de PrEP que eran flexibles y oportunos en este entorno probablemente minimizó la interrupción de la atención médica de la PrEP durante COVID-19.

COVID-19 has disproportionately affected vulnerable populations across the U.S. Street-based sex workers are one vulnerable population whose health and impact of COVID-19 have been understudied to date. The goal of this study was to evaluate findings from a community needs assessment with street-based sex workers on impact of COVID-19 on health behaviors and social circumstances. A brief survey was developed at a community-based harm reduction and recovery services organization. Surveys were administered by peer specialists to street-based sex workers during street outreach in April and May 2020. A total of 46 surveys were analyzed. Many individuals reported continuing to do sex work and use substances during the COVID pandemic. Slightly more than a quarter of individuals (n = 13; 28.3%) indicated using personal protective equipment while doing sex work and described challenges to using precautions when working with clients. Individuals had used marijuana (n = 32, 71.1%), cocaine (n = 17, 39.5%), prescription stimulants (n = 9, 21.4%), methamphetamines (n = 5, 11.9%), prescription opioids (n = 12, 27.3%), street opioids (n = 12, 27.3%), sedatives (n = 11, 25.0%), hallucinogens (n = 3, 6.8%), inhalants (n = 3, 7.0%), or some other substance (n = 4, 8.7%) in the past 30 days. About half (48.8%) reported that COVID-19 had a major impact on their lives. This study is among the first to characterize the impact of COVID-19 on street-based sex workers. From a public health standpoint, this group also represents a high-priority population given their vulnerability and close contact with others, which increases the potential for community spread.

Latino sexual minority men (LSMM) are affected by HIV and behavioral health disparities. Evidence-based HIV-prevention and behavioral health (BH) services are not sufficiently scaled up to LSMM. The current study identified multilevel barriers and facilitators to LSMM's use of HIV-prevention and BH services. LSMM (N = 290) in South Florida, a US HIV epicenter, completed a battery of measures potentially associated with pre-exposure prophylaxis (PrEP) and BH treatment use. Stochastic search variable selection (SSVS) followed by multiple linear regression analyses identified variables associated with engagement in PrEP and BH treatment. Multilevel determinants of PrEP and BH treatment engagement were identified, with most identified determinants being at the relational level (e.g., stigma, discrimination based on income and immigration status, personal recommendation for treatment). Individual (e.g., knowledge, self-efficacy) and structural (e.g., financial stress) determinants were also identified. Accordingly, modifiable leverage points to enhance the reach of PrEP and BH treatment to LSMM include educating and enhancing the perceived relevance of services, de-stigmatizing and normalizing via peer examples, bolstering self-efficacy, and building trust.

Models of personality disorders have overwhelmingly developed in a socially decontextualized manner. Some historical models of personality pathology formally embraced the interactions between the individual and their environment. However, the field of personality disorder theory, research, and treatment has evolved in a manner that situates dysfunction within intra-individual deficiency processes. By doing so the field limits its applicability to populations that do not represent the norm in clinical psychological science (e.g., sexual/gender minority [SGM] persons for our purposes). Assumptions about personality disorders conflict with evidence-based ways of understanding psychosocial dysfunction among minoritized populations. Using research on SGM populations, and the detrimental impact of minority stress, we demonstrate how sociocultural context is inextricably linked to psychosocial functioning, which remains at odds with personality disorder theory and research. We first briefly review the historical roots of personality disorder theory; explore how sociocultural context is currently instantiated in official nosologies as the Diagnostic and Statistical Manual (DSM) and the Psychodynamic Diagnostic Manual (PDM); and illustrate how intra-individual personality disorder conceptualization fails to align with the accepted understanding of how minority stress impacts the health of SGM populations. Finally, we end with a few recommendations for (1) future research on personality disorders and (2) clinical work with SGM individuals who might demonstrate behaviors typically associated with a personality disorder diagnosis.

Despite many successful clinical trials to test HIV-prevention interventions for sexual minority men (SMM), not all SMM are reached by these trials. Identifying factors associated with non-participation in these trials could help to ensure the benefits of research extend to all SMM. Prospective participants in New York City and Miami were screened to determine eligibility for a baseline assessment for a mental health/HIV-prevention trial (N = 633 eligible on screen). Logistic regression and classification and regression tree (CART) analysis identified predictors of non-participation in the baseline, among those who were screened as eligible and invited to participate. Individuals who reported unknown HIV status were more likely to be non-participators than those who reported being HIV-negative (OR = 2.39; 95% CI 1.41, 4.04). In New York City, Latinx SMM were more likely to be non-participators than non-Latinx white SMM (OR = 1.81; 95% CI, 1.09, 2.98). A CART model pruned two predictors of non-participation: knowledge of HIV status and age, such that SMM with unknown HIV status and SMM ages 18-19 were less likely to participate. Young SMM who did not know their HIV status, and thus are more likely to acquire and transmit HIV, were less likely to participate. Additionally, younger SMM (18-19 years) and Latinx SMM in New York City were less likely to participate. The findings suggest the importance of tailored recruitment to ensure HIV-prevention/mental health trials reach all SMM.A pesar de muchos ensayos clínicos exitosos para probar intervenciones de prevención del VIH para hombres de minorías sexuales (HMS), no todos los HMS son alcanzados por estos ensayos. La identificación de factores asociados con la no participación en estos ensayos podría ayudar a asegurar que los beneficios de la investigación se extiendan a todos los HMS. Se realizaron evaluaciones de teléfono para determinar la elegibilidad para la visita inicial para un ensayo de salud mental/prevención del VIH (N = 633 elegibles en las evaluaciones). La regresión logística y el análisis de arboles de regresión y clasificación (ARC) identificaron predictores de no participación en la visita inicial, entre aquellos que fueron evaluados como elegibles e invitados a participar. Los individuos que reportaron estado desconocido de VIH fueron más probables a ser no participantes que aquellos que reportaron ser VIH negativos (RP = 2.39; IC 95% 1.41, 4.04). En la ciudad de Nueva York, HMS latinx eran más probable a no participar que los HMS blancos no latinx (RP = 1.81; IC 95%, 1.09, 2.98). Un modelo de ARC podó dos predictores de no participación: el conocimiento del estado de VIH y la edad, tal que los HMS con estado desconocido del VIH y las HMS de 18–19 años eran menos probables a participar. Los HMS jóvenes que no conocían su estado de VIH, y por lo tanto eran más probables a adquirir y transmitir el VIH, tenían menos probabilidades de participar. Además, las HMS más jóvenes (18–19 años) y los HMS latinx en la ciudad de Nueva York eran menos probables a participar. Los resultados sugieren la importancia de un reclutamiento personalizado para garantizar que los ensayos de prevención del VIH y salud mental lleguen a todos los SMM.

Syndemics, or comorbid and mutually reinforcing psychosocial problems, are associated with increased HIV risk among men who have sex with men (MSM). Although the dynamic interplay among syndemic indicators is theorized to be crucial for increasing risk of HIV acquisition, novel approaches are needed to understand how these syndemic problems interrelate. This study examined the associations between nine self-reported syndemic indicators in 194 MSM at high risk of HIV acquisition. We compared exploratory factor analyses (EFA) to a network analysis. In the present study, network analysis consisted of edges representing bidirectional partial polychoric correlations between nodes, which represent psychosocial syndemic indicators. EFA yielded a 1-factor solution including suicidal ideation (SI), injection drug use (IDU), depression, social anxiety, intimate partner violence, substance use, and sexual compulsivity, and excluded heavy drinking and childhood sexual abuse. Network analysis yielded a pattern of interconnectedness with the most central nodes being SI, IDU, substance use, and depression. Statistically significant relationships (absolute edge weights) were found between SI and depression, social anxiety, and IDU, and IDU and substance use. These results suggest that depression and substance use, especially more severe presentations of these conditions such as SI and IDU, are prominent interconnected components of the HIV syndemic among MSM at high risk for HIV acquisition. SI, IDU, substance use, and depression may indeed be prudent targets of intervention. Future research on the inclusion of these syndemic indicators in analytical models involving interaction terms may be warranted.

OBJECTIVES: Acceptance and Commitment Therapy (ACT) is a third-wave behavioral and cognitive therapy that increases psychological flexibility through mindfulness, acceptance, and value-driven behavior change. ACT has been successfully used to inform a variety of health interventions. Using non-therapists to deliver ACT-based behavioral health interventions offers an opportunity to provide cost efficient and integrated care, particularly among underserved populations experiencing barriers to mental health care, such as inadequate insurance, mental health stigma, and provider shortages. This systematic review aims to: 1) identify ACT-informed behavioral health interventions delivered by laypeople and 2) review the specific characteristics of each intervention including number and duration of sessions, delivery modality, interventionist training, and intervention outcomes. METHODS: Two databases (PubMed and PsycINFO) were systematically searched for relevant literature. To further identify relevant studies, references of included manuscripts were checked, the Association for Contextual Behavioral Science’s webpage was examined, and an email was sent to the ACBS Health Special Interest Group listserv. Study abstracts and full texts (in English) were screened, resulting in 23 eligible articles describing 19 different interventions. RESULTS: A total of 1,781 abstracts were screened, 76 were eligible for full-text review, and 23 were included in a narrative synthesis. There were 19 unique interventions identified and delivered by the following: general healthcare workers (n= 7), trained researchers (n = 5), women/mothers (n= 2), municipal workers (n= 2), and teachers (n = 3). Eleven studies were RCTs and eight utilized alternative study designs. Study quality varied, with two rated as high risk for bias and eight rated to have some concerns. Target populations included clinical and non-clinical samples. There was some consistency in the effects reported in the studies: increases in pain tolerance, acceptance, and identifying and engaging in value driven behavior, improvements in cognitive flexibility, and reductions in psychological distress. CONCLUSIONS: Findings suggest that ACT interventions can be successfully delivered by a variety of laypeople and effectively address psychological distress and increase health behaviors.

Background: Pre-exposure prophylaxis (PrEP) can significantly reduce HIV acquisition especially among communities with high HIV prevalence, including men who have sex with men (MSM). Much research has been finding suboptimal PrEP persistence; however, few studies examine factors that enhance PrEP persistence in real-world settings. Methods: We interviewed 33 patients who identified as MSM at three different PrEP clinics in three regions of the U.S. (Northeast, South, Midwest). Participants were eligible if they took PrEP and had been retained in care for a minimum of 6 months. Interviews explored social, structural, clinic-level and behavioral factors that influencing PrEP persistence. Results: Through thematic analysis we identified the following factors as promoting PrEP persistence: (1) navigation to reduce out-of-pocket costs of PrEP (structural), (2) social norms that support PrEP use (social), (3) access to LGBTQ+ affirming medical providers (clinical), (4) medication as part of a daily routine (behavioral), and (5) facilitation of sexual health agency (belief).Conclusions: In this sample, persistence in PrEP care was associated with structural and social supports as well as a high level of perceived internal control over protecting their health by taking PrEP. Patients might benefit from increased access, LGBTQ+ affirming medical providers, and communications that emphasize PrEP can promote sexual health.

The coronavirus disease 2019 (COVID-19) pandemic continues to put strain on health systems in the United States, leading to significant shifts in the delivery of routine clinical services, including those offering HIV pre-exposure prophylaxis (PrEP). We aimed to assess whether individuals discontinued PrEP use at higher rates during the COVID-19 pandemic and the extent to which disruptions to usual clinical care were mitigated through telehealth.Using data from an ongoing prospective cohort of men who have sex with men (MSM) newly initiating PrEP in 3 mid-sized cities (n = 195), we calculated the rate of first-time discontinuation of PrEP use in the period before the COVID-19 pandemic and during the COVID-19 pandemic and compared these rates using incidence rate ratios (IRRs). Furthermore, we compared the characteristics of patients who discontinued PrEP use during these periods with those who continued to use PrEP during both periods.Rates of PrEP discontinuation before the COVID pandemic and during the COVID-19 pandemic were comparable [4.29 vs. 5.20 discontinuations per 100 person-months; IRR: 1.95; 95% confidence interval (CI): 0.83 to 1.77]. Although no significant differences in the PrEP discontinuation rate were observed in the overall population, the rate of PrEP discontinuation increased by almost 3-fold among participants aged 18-24 year old (IRR: 2.78; 95% CI: 1.48 to 5.23) and by 29% among participants covered by public insurance plans at enrollment (IRR: 1.29; 95% CI: 1.03 to 5.09). Those who continued to use PrEP were more likely to have had a follow-up clinical visit by telehealth in the early months of the pandemic (45% vs. 17%).In this study, rates of PrEP discontinuation were largely unchanged with the onset of the COVID-19 pandemic. The use of telehealth likely helped retain patients in PrEP care and should continue to be offered in the future.

The COVID-19 pandemic qualifies as a major national and global disaster. Behavioral health providers are poised to provide psychological crisis interventions to reduce the psychosocial effects. This paper presents a brief transdiagnostic mental health maintenance intervention tailored to treat adults and families with distress symptoms as a consequence of the ongoing COVID-19 pandemic. The intervention components include evidence-based techniques which have been strategically selected to address mental health distress related to the pandemic and to prevent the escalation of distress as the pandemic continues. The intervention aims to be flexibly incorporated into care based on the provider and needs of the presenting individuals. The intervention incorporates components of evidence-based treatments such as Cognitive Behavioral Therapy and associated “third wave” therapies (e.g. Dialectical Behavioral Therapy and Acceptance and Commitment Therapy). The intervention can be delivered via telehealth and includes the following modules: 1) Agenda Setting & Avoidance Identification; 2) Responding to Difficult News/Normalizing Reactions; 3) Perspective Taking; 4) Situational Control/Acceptance; 5) Maintaining a Healthy Routine; 6) Coping with Stress; 7) Insomnia Preventions; and 8) Building Resiliency & Hope. A list of pleasurable activities that can be completed at home and technology modalities to maintain social interactions is included. The intervention also includes the Pandemic Mental Health Maintenance Intervention handout to provide to patients. Research is needed to test this intervention in a randomized controlled trial and assess efficacious intervention implementation strategies.

Sexual minority clients are more likely to experience emotional disorders and other psychiatric conditions than the general population. This health disparity is not attributable to an individual's sexual minority identity, but rather, the social milieu that produces a unique set of stigma-related stressors. Therefore, mental health disparities affecting sexual minority communities are best understood through a minority stress framework. This chapter outlines mental health disparities affecting sexual minority communities, tailored evidence-based treatments, and clinical considerations for working with sexual minority clients. We hope this chapter can offer pragmatic guidance on how best to tailor intervention approaches given the unique needs and lived experiences of this population.

SARS-CoV-2 is a novel coronavirus and the cause of COVID-19 (https://www.who.int/). There are currently 45 million individuals diagnosed with COVID-19 and over 1.2 million who have died worldwide.1 Of these, nine million cases and over 228 000 deaths have occurred in the USA.1 COVID-19 has disproportionately impacted individuals with comorbidities and of older age. Other social risk factors predicting vulnerability to COVID-19 include low socioeconomic status, race/ethnicity and occupational setting. There has been a higher number of COVID-19 cases and deaths among marginalised groups. Populations in the USA with a greater COVID-19 burden include African American/black and Hispanic/Latino communities. There are limited data on SARS-CoV-2 and sexual orientation and gender diversity. However, based on existing health disparities, the lesbian, gay, bisexual, transgender and queer (LGBTQ+) community is also likely to be disproportionately impacted by COVID-19. A key component of addressing COVID-19 is diagnostic testing for SARS-CoV-2. However, approaches and models to implementing accessible SARS-CoV-2 testing, especially for vulnerable communities, have not been well described. STIs also disproportionately affect underserved and marginalised communities, with 376 million new infections of curable STIs worldwide in 2016.2 In the USA, African American/black, Hispanic/Latino and LGBTQ+ individuals are at a greater risk for STIs due to proximal and distal social determinants of health, including economic stability, physical environments, social and community context, education, and healthcare access.3 Similarly, the impact of social determinants has worsened STI health outcomes among vulnerable populations across the world.3 Given the overlap in communities affected by COVID-19 and STIs, there are significant lessons to be learned from experiences with STI testing. We examine challenges related to COVID-19 testing and offer potential solutions derived from STI testing that may increase access for those most at risk and mitigate health disparities (figure 1). Figure 1 Improving access to COVID-19 testing. The ability to …

Due to minority stress, sexual minority men experience mental health disparities. Sexual minority men who engaged in cognitive-behavioral therapy to address the minority stress underlying their distress completed an exercise eliciting their own resilience. This exercise involved writing an advice letter to a hypothetical peer about coping with minority stress. Qualitative analysis of these letters yielded 18 codes grouped into three categories reflecting resilience to minority stress. Categories included (1) cultivating internal affirmation strategies, (2) building supportive relationships and community, and (3) using cognitive and behavioral skills to cope with minority stress. Findings highlight this population’s resilience and suggest building resilience through treatment.

Retention in HIV pre-exposure prophylaxis (PrEP) care is critical for effective PrEP implementation. Few studies have reported long-term lost to follow-up (LTFU) and re-engagement in PrEP care in the United States. Medical record data for all cisgender patients presenting to the major Rhode Island PrEP clinic from 2013 to 2019 were included. LTFU was defined as no PrEP follow-up appointment within 98 days. Re-engagement in care was defined as individuals who were ever LTFU and later attended a follow-up appointment. Recurrent event survival analysis was performed to explore factors associated with PrEP retention over time. Of 654 PrEP patients, the median age was 31 years old [interquartile range (IQR): 25, 43]. The majority were male (96%), White (64%), non-Hispanic (82%), and insured (97%). Overall, 72% patients were ever LTFU and 27% of those ever LTFU re-engaged in care. Female patients were 1.37 times [crude hazard ratio (cHR): 1.37; 95% confidence interval (CI): 0.86–2.18] more likely to be LTFU than male patients, and a 1-year increase in age was associated with a 1% lower hazard of being LTFU (cHR: 0.99; CI: 0.98–0.99). Being either heterosexual (aHR: 2.25, 95% (CI): 1.70–2.99] or bisexual (aHR: 2.35, 95% CI: 1.15–4.82) was associated with a higher hazard of loss to follow-up compared with having same-sex partners only. The majority of PrEP users were LTFU, especially at the first 6 months of PrEP initiation. Although a significant number were re-engaged in care, targeted interventions are needed to improve retention in PrEP care. This study characterized the natural projection of loss to follow-up and re-engagement in HIV PrEP care using a longitudinal clinic cohort data and explored associated factors for guiding future interventions to improve retention in PrEP 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

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.

Author(s): Satyanarayana, Satyanand; Safren, Steven A; Rogers, Brooke G; Bainter, Sierra A; Christopoulos, Katerina A; Fredericksen, Rob J; Mathews, William C; Moore, Richard D; Mugavero, Michael J; Napravnik, Sonia; Carrico, Adam W; Mimiaga, Matthew J; Mayer, Kenneth H; Crane, Heidi M | Abstract: IntroductionLittle 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.MethodsData 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 (meann=n4.3 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 RNAnln400/mL) using hierarchical linear modelling.ResultsPatients 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; pnln0.0005). Cisgender women, cisgender heterosexual men and cisgender men of undisclosed sexual orientation had, respectively, 0.47 (95% CI: 0.35 to 0.59; pnln0.0005), 0.34 (95% CI: 0.20 to 0.49; pnln0.0005) and 0.22 (95% CI: 0.09 to 0.35; pnln0.005) 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; pnln0.0005). Each between-syndemic condition predicted 0.23 estimated HIV transmissions/100 patients/year (95% CI: 0.17 to 0.28; pnln0.0005).ConclusionsEstimated 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.

OBJECTIVE/BACKGROUND: Insomnia is a prevalent and interfering comorbidity of HIV infection. Nearly 70% of people living with HIV/AIDS (PLWHA) experience symptoms of insomnia and associated distress. The current study examined the mechanisms of insomnia in HIV health status and health-related quality of life and explored behavioral pathways to explain relationships. PARTICIPANTS: Participants (N = 103) were active patients in an HIV clinic located within a nonprofit, tertiary care hospital in a large, urban city in the Southeast United States. METHODS: Participants completed a clinical sleep interview and self-report assessments for adherence to antiretroviral medication, depression (PHQ-9), quality of life (ACTG-QOL), and relevant covariates. Viral load and CD4 were obtained via medical chart review. RESULTS: Insomnia affected 67% of the clinic sample. Insomnia symptoms were directly associated with poorer health-related quality of life (p

Interventions addressing syndemics and ART adherence are needed for individuals with uncontrolled HIV and psychosocial problems. Twenty-seven participants with detectable HIV plasma viral load (PVL) or recent STI participated in an open trial of transdiagnostic adherence counseling and cognitive behavioral therapy. Outcomes were collected at baseline, 4-, and 8-months. Log PVL improved from baseline to 4-month (γ = − 1.13, 95% CI − 1.72, − 0.55, p

OBJECTIVE: People living with HIV/AIDS (PLWHA) are disproportionally exposed to a host of structural, community, and individual-level physical and psychosocial stressors also termed ‘syndemic conditions.’ The current study aimed to examine the association between experiencing syndemic conditions and physiological stress response and be associated with bodily inflammation, including Interlekin-6 (IL-6) and C-reactive protein (CRP) in PLWHA. DESIGN: Participants (N = 103) were recruited from a public HIV clinic. They provided saliva samples of IL-6 and CRP and completed psychosocial measures. MAIN OUTCOME MEASURES: Levels of circulating salivary IL-6 and CRP. RESULTS: When predictors (birth country, recent housing instability, and incarceration history) were simultaneously entered into a regression model, only incarceration history was negatively associated with IL-6 [b = −.27, t(98) = −3.11, p = .002]. For CRP, the resulting regression model was not significant, [F(3, 98) = 2.23, p = .090]. CONCLUSION: Although we had expected higher levels of syndemics to be associated with higher levels of circulating inflammation, in our sample, length of incarceration was associated with lower levels of circulating IL-6. Findings are therefore suggestive of a stress response disruption resulting in a negative feedback loop as the long-term impact of chronic stress on inflammation.

PURPOSE: There have been significant biomedical improvements in the treatment and prevention of HIV over the past few decades. However, new transmissions continue to occur. Alcohol use is a known barrier to medication adherence and consistent condom use and therefore may affect treatment as prevention (TasP) efforts. The purpose of this study was to further explore how alcohol is associated with condom use and sexual transmission behavior in three international cities. METHOD: HIV Prevention Trials Network 063 was an observational mixed-methods study of HIV-infected patients currently in care in Rio de Janeiro, Brazil; Chiang Mai, Thailand; and Lusaka, Zambia. Across these three global cities, 80 qualitative interviews were conducted from 2010 to 2012. From these interviews, quotes related to substance use, almost all of which were alcohol, were analyzed using thematic analysis to identify how the use was related to sexual transmission behaviors. RESULTS: Overall, the theme that alcohol impairs cognitive abilities emerged from the data and included the following subthemes: expectancies, impaired decision-making, loss of control, and less concern for others. Themes specific to international settings and risk subgroups were also identified. CONCLUSION: Our analysis identified how alcohol influences sexual transmission behavior in HIV patients in three international settings. These findings may provide direction for content development for future secondary prevention interventions to effectively implement TasP internationally.

Sleep problems are prevalent in people living with HIV/AIDS; however, few studies examine how poor sleep affects mental health and quality of life longitudinally. A sample of people living with HIV/AIDS from a randomized trial ( N = 240; mean age = 47.18; standard deviation = 8.3; 71.4% male; 61.2% White) completed measures of depression (Montgomery–Åsberg Depression Rating Scale), health-related quality of life (AIDS Clinical Trial Group Quality of Life Measure), and life satisfaction (Quality of Life Inventory) at baseline and 4, 8, and 12 months. Controlling for time, condition, and relevant interactions, sleep problems significantly predicted worse outcomes over time ( ps

People with HIV experience elevated levels of co-occurring psychosocial concerns, which can interfere with HIV-related self-care behaviors, such as medication adherence. We recently developed transdiagnostic, integrated cognitive-behavioral therapy and motivational interviewing psychotherapy to address interrelated psychosocial problems (syndemics) that can interfere with medication adherence and self-care among people with uncontrolled HIV (i.e., a detectable viral load). Through completion of a field trial that included development, clinical supervision, treatment, and administrative coordination of this project, we identified recommendations for engaging, retaining, and delivering transdiagnostic cognitive-behavioral therapy/motivational interviewing to individuals with HIV and experiencing psychosocial and structural barriers to mental and physical health. We describe these recommendations, which include (a) building the relationship; (b) addressing HIV in the context of syndemics; (c) attending to the impact of stigma on health; (d) being flexible in delivering the treatment; (e) managing emergent crises with relevant skill material; (f) tailoring the treatment to education, language, and sociocultural context; (g) implementing problem-solving skills for structural barriers; (h) scheduling flexibly and following up; (i) colocating mental health services and coordinating among providers; and (j) providing a comfortable and affirming physical space. In addition to describing these recommendations, we provide clinical examples and highlight empirical research to illustrate and support using these recommendations. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Approximately 1.1 million individuals in the United States are living with HIV/AIDS. HIV disproportionately affects young, black men who have sex with men (YBMSM). Recent biomedical advances, including the use of antiretroviral therapy as pre-exposure prophylaxis (PrEP), hold promise for preventing HIV infections. However, PrEP uptake remains slow among those most at-risk. To develop and test an intervention to address HIV disparities in YBMSM, we conducted qualitative interviews with 29 YBMSM from Jackson, Mississippi, to learn more about their views of PrEP. Twenty-nine PrEP-eligible YBMSM were enrolled and participated in either semistructured interviews or focus groups. They were asked about PrEP use, messaging, and promotion. Data were coded based on an iteratively developed coding scheme and entered into NVivo to facilitate thematic analysis. Our analysis identified the following three main themes: (1) the role of setting, context, and stigma in health care, (2) targeted PrEP messaging is further stigmatizing, and (3) recommendations for PrEP messaging and care. YBMSM in our sample felt highly stigmatized in their current environment and felt that PrEP messaging targeting YBMSM only enhanced their sense of marginalization. They concluded that broad and inclusive messaging would be just as relevant and cause less stigma. Our findings were somewhat surprising, as several prior studies benefited from using targeted materials to engage YBMSM in HIV prevention and PrEP uptake. The study's location may explain this difference in findings, which suggests the importance of considering local conditions and opinions when developing interventions for HIV prevention among minority populations.

Epidemiologic studies have demonstrated a positive association between obesity and food insecurity, but the mechanisms of this relationship are not well established. The purpose of the current study was to explore 5 potential mediating variables of the relationship between food insecurity and obesity: (1) home food environment, (2) eating out, (3) unhealthy food preparation, (4) food cost, and (5) mental health. Data were from 116 participants enrolled in a community-based weight gain prevention study in rural south Georgia. No evidence of complete mediation was found; however, strong relationships among demographic factors, food insecurity, and obesity were documented. Future research should seek to confirm our findings in larger, more diverse samples. Practice implications include working with communities to develop multilevel interventions that could address both overweight and food insecurity.

The purpose of this study was to systematically review recent empirical literature on smoking cessation in racial/ethnic minority groups. Specifically, we focused on smoking cessation intervention trials and investigations of factors associated with cessation. Studies published between 2010 and September 2014 were considered. Nine smoking cessation intervention trials and 16 studies examining correlates of smoking behavior were published in within the past 3 years. Results demonstrated promise for varenicline in facilitating cessation among African Americans and Hispanics, and culturally specific behavioral counseling appears to be efficacious among Asian Americans. In trans-group comparisons, racial/ethnic minorities reported greater quit attempts compared to Whites; yet success may be reduced due to factors such as menthol smoking, low pharmacotherapy use, and lower readiness to quit. Recommendations for evidence-based interventions and future research are offered.