Publications by authors named "Alberto Edeza"

18 Publications

  • Page 1 of 1

Psychosocial Problems and Vulnerability to HIV in a Multi-City Prospective Cohort of Young Transgender Women in the United States: A Structural Equation Modeling Study.

J Acquir Immune Defic Syndr 2021 Apr;86(5):544-551

Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI.

Background: Gender-based stigma contributes to increased HIV prevalence, but little is known about psychosocial mechanisms linking stigma and HIV risk among young transgender women (YTW).

Setting: This study uses data from Project LifeSkills, a randomized controlled efficacy trial of an empowerment-based HIV prevention intervention for YTW (N = 233). YTW were recruited in Boston, MA, and Chicago, IL, between 2012 and 2015 and completed study assessment visits at baseline and months 4 and 12.

Methods: Using autoregressive structural equation modeling, we examined whether poor social support and psychological distress at 4 months mediate the prospective relationship between gender-based stigma at baseline and condomless anal and vaginal sex (CAVS) acts at 4 and 12 months; all models were adjusted for treatment arm, HIV serostatus, study site, and sociodemographics.

Results: Gender-based stigma at baseline was directly associated with increased CAVS at 4 months [adjusted incidence rate ratio (aIRR) = 1.18, 95% confidence interval (CI): (1.05 to 1.33)] and 12 months [aIRR = 1.17, 95% CI: (1.02 to 1.34)]. Gender-based stigma was also associated with higher psychological distress at 4 months [b = 0.70, 95% CI: (0.13 to 1.27)], which in turn was marginally associated with increased CAVS at 12 months [aIRR = 1.03, 95% CI: (1.00 to 1.06)]. Contrary to expectations, poor social support at 4 months was associated with decreased CAVS at 12 months [aIRR = 0.40, 95% CI: (0.28 to 0.59)].

Conclusions: Future HIV prevention interventions with YTW should consider addressing experiences of gender-based stigma and the psychological distress that may ensue from gender-based stigma. More research is needed to understand the influence of poor social support on sexual behaviors in this population.
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http://dx.doi.org/10.1097/QAI.0000000000002615DOI Listing
April 2021

Expanding Gender-Based Health Equity Framework for Transgender Populations.

Transgend Health 2021 Feb 15;6(1):1-4. Epub 2021 Feb 15.

Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, USA.

The gender-transformative approach to health promotion in the United States and globally has been central to defining gender as a determinant of health and advancing health programs, services, and policies that respond to gender-based inequities. However, current gender frameworks are built on historical perspectives that center cisgender people's experiences and reinforce the gender binary. This restricted focus does not respond to health inequities experienced by transgender people-to the detriment of health programs, services, and policies. As transgender people's health and rights continue to garner attention in movements across health services and policy spaces, it is crucial for frameworks to be expansively redefined to achieve truly transformative gender equality and equity for all gender identities and expressions.
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http://dx.doi.org/10.1089/trgh.2020.0026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7906221PMC
February 2021

Transactional Sex Is Associated with Income Level and Psychosocial Health Problems among Gay and Bisexual Men (GBM) in Nigeria, Africa.

J Sex Res 2020 Dec 7:1-7. Epub 2020 Dec 7.

Department of Behavioral and Social Sciences, Brown University School of Public Health.

Gay and bisexual men (GBM) who report engagement in transactional sex are at increased risk for HIV acquisition. The current study aimed to assess the prevalence of transactional sex and its association with demographic characteristics, social marginalization, HIV sexual risk behaviors, psychosocial health problems, and access to healthcare services among a multi-site sample of GBM in Nigeria. Bivariate and multivariable logistic regression were used to examine factors associated with engagement in transactional sex in the previous 3 months. More than a third (39.6%) of the participants reported engagement in transactional sex in the previous 3 months. In the multivariable model, factors associated with engagement in transactional sex included: reporting a monthly income of 30,000 Naira [adjusted odds ratio (aOR) 1.98; 95% CI: 1.12 to 3.35], compared to 30,000 or more Naira monthly income, reporting 4 or more receptive anal sex acts in the previous 30 days (aOR 2.45; 95% CI: 1.31 to 4.57) compared to reporting none, and having depressive symptoms (aOR 1.82; 95% CI: 1.06 to 3.14). There is an urgent need for interventions that address the economic disenfranchisement and psychosocial problems experienced by GBM in Nigeria, which has implications for sexual health.
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http://dx.doi.org/10.1080/00224499.2020.1854649DOI Listing
December 2020

Sexual orientation and social network size moderate associations between stigma and problematic alcohol use among male sex workers in the US Northeast: an observational study.

Sex Health 2020 11;17(5):429-436

Department of Behavioral and Social Sciences, Brown University School of Public Health, 121 South Main Street, 4th Floor, Providence, RI 02912, USA; and Center for Health Promotion and Health Equity, Brown University School of Public Health, 121 South Main Street, 8th Floor, Providence, RI 02912, USA; and Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, 2nd Floor, Providence, RI 02912, USA; and The Fenway Institute, Fenway Health, 1340 Boylston Street, Boston, MA 02215, USA; and Corresponding author. Email:

Background Stigma is associated with poor health among sexual minority individuals. However, no studies have examined the relationship between stigma and problematic drinking among male sex workers (MSWs). This study examined the relationship between sex work stigma and problematic alcohol use among MSWs.

Methods: Using baseline data from a cohort of 98 MSWs in the US Northeast enrolled between 2015 and 2016, we used logistic regression to examine associations between sex work stigma and hazardous drinking (Alcohol Use Disorders Identification Test (AUDIT) score ≥8) and sex work while drunk, and tested whether sexual orientation (gay vs non-gay identified) and social network size moderated these associations.

Results: Almost half the sample (n = 46; 44%) reported hazardous drinking and 56 MSWs (57%) reported engaging in sex work while drunk. Sex work stigma was associated with hazardous drinking (adjusted odds ratio (aOR) 1.2, 95% confidence interval (CI) 1.05-1.36). Sexual orientation marginally moderated this relationship (P = 0.07), such that it was only significant among gay-identified MSWs (aOR 1.91, 95% CI 1.11-3.28), not among non-gay MSW. Similarly, sexual orientation moderated the effect of sex work stigma on sex work while drunk (P = 0.02), which was only significant among gay-identified MSWs (aOR 1.65, 95% CI 1.05-1.60). Social network size also moderated the effect of sex work stigma on sex work while drunk (P = 0.02), which was only significant among MSWs with small networks (aOR 1.26, 95% CI 1.00-1.58), suggesting large networks can be protective.

Conclusions: Gay MSWs may be particularly vulnerable to alcohol-related effects of stigma. Future interventions should consider engaging social networks to curb problematic drinking among MSWs.
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http://dx.doi.org/10.1071/SH20137DOI Listing
November 2020

"Health Is on the Back Burner:" Multilevel Barriers and Facilitators to Primary Care Among People Who Inject Drugs.

J Gen Intern Med 2021 Jan 11;36(1):129-137. Epub 2020 Sep 11.

Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, 02118, USA.

Background: The estimated 2.2 million people who inject drugs (PWID) in the USA experience significant gaps in preventive healthcare and a high burden of infectious, psychiatric, and other chronic diseases. Many PWID rely on emergency medical services, which are costly and not designed to deliver preventive services, manage chronic conditions, or address social needs.

Objective: The objective of this study was to explore barriers and facilitators to primary care utilization from the perspectives of PWID in New England, a region highly affected by the overdose crisis.

Design: Participants completed semi-structured qualitative interviews exploring substance use and healthcare utilization patterns.

Participants: We recruited 78 PWID through community-based organizations (e.g., syringe service programs) in 16 urban and non-urban communities throughout Massachusetts and Rhode Island.

Approach: Thematic analysis identified barriers and facilitators to primary care utilization at the individual, interpersonal, and systemic levels.

Key Results: Among 78 PWID, 48 described recent primary care experiences; 33 had positive experiences and 15 described negative experiences involving discrimination or mistrust. Individual-level barriers to primary care utilization included perceived lack of need and competing priorities (e.g., avoiding opioid withdrawal, securing shelter beds). Interpersonal-level barriers included stigma and perceived low quality of care for PWID. Systemic-level barriers included difficulty navigating healthcare systems, inadequate transportation, long wait times, and frequent provider turnover. Participants with positive primary care experiences explained how appointment reminders, flexible hours, addiction medicine-trained providers, case management services, and transportation support facilitated primary care utilization and satisfaction.

Conclusions: Findings regarding the multilevel barriers and facilitators to accessing primary care among PWID identify potential targets for programmatic interventions to improve primary care utilization in this population. Based on these findings, we make recommendations for improving the engagement of PWID in primary care as a means to advance individual and public health outcomes.
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http://dx.doi.org/10.1007/s11606-020-06201-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7858998PMC
January 2021

Experienced barriers to adherence to pre-exposure prophylaxis for HIV prevention among MSM: a systematic review and meta-ethnography of qualitative studies.

AIDS Care 2020 Jun 12:1-9. Epub 2020 Jun 12.

Department of Social and Behavioral Health Sciences, Brown University School of Public Health, Providence, RI, USA.

Men who have sex with men (MSM) in the United States are at disproportionate risk for HIV. Once-daily pre-exposure prophylaxis (PrEP) for HIV prevention is a highly effective method of preventing HIV infection; however, optimal adherence is necessary to maintain effectiveness. Many studies have profiled perceived barriers to adherence among at-risk MSM; however, nearly a decade after FDA approval, there has been little work examining experienced barriers to adherence among MSM who have previously used the medication. To assess the current state of this literature and its implications for behavioral interventions, we conducted a meta-ethnography (i.e., A systematic review and synthesis of qualitative studies) of experiences with PrEP use among cis-gender MSM in the United States. We found that structural-level interventions, such as telehealth and pharmacist-prescribed approaches to PrEP distribution, may circumvent barriers to uptake and adherence for some MSM, but may not be enough for already underserved communities, such as MSM of color. Furthermore, interpersonal-level factors, such as enacted PrEP stigma by providers and peers, highlight the necessary consideration of social identity in the branding of PrEP for HIV prevention. Tailored interventions should consider experienced barriers to PrEP adherence across socioecological levels to be most effective.
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http://dx.doi.org/10.1080/09540121.2020.1778628DOI Listing
June 2020

Poor sleep health is associated with increased mental health problems, substance use, and HIV sexual risk behavior in a large, multistate sample of gay, bisexual and other men who have sex with men (GBMSM) in Nigeria, Africa.

Sleep Health 2020 10 20;6(5):662-670. Epub 2020 Mar 20.

Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA; Center for Health Equity Research, Brown School of Public Health, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; The Fenway Institute, Fenway Health, Boston, MA, USA; Department of Psychiatry and Human Behavior, Brown University Alpert Medical School, Providence, RI, USA.

Background: Poor sleep health has been linked to mental health problems, substance use, and sexual risk-taking among gay, bisexual, and other men who have sex with men (GBMSM). No known published study has examined these relationships among African GBMSM. Consequently, we investigated poor sleep health and associated health-related factors among a large multistate sample of Nigerian GBMSM.

Methods: Between March and June 2019, 406 GBMSM were recruited from Abuja, Delta, Lagos, and Plateau and asked to complete an interviewer-administered survey. Bivariate and multivariable logistic regression models were constructed to examine the relationship between poor sleep health and other health-related factors.

Results: In the past month, 45.5% of participants reported sleeping an average of 6 hours or less every night, and 30.7% reported experiencing a sleep problem. Factors associated with increased odds of reporting short sleep included: residing in Delta [adjusted odds ratio (aOR) 2.16; 95% confidence interval (CI): 1.15 to 4.04] and Lagos (aOR 2.40; 95% CI: 1.29 to 4.45), depressive symptoms (aOR 1.94; 95% CI: 1.13 to 3.32), and reporting lifetime history of using four or more drugs (aOR 2.52; 95% CI: 1.06 to 6.01). Reporting condom use at last anal sex was associated with decreased odds of reporting short sleep in the last month (aOR 0.54; 95% CI: 0.31 to 0.92). Factors associated with increased odds of reporting sleep problems included: reporting an STI diagnosis in the last year (aOR 1.79; 95% CI: 1.05 to 3.05) and reporting monthly or higher polydrug use in the last 3 months (aOR 2.19; 95% CI: 1.14 to 4.24).

Discussion: Sleep health interventions should be developed for Nigerian GBMSM, which may improve mental health and reduce substance use and sexual risk-taking.
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http://dx.doi.org/10.1016/j.sleh.2020.02.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7501157PMC
October 2020

Network-Level Correlates of Sexual Risk Among Male Sex Workers in the United States: A Dyadic Analysis.

J Acquir Immune Defic Syndr 2020 02;83(2):111-118

Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, RI.

Background: Male sex workers (MSWs) are at increased risk of HIV infection in the United States. Research is limited on sexual and drug use network characteristics of MSWs.

Setting: Community-based organization and health center in 2 US Northeast cities.

Methods: One hundred MSWs completed a behavioral assessment and sexual and drug network inventory. Using dyadic analyses, we assessed whether network characteristics, including sex worker-male client age, race, and HIV status homophily and risk multiplexity (ie, overlap in drug-use and sex networks), were associated with condom use.

Results: MSW participants' mean age was 33.6. Two-thirds identified as Black or Latino, 12% identified as heterosexual, and 90% reported recent drug use. Participants reported an average of 5.3 male clients in the past month (SD = 3.4), and having anal sex with 74% of these clients, at a rate of 2.2 times per month (SD = 4.6). Participants reported inconsistent condom use during anal sex with 53% of clients. In multivariable models, inconsistent condom use was more common in relationships with presumed HIV status homophily [odds ratio (OR): 1.25; 95% confidence interval (CI): 1.07 to 1.46] and sexual and drug network multiplexity (OR: 1.19; 95% CI: 1.09 to 1.30); and less common within relationships where the client is older than the MSW participant (OR: 0.83; 95% CI: 0.74 to 0.93). Number of multiplex relationships was positively associated with number of condomless anal sex acts with male clients (incidence rate ratio: 1.35; 95% CI: 1.19 to 1.54).

Conclusions: Network characteristics may contribute to disproportionate HIV risk among MSWs. Modeling studies should include network characteristics when simulating HIV transmission, and future HIV interventions should address the role of networks.
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http://dx.doi.org/10.1097/QAI.0000000000002230DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7262793PMC
February 2020

"We don't get much of a voice about anything": perspectives on photovoice among people who inject drugs.

Harm Reduct J 2019 11 27;16(1):61. Epub 2019 Nov 27.

Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA.

Background: In the context of the current US opioid crisis, people who inject drugs (PWID) are increasingly researched, but their ability to tell their own stories may be limited. Photovoice is a participatory action research method that allows participants to use photography to directly depict their experiences.

Methods: We conducted interviews with PWID (n = 33) as part of a qualitative study on the health needs of PWID in the USA to explore interest and acceptability of photovoice as a potential research method and way to share their voices.

Results: Participants identified facilitators and barriers to participating in a future photovoice project. Facilitators included a chance to depict one's unique experience, help others in need by sharing one's own story, and photography being a more "comfortable" way to tell their stories than traditional research methods. Barriers included safety concerns, embarrassment, and ability to retain cameras. Participants also identified areas of sensitivity related to documenting drug use.

Conclusions: While we found broad acceptability of photovoice, barriers would need to be addressed and additional training and support for research staff and potential participants related to the ethics of public photography and engaging PWID in photovoice research would be required.
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http://dx.doi.org/10.1186/s12954-019-0334-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6882205PMC
November 2019

HIV Pre-exposure Prophylaxis for People Who Inject Drugs: The Context of Co-occurring Injection- and Sexual-Related HIV Risk in the U.S. Northeast.

Subst Use Misuse 2020 9;55(4):525-533. Epub 2019 Oct 9.

Department of Behavioral & Social Health Sciences, Brown University School of Public Health, Providence, Rhode Island, USA.

People who inject drugs (PWID) are at increased risk for HIV infection through sharing contaminated needles and injection equipment, and engaging in condomless sex. To qualitatively examine the overlapping nature of these behaviors among PWID in the US Northeast. We recruited HIV-uninfected PWID and key informants through community-based organizations. Qualitative interviews explored sexual partnerships as they related to sharing contaminated needles and injection equipment, engaging in condomless sex, and associated indications for PrEP among PWID. Among 33 PWID, 66% engaged in condomless vaginal or anal sex in the past 3 months, and 27% had three or more sexual partners in this same time period. Over half engaged in any past month distributive or receptive syringe sharing (64%). We identified three contexts through which overlapping sexual and injection-related HIV risks emerged, including (1) multiple concurrent sexual partnerships; (2) using and injecting drugs with sexual partners (including increase injecting of crystal methamphetamine); and (3) exchanging sex for money or drugs (including among male PWID). Condom use was inconsistent across these contexts. Limited interactions with healthcare providers often resulted in sexual risks being overlooked in light of competing health concerns. Sexual risk for HIV acquisition is complex and multi-faceted among PWID yet may be overlooked by prevention and healthcare providers. Comprehensive HIV prevention efforts must acknowledge the distinct contexts in which overlapping injection and sexual risk behaviors occur. Increased sexual health screening and risk reduction services including PrEP for PWID may help curtail transmission in this population.
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http://dx.doi.org/10.1080/10826084.2019.1673419DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7028455PMC
October 2019

HIV Pre-exposure Prophylaxis for People Who Inject Drugs: The Context of Co-occurring Injection- and Sexual-Related HIV Risk in the U.S. Northeast.

Subst Use Misuse 2020 9;55(4):525-533. Epub 2019 Oct 9.

Department of Behavioral & Social Health Sciences, Brown University School of Public Health, Providence, Rhode Island, USA.

People who inject drugs (PWID) are at increased risk for HIV infection through sharing contaminated needles and injection equipment, and engaging in condomless sex. To qualitatively examine the overlapping nature of these behaviors among PWID in the US Northeast. We recruited HIV-uninfected PWID and key informants through community-based organizations. Qualitative interviews explored sexual partnerships as they related to sharing contaminated needles and injection equipment, engaging in condomless sex, and associated indications for PrEP among PWID. Among 33 PWID, 66% engaged in condomless vaginal or anal sex in the past 3 months, and 27% had three or more sexual partners in this same time period. Over half engaged in any past month distributive or receptive syringe sharing (64%). We identified three contexts through which overlapping sexual and injection-related HIV risks emerged, including (1) multiple concurrent sexual partnerships; (2) using and injecting drugs with sexual partners (including increase injecting of crystal methamphetamine); and (3) exchanging sex for money or drugs (including among male PWID). Condom use was inconsistent across these contexts. Limited interactions with healthcare providers often resulted in sexual risks being overlooked in light of competing health concerns. Sexual risk for HIV acquisition is complex and multi-faceted among PWID yet may be overlooked by prevention and healthcare providers. Comprehensive HIV prevention efforts must acknowledge the distinct contexts in which overlapping injection and sexual risk behaviors occur. Increased sexual health screening and risk reduction services including PrEP for PWID may help curtail transmission in this population.
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http://dx.doi.org/10.1080/10826084.2019.1673419DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7028455PMC
October 2019

The HIV-Related Risk Factors of the Cisgender Male Sexual Partners of Transgender Women (MSTW) in the United States: A Systematic Review of the Literature.

AIDS Educ Prev 2019 10;31(5):463-478

Brown University School of Public Health, Providence, Rhode Island.

Cisgender male sexual partners of transgender women (MSTW) may be at risk for HIV infection. We performed a review of HIV risk factors among MSTW. We searched PubMed database for empirical quantitative U.S.-based studies that included MSTW and were published in English up to November 2018. Of the 4,680 total papers identified, 6 unique studies were included. MSTW displayed heterogeneity in HIV risk factors (e.g., condom use, sexual partners, sexual positions, substance use). In our exploratory meta-analyses, estimated prevalence of self-reported HIV positive status among MSTW was 30.6%, HIV unknown status was 8.8%, and self-reported condomless anal sex with transgender women was 46.1%. Reports of sexual health communication with transgender women was low. More research on MSTW populations is needed to better understand this population's unique needs in the context of recent advancements in HIV prevention.
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http://dx.doi.org/10.1521/aeap.2019.31.5.463DOI Listing
October 2019

Development of a Social Network-Based Intervention to Overcome Multilevel Barriers to ART Adherence Among Adolescents in Brazil.

AIDS Educ Prev 2019 04;31(2):111-126

Brown University School of Public Health, Providence, Rhode Island.

Brazil's comprehensive HIV treatment program does not specifically address ART adherence challenges for adolescents-a group accounting for the largest number of incident HIV infections in Brazil. We conducted three focus groups with 24 adolescents (age 15-24) living with HIV in Rio de Janeiro, separately for cisgender men who have sex with men, heterosexual-identified cisgender men and women, and transgender women of any sexual orientation, and key informant interviews (n = 7) with infectious disease specialists and HIV/AIDS service organization staff. Content analysis identified socioecological barriers and facilitators to adherence, including individual (e.g., low knowledge, side effects, and substance use), interpersonal (e.g., stigma from partners and health care providers) and structural (e.g., transportation and medication access) barriers. Overlapping and unique barriers emerged by sexual/gender identity. A community-informed, theory-driven ART adherence intervention for adolescents that is organized around identity and leverages social networks has the potential to improve HIV treatment and health outcomes for Brazilian adolescents.
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http://dx.doi.org/10.1521/aeap.2019.31.2.111DOI Listing
April 2019

Strategies used by people who inject drugs to avoid stigma in healthcare settings.

Drug Alcohol Depend 2019 05 8;198:80-86. Epub 2019 Mar 8.

Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, United States. Electronic address:

Background: People who inject drugs (PWID) have limited engagement in healthcare services and report frequent experiences of stigma and mistreatment when accessing services. This paper explores the impact of stigma against injection drug use on healthcare utilization among PWID in the U.S. Northeast.

Methods: We recruited PWID through community-based organizations (CBOs; e.g., syringe service programs). Participants completed brief surveys and semi-structured interviews lasting approximately 45 min exploring HIV risk behaviors and prevention needs. Thematic analysis examined the emergent topic of stigma experiences in relation to healthcare utilization.

Results: Among 33 PWID (55% male; age range 24-62 years; 67% White; 24% Latino), most used heroin (94%) and injected at least daily (60%). Experiences of dehumanization in healthcare settings were common, with many participants perceiving that they had been treated unfairly or discriminated against due to their injection drug use. As participants anticipated this type of stigma from healthcare providers, they developed strategies to avoid it, including delaying presenting for healthcare, not disclosing drug use, downplaying pain, and seeking care elsewhere. In contrast to large institutional healthcare settings, participants described non-stigmatizing environments within CBOs, where they experienced greater acceptance, mutual respect, and stronger connections with staff.

Conclusions: Stigma against injection drug use carries important implications for PWID health. Increased provider training on addiction as a medical disorder could improve PWID healthcare experiences, and integrating health services into organizations frequented by PWID could increase utilization of health services by this population.
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http://dx.doi.org/10.1016/j.drugalcdep.2019.01.037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6521691PMC
May 2019

Evidence-based and guideline-concurrent responses to narratives deferring HCV treatment among people who inject drugs.

Harm Reduct J 2019 02 11;16(1):14. Epub 2019 Feb 11.

Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Ave, 442e, Boston, MA, 02118, USA.

Background: Hepatitis C virus (HCV) infection is increasingly prevalent among people who inject drugs (PWID) in the context of the current US opioid crisis. Although curative therapy is available and recommended as a public health strategy, few PWID have been treated. We explore PWID narratives that explain why they have not sought HCV treatment or decided against starting it. We then compare these narratives to evidence-based and guideline-concordant information to better enable health, social service, harm reduction providers, PWID, and other stakeholders to dispel misconceptions and improve HCV treatment uptake in this vulnerable population.

Methods: We recruited HIV-uninfected PWID (n = 33) through community-based organizations (CBOs) to participate in semi-structured, in-depth qualitative interviews on topics related to overall health, access to care, and knowledge and interest in specific HIV prevention methods.

Results: In interviews, HCV transmission and delaying or forgoing HCV treatment emerged as important themes. We identified three predominant narratives relating to delaying or deferring HCV treatment among PWID: (1) lacking concern about HCV being serious or urgent enough to require treatment, (2) recognizing the importance of treatment but nevertheless deciding to delay treatment, and (3) perceiving that clinicians and insurance companies recommend that patients who currently use or inject drugs should delay treatment.

Conclusions: Our findings highlight persistent beliefs among PWID that hinder HCV treatment utilization. Given the strong evidence that treatment improves individual health regardless of substance use status while also decreasing HCV transmission in the population, efforts are urgently needed to counter the predominant narratives identified in our study. We provide evidence-based, guideline-adherent information that counters the identified narratives in order to help individuals working with PWID to motivate and facilitate treatment access and uptake. An important strategy to improve HCV treatment initiation among PWID could involve disseminating guideline-concordant counternarratives to PWID and the providers who work with and are trusted by this population.
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http://dx.doi.org/10.1186/s12954-019-0286-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6371610PMC
February 2019

The role of sexual risk behaviors on PrEP awareness and interest among men who have sex with men in Latin America.

Int J STD AIDS 2019 05 5;30(6):542-549. Epub 2019 Feb 5.

1 Department of Behavioral and Social Health Sciences, Brown University School of Public Health, Providence, RI, USA.

In Latin America, men who have sex with men (MSM) remain disproportionately impacted by HIV. Pre-exposure prophylaxis (PrEP) is an effective HIV prevention tool and has been FDA approved in the United States since 2012, but no Latin American state, with the recent exception of Brazil, has implemented PrEP guidelines. We carried out a multinational online survey of MSM in Latin America (n = 22698) in 2012 to assess whether MSM at highest risk of HIV acquisition (i.e., those engaging in condomless anal sex [CAS; n = 2606] and transactional sex [n = 1488]) had higher levels of awareness of PrEP, PrEP use and interest in participating in a PrEP trial. After adjusting for demographic and psychosocial characteristics including depressive symptoms, hazardous alcohol use, childhood sexual abuse, and sexual compulsivity, transactional sex and CAS were associated with increased PrEP awareness (aOR = 1.29, 95% CI: 1.05-1.59, p < .001 and aOR = 1.22, 95% CI: 1.11-1.34, p < .001, respectively) and PrEP trial interest (aOR = 1.45, 95% CI: 1.25-1.71, p < .001 and aOR = 1.74, 95% CI: 1.57-1.95, p < .001, respectively). Findings demonstrate substantial awareness of and interest in PrEP among MSM with behavioral risk factors for HIV in Latin America, suggesting that this region is primed for PrEP implementation, which has been slow.
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http://dx.doi.org/10.1177/0956462419825944DOI Listing
May 2019

Limited Knowledge and Mixed Interest in Pre-Exposure Prophylaxis for HIV Prevention Among People Who Inject Drugs.

AIDS Patient Care STDS 2018 12 11;32(12):529-537. Epub 2018 Oct 11.

6 Center for Health Equity Research, Brown University , Providence, Rhode Island.

People who inject drugs (PWID) experience sexual and injection-related HIV risks, but uptake of pre-exposure prophylaxis (PrEP) for HIV prevention among PWID has been low. Improving PrEP uptake in this population will require understanding of PrEP knowledge and interest. In 2017, we conducted in-depth, semistructured interviews with HIV-uninfected PWID and key informants (PrEP and harm reduction providers) in the US Northeast. Thematic analysis of coded data explored PrEP knowledge and the factors that influence PrEP interest. Among PWID (n = 33), median age was 36 years, 55% were male, 67% were white, and 24% identified as Hispanic/Latino. Accurate PrEP knowledge among PWID was low, which key informants (n = 12) attributed to PrEP marketing focused on other risk populations, as well as healthcare providers' lack of time and unwillingness to discuss PrEP with PWID. There was a discrepancy between self-reported HIV risk behaviors, which were common, and HIV risk perceptions, which varied and strongly influenced PrEP interest. Most PWID and key informants thought that PrEP would be most beneficial for those who shared syringes, used discarded syringes, engaged in transactional sex, or were homeless. Improving uptake of PrEP for HIV prevention among high-risk PWID will require education to increase PrEP knowledge and addressing factors that negatively influence PrEP interest such as perceptions regarding low HIV risk and the process for obtaining PrEP. This may require specialized PrEP marketing and outreach efforts and improved capacity of healthcare providers to effectively assess HIV risk (and perceptions) and communicate the benefits of PrEP to at-risk PWID.
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http://dx.doi.org/10.1089/apc.2018.0126DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6300044PMC
December 2018

Risk Perception and Interest in HIV Pre-exposure Prophylaxis Among Men Who Have Sex with Men with Rectal Gonorrhea and Chlamydia Infection.

Arch Sex Behav 2019 05 13;48(4):1185-1190. Epub 2018 Aug 13.

Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA.

Rectal gonorrhea and chlamydia infections are associated with significantly increased risk of HIV transmission among gay, bisexual, and other men who have sex with men (MSM). MSM diagnosed with rectal gonorrhea or chlamydia may benefit from pre-exposure prophylaxis (PrEP) for HIV prevention. We analyzed HIV risk perception, PrEP interest, and sexually transmitted infection (STI) test results among MSM presenting to a publicly funded STI clinic from 2014 to 2016. A total of 401 MSM were tested for rectal STIs during the study period: 18% were diagnosed with rectal gonorrhea or chlamydia infection. Patients who perceived themselves to be at medium or high risk for HIV were significantly more likely to express interest in PrEP compared to those who reported low or no perceived risk (OR 1.88, 95% CI 1.13-3.11; p = .014). However, there was no significant difference in perceived HIV risk between those who were diagnosed with a rectal STI and those who were not. Although rectal STIs are a significant risk factor for HIV infection, MSM diagnosed with a rectal STI did not perceive themselves to be at increased risk for HIV infection, indicating a potential barrier to successful PrEP implementation in this population.
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http://dx.doi.org/10.1007/s10508-018-1260-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6374209PMC
May 2019