Publications by authors named "Matthew J Mimiaga"

272 Publications

Correlates of Geosocial Networking Applications (GSN Apps) Usage among Gay, Bisexual, and Other Men Who Have Sex with Men in Nigeria, Africa.

Arch Sex Behav 2021 Apr 12. Epub 2021 Apr 12.

Department of Behavioral and Social Sciences, Brown University School of Public Health, 121 S Main Street, Box G-S121-3, Providence, RI, 02903, USA.

Geosocial networking applications (GSN apps) are widely utilized by gay, bisexual, and other men who have sex with men (GBMSM) to meet potential sexual/romantic partners, foster friendships, and build community. However, GSN apps usage has been linked to elevated levels of HIV sexual risk behavior among GBMSM. Little is known about how GSN apps can facilitate HIV sexual risk behaviors, especially among GBMSM in Africa. To fill this gap in research, the present study aimed to characterize the frequency of GSN apps usage and its association with sociodemographic characteristics, sexual health, healthcare access, psychosocial problems, and substance use in a large multicity sample of community-recruited GBMSM in Nigeria (N = 406). Bivariate and multivariable ordinal logistic regression procedures were used to examine factors associated with GSN apps usage. We found that 52.6% of participants reported recent (≤ 3 months) GSN apps use to meet sexual partners. Factors associated with increased odds of GSN apps usage included: being single, having a university degree or higher, reporting higher recent receptive anal sexual acts, being aware of PrEP, having a primary care provider, and reporting higher levels of identity concealment. HIV-related intervention delivered through GSN apps may help curb the spread of HIV among Nigerian GBMSM.
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http://dx.doi.org/10.1007/s10508-020-01889-3DOI Listing
April 2021

A Uniquely Targeted, Mobile App-Based HIV Prevention Intervention for Young Transgender Women: Adaptation and Usability Study.

J Med Internet Res 2021 Mar 31;23(3):e21839. Epub 2021 Mar 31.

Fenway Institute, Boston, MA, United States.

Background: Young transgender women (YTW) are a key population for HIV-related risk reduction, yet very few interventions have been developed to meet their needs. Mobile health interventions with the potential for both efficacy and wide reach are a promising strategy to reduce HIV risk among YTW.

Objective: This study aims to adapt an efficacious group-based intervention to a mobile app, Project LifeSkills, to reduce HIV risk among YTW, and to test its acceptability and usability.

Methods: The group-based intervention was adapted to a mobile app, LifeSkills Mobile, with input from an expert advisory group and feedback from YTW collected during user-centered design sessions. A beta version of the app was then tested in a usability evaluation using a think-aloud protocol with debriefing interviews, recordings of screen activity, and assessments of usability via the Post-Study System Usability Questionnaire (PSSUQ) and the Health Information Technology Usability Evaluation Scale (Health-ITUES).

Results: YTW (n=8; age: mean 24 years, SD 3 years; racial or ethnic minority: 7/8, 88%) provided feedback on the app prototype in design sessions and then tested a beta version of the app in a usability trial (n=10; age: mean 24 years, SD 3 years; racial or ethnic minority: 8/10, 80%). Both usability ratings (Health-ITUES: mean 4.59, SD 0.86; scale range: 1-5) and ratings for satisfaction and accessibility (PSSUQ: mean 4.64, SD 0.90; scale range 1-5) were in the good to excellent range. No functional bugs were identified, and all mobile activities were deployed as expected. Participant feedback from the usability interviews indicated very good salience of the intervention content among the focal population. Participants' suggestions to further increase app engagement included adding animation, adding audio, and reducing the amount text.

Conclusions: We conclude that the LifeSkills Mobile app is a highly usable and engaging mobile app for HIV prevention among YTW.
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http://dx.doi.org/10.2196/21839DOI Listing
March 2021

Opioid pain medication misuse, concomitant substance misuse, and the unmet behavioral health treatment needs of transgender and gender diverse adults.

Drug Alcohol Depend 2021 Mar 18:108674. Epub 2021 Mar 18.

The Fenway Institute, Fenway Health, 1340 Boylston Street, Boston, MA, 02215, United States; Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, BOX 951772, 71-267 CHS, Los Angeles, CA, 90095, United States; Department of Psychiatry and Biobehavioral Science, David Geffen School of Medicine, University of California Los Angeles, BOX 951772, 71-267 CHS, Los Angeles, CA, 90095, United States; UCLA Center for LGBTQ Advocacy, Research & Health, BOX 951772, 71-267 CHS, Los Angeles, CA, 90095, United States. Electronic address:

Background: Limited research has explored risk factors for opioid pain medication misuse, concomitant substance misuse, and the unmet behavioral health treatment (BHTx) needs of transgender and gender diverse (TGD) adults.

Methods: In 2019, TGD adults (N = 562) in Massachusetts and Rhode Island were purposively recruited and completed a psychosocial and behavioral health survey (95 % online; 5% in-person). Multivariable logistic regression was used to examine factors associated with past 12-month opioid pain medication misuse and unmet BHTx needs.

Results: Overall, 24.4 % of participants were trans women; 32.0 % trans men; and 43.6 % were non-binary. Past-year substance misuse included: marijuana (56.8 %), hazardous drinking (37.5 %), hallucinogens (9.8 %), benzodiazepines (8.2 %), and opioid pain medication (8.0 %). Among participants with past-year substance misuse and BHtx need (n = 326), 81.3 % received BHtx and 18.7 % had unmet BHtx needs. Being a trans woman, having HIV, stigma in healthcare, and number of substances misused were associated with increased odds of past-year opioid pain medication misuse; high social connectedness was associated with decreased odds of opioid pain medication misuse (p-values<0.05). Younger age, stigma in healthcare, and misusing opioid pain medications were associated with increased odds of unmet BHTx needs; post-traumatic stress disorder and family support were associated with decreased odds of unmet BHtx needs (p-values<0.05).

Conclusions: Addressing disparities in opioid pain medication misuse among TGD people requires systematic improvements in healthcare access, including efforts to create TGD-inclusive BHtx environments with providers who are equipped to recognize and treat the social and structural drivers of TGD health inequities, including opioid pain medication misuse.
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http://dx.doi.org/10.1016/j.drugalcdep.2021.108674DOI Listing
March 2021

Development and Evaluation of a Mobile App Designed to Increase HIV Testing and Pre-exposure Prophylaxis Use Among Young Men Who Have Sex With Men in the United States: Open Pilot Trial.

J Med Internet Res 2021 Mar 24;23(3):e25107. Epub 2021 Mar 24.

The Fenway Institute, Fenway Health, Boston, MA, United States.

Background: HIV disproportionately affects young men who have sex with men (YMSM) in the United States. Uptake of evidence-based prevention strategies, including routine HIV testing and use of pre-exposure prophylaxis (PrEP), is suboptimal in this population. Novel methods for reaching YMSM are required.

Objective: The aim of this study is to describe the development and evaluate the feasibility and acceptability of the MyChoices app, a mobile app designed to increase HIV testing and PrEP use among YMSM in the United States.

Methods: Informed by the social cognitive theory, the MyChoices app was developed using an iterative process to increase HIV testing and PrEP uptake among YMSM. In 2017, beta theater testing was conducted in two US cities to garner feedback (n=4 groups; n=28 YMSM). These findings were used to refine MyChoices, which was then tested for initial acceptability and usability in a technical pilot (N=11 YMSM). Baseline and 2-month postbaseline assessments and exit interviews were completed. Transcripts were coded using a deductive approach, and thematic analysis was used to synthesize data; app acceptability and use data were also reported.

Results: The MyChoices app includes personalized recommendations for HIV testing frequency and PrEP use; information on types of HIV tests and PrEP; ability to search for nearby HIV testing and PrEP care sites; and ability to order free home HIV and sexually transmitted infection test kits, condoms, and lube. In theater testing, YMSM described that MyChoices appears useful and that they would recommend it to peers. Participants liked the look and feel of the app and believed that the ability to search for and be pinged when near an HIV testing site would be beneficial. Some suggested that portions of the app felt repetitive and preferred using casual language rather than formal or medicalized terms. Following theater testing, the MyChoices app was refined, and participants in the technical pilot used the app, on average, 8 (SD 5.0; range 2-18) times over 2 months, with an average duration of 28 (SD 38.9) minutes per session. At the 2-month follow-up, the mean System Usability Scale (0-100) score was 71 (ie, above average; SD 11.8). Over 80% (9/11) of the participants reported that MyChoices was useful and 91% (10/11) said that they would recommend it to a friend. In exit interviews, there was a high level of acceptability for the content, interface, and features.

Conclusions: These data show the initial acceptability and user engagement of the MyChoices app. If future studies demonstrate efficacy in increasing HIV testing and PrEP uptake, the app is scalable to reach YMSM across the United States.

Trial Registration: Clinicaltrials.gov NCT03179319; https://clinicaltrials.gov/ct2/show/NCT03179319.

International Registered Report Identifier (irrid): RR2-10.2196/10694.
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http://dx.doi.org/10.2196/25107DOI Listing
March 2021

Strengthening resilience to reduce HIV risk in Indian MSM: a multicity, randomised, clinical efficacy trial.

Lancet Glob Health 2021 04;9(4):e446-e455

Fenway Institute, Fenway Health, Boston, MA, USA; Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioural Sciences, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.

Background: Men who have sex with men (MSM) in India are extremely marginalised and stigmatised, and therefore experience immense psychosocial stress. As current HIV prevention interventions in India do not address mental health or resilience to these stressors, we aimed to evaluate a resilience-based psychosocial intervention in the context of HIV and sexually transmitted infection (STI) prevention.

Methods: We did a multicity, randomised, clinical efficacy trial in Chennai (governmental tuberculosis research institute) and Mumbai (non-governmental organisation for MSM), India. Inclusion criteria were MSM, aged 18 years or older, who were at risk of HIV acquisition or transmission, defined as having any of the following in the 4 months before screening: anal sex with four or more male partners (protected or unprotected), diagnosis of an STI, history of transactional sex activity, or condomless anal sex with a man who was of unknown HIV status or serodiscordant. Participants were required to speak English, Tamil (in Chennai), or Hindi (in Mumbai) fluently. Eligible individuals were randomly assigned (1:1) to either a resilience-based psychosocial HIV prevention intervention, consisting of group (four sessions) and individual (six sessions) counselling alongside HIV and STI voluntary counselling and testing, or a standard-of-care control comprising voluntary counselling and testing alone. The primary outcomes were number of condomless anal sex acts with male partners during the past month (at baseline and 4 months, 8 months, and 12 months after randomisation), and incident bacterial STIs (at 12 months after randomisation). Resilience-related mediators included self-esteem, self-acceptance, and depression. Recruitment is now closed. This trial is registered with ClinicalTrials.gov, NCT02556294.

Findings: Between Sept 4, 2015, and June 28, 2018, we enrolled 608 participants; 305 (50%) were assigned to the psychosocial intervention condition and 303 (50%) were assigned to the control condition. 510 (84%) of 608 men completed an assessment at 4 months after randomisation, 483 (79%) at 8 months, and 515 (85%) at 12 months. 512 (99%) of 515 men had STI data from the 12-month assessment. The intervention condition had a 56% larger reduction in condomless anal sex acts (95% CI 35-71; p<0·0001) from baseline to 4-month follow-up, 72% larger reduction (56-82; p<0·0001) from baseline to 8-month follow-up, and 72% larger reduction (53-83; p<0·0001) from baseline to 12-month follow-up, compared with the standard-of-care control condition (condition by time interaction; χ=40·29, 3 df; p<0·0001). Improvements in self-esteem and depressive symptoms both mediated 9% of the intervention effect on condomless anal sex acts. Bacterial STI incidence did not differ between study conditions at 12-month follow-up.

Interpretation: A resilience-based psychosocial intervention for MSM at risk of HIV acquisition or transmission in India was efficacious in reducing condomless anal sex acts, with evidence for mediation effects in two key target resilience variables. HIV prevention programmes for MSM in India should address mental health resilience to augment reductions in the risk of sexually transmitted HIV.

Funding: National Institute of Mental Health.
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http://dx.doi.org/10.1016/S2214-109X(20)30547-7DOI Listing
April 2021

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

J Int AIDS Soc 2021 Mar;24(3):e25679

Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.

Introduction: Little is known about onward HIV transmissions from people living with HIV (PLWH) in care. Antiretroviral therapy (ART) has increased in potency, and treatment as prevention (TasP) is an important component of ending the epidemic. Syndemic theory has informed modelling of HIV risk but has yet to inform modelling of HIV transmissions.

Methods: Data were from 61,198 primary HIV care visits for 14,261 PLWH receiving care through the Centers for AIDS Research (CFAR) Network of Integrated Clinical Systems (CNICS) at seven United States (U.S.) sites from 2007 to 2017. Patient-reported outcomes and measures (PROs) of syndemic conditions - depressive symptoms, anxiety symptoms, drug use (opiates, amphetamines, crack/cocaine) and alcohol use - were collected approximately four to six months apart along with sexual behaviours (mean = 4.3 observations). Counts of syndemic conditions, HIV sexual risk group and time in care were modelled to predict estimated HIV transmissions resulting from sexual behaviour and viral suppression status (HIV RNA < 400/mL) using hierarchical linear modelling.

Results: Patients averaged 0.38 estimated HIV transmissions/100 patients/year for all visits with syndemic conditions measured (down from 0.83, first visit). The final multivariate model showed that per 100 patients, each care visit predicted 0.05 fewer estimated transmissions annually (95% confidence interval (CI): 0.03 to 0.06; p < 0.0005). Cisgender women, cisgender heterosexual men and cisgender men of undisclosed sexual orientation had, respectively, 0.47 (95% CI: 0.35 to 0.59; p < 0.0005), 0.34 (95% CI: 0.20 to 0.49; p < 0.0005) and 0.22 (95% CI: 0.09 to 0.35; p < 0.005) fewer estimated HIV transmissions/100 patients/year than cisgender men who have sex with men (MSM). Each within-patient syndemic condition predicted 0.18 estimated transmissions/100 patients/year (95% CI: 0.12 to 0.24; p < 0.0005). Each between-syndemic condition predicted 0.23 estimated HIV transmissions/100 patients/year (95% CI: 0.17 to 0.28; p < 0.0005).

Conclusions: Estimated HIV transmissions among PLWH receiving care in well-resourced U.S. clinical settings varied by HIV sexual risk group and decreased with time in care, highlighting the importance of TasP efforts. Syndemic conditions remained a significant predictor of estimated HIV transmissions notwithstanding the effects of HIV sexual risk group and time in care.
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http://dx.doi.org/10.1002/jia2.25679DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7962793PMC
March 2021

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

Stronger Together: Results from a Randomized Controlled Efficacy Trial of a Dyadic Intervention to Improve Engagement in HIV Care Among Serodiscordant Male Couples in Three US Cities.

AIDS Behav 2021 Feb 25. Epub 2021 Feb 25.

Center for LGBTQ Advocacy, Research, and Health, UCLA, Los Angeles, CA, USA.

Engagement in HIV care and a high level of antiretroviral therapy (ART) adherence for people living with HIV is crucial to treatment success and can minimize the population burden of the disease. Despite this, there is a critical gap in HIV prevention science around the development of interventions for serodiscordant male couples. This paper reports on the results of a randomized controlled trial to assess the efficacy of Stronger Together, a dyadic counseling intervention aimed at increasing engagement in and optimizing HIV care among serodiscordant male couples in Atlanta, GA, Boston, MA, and Chicago, IL. Between 2014 and 2017, 159 male serodiscordant couples (total N = 318) in Atlanta, GA, Boston, MA, and Chicago, IL were enrolled and equally randomized to either the Stronger Together intervention arm (a three-session dyadic intervention involving HIV testing and adherence counseling) or a standard of care (SOC) control arm. Couples completed individual study assessments via an audio computer assisted self-interviewing (ACASI) system at baseline, 6, 12 and 18 months. Primary outcomes included being prescribed and currently taking ART, and fewer missed doses of ART in the past 30 days; because the trial was not powered to examine viral suppression, we examined this as an exploratory outcome. Longitudinal data analysis was by an intention-to-treat approach. Participants ages ranged from 18 to 69 (mean = 35.9), and are predominantly white (77.5%), and college educated (68.4% earned a college degree or higher). Participants randomized to the Stronger Together arm had a significantly greater odds of being prescribed and currently taking ART over time than those in the SOC arm (at 12 months OR 2.75, 95%CI 1.35-4.67, p-value 0.020, and at 18 months OR 2.91, 95%CI 1.61-4.88, p-value 0.013). Similarly, those in the Stronger Together arm had a significantly lower odds of missing a dose of ART in the past 30 days over time compared to those in the SOC arm (at 12 months OR 0.28, 95%CI 0.09-0.81, p-value 0.019, and at 18 months OR 0.25, 95%CI 0.07-0.82, p-value 0.023). Among male couples in serodiscordant relationships, the Stronger Together intervention resulted in significantly improved HIV treatment outcomes at both 12 and 18 months of follow-up. This trial is the first to date to demonstrate evidence of efficacy for a dyadic counseling intervention and has the potential to fill a critical gap in secondary HIV prevention interventions for serodiscordant male couples.
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http://dx.doi.org/10.1007/s10461-021-03199-8DOI Listing
February 2021

The persistent and evolving HIV epidemic in American men who have sex with men.

Lancet 2021 Mar 19;397(10279):1116-1126. Epub 2021 Feb 19.

Rollins School of Public Health, Emory University, Atlanta, GA, USA.

Men who have sex with men (MSM) in the USA were the first population to be identified with AIDS and continue to be at very high risk of HIV acquisition. We did a systematic literature search to identify the factors that explain the reasons for the ongoing epidemic in this population, using a social-ecological perspective. Common features of the HIV epidemic in American MSM include role versatility and biological, individual, and social and structural factors. The high-prevalence networks of some racial and ethnic minority men are further concentrated because of assortative mixing, adverse life experiences (including high rates of incarceration), and avoidant behaviour because of negative interactions with the health-care system. Young MSM have additional risks for HIV because their impulse control is less developed and they are less familiar with serostatus and other risk mitigation discussions. They might benefit from prevention efforts that use digital technologies, which they often use to meet partners and obtain health-related information. Older MSM remain at risk of HIV and are the largest population of US residents with chronic HIV, requiring culturally responsive programmes that address longer-term comorbidities. Transgender MSM are an understudied population, but emerging data suggest that some are at great risk of HIV and require specifically tailored information on HIV prevention. In the current era of pre-exposure prophylaxis and the undetectable equals untransmittable campaign, training of health-care providers to create culturally competent programmes for all MSM is crucial, since the use of antiretrovirals is foundational to optimising HIV care and prevention. Effective control of the HIV epidemic among all American MSM will require scaling up programmes that address their common vulnerabilities, but are sufficiently nuanced to address the specific sociocultural, structural, and behavioural issues of diverse subgroups.
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http://dx.doi.org/10.1016/S0140-6736(21)00321-4DOI Listing
March 2021

Young Transgender Women Survivors of Intimate Partner Violence: A Latent Class Analysis of Protective Processes.

Psychol Sex Orientat Gend Divers 2020 Dec 23;7(4):386-395. Epub 2020 Mar 23.

Division of Adolescent Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago,Chicago, Illinois.

Research is critically needed to understand protective processes that may lessen the impact of intimate partner violence (IPV) on negative outcomes for transgender individuals. The current study utilized a latent class analysis to identify combinations of protective processes (i.e., collective self-esteem and social support) in relation to internalizing mental health symptoms among young transgender women (YTW) survivors of IPV. Data from Project LifeSkills (2012-2015), a multisite trial for HIV sexual risk reduction intervention, were used for the present study. A subsample of 78 YTW (ages 16 to 29) who were IPV survivors (i.e., indicated lifetime IPV) were included in the analyses. Participants completed measures of general social support, perceived social support from their mother and friends, and collective self-esteem, as well as mental health symptoms. Three latent classes emerged: 1) YTW who perceived high levels of social support and collective self-esteem (48%), 2) YTW who perceived low levels of collective self-esteem, but average to high levels of social support from mother and friends (23%), and 3) YTW who perceived low levels of collective self-esteem and low to average levels of social support from mother and friends (29%). YTW in the overall low class had significantly higher levels of depressive, anxiety, and somatization symptoms, compared to the other two classes. These findings highlight how low levels of social support and collective self-esteem can place YTW survivors of IPV at significant risk for experiencing negative internalizing mental health symptoms.
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http://dx.doi.org/10.1037/sgd0000379DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7781223PMC
December 2020

Young Transgender Women Survivors of Intimate Partner Violence: A Latent Class Analysis of Protective Processes.

Psychol Sex Orientat Gend Divers 2020 Dec 23;7(4):386-395. Epub 2020 Mar 23.

Division of Adolescent Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago,Chicago, Illinois.

Research is critically needed to understand protective processes that may lessen the impact of intimate partner violence (IPV) on negative outcomes for transgender individuals. The current study utilized a latent class analysis to identify combinations of protective processes (i.e., collective self-esteem and social support) in relation to internalizing mental health symptoms among young transgender women (YTW) survivors of IPV. Data from Project LifeSkills (2012-2015), a multisite trial for HIV sexual risk reduction intervention, were used for the present study. A subsample of 78 YTW (ages 16 to 29) who were IPV survivors (i.e., indicated lifetime IPV) were included in the analyses. Participants completed measures of general social support, perceived social support from their mother and friends, and collective self-esteem, as well as mental health symptoms. Three latent classes emerged: 1) YTW who perceived high levels of social support and collective self-esteem (48%), 2) YTW who perceived low levels of collective self-esteem, but average to high levels of social support from mother and friends (23%), and 3) YTW who perceived low levels of collective self-esteem and low to average levels of social support from mother and friends (29%). YTW in the overall low class had significantly higher levels of depressive, anxiety, and somatization symptoms, compared to the other two classes. These findings highlight how low levels of social support and collective self-esteem can place YTW survivors of IPV at significant risk for experiencing negative internalizing mental health symptoms.
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http://dx.doi.org/10.1037/sgd0000379DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7781223PMC
December 2020

The provision of counseling to patients receiving medications for opioid use disorder: Telehealth innovations and challenges in the age of COVID-19.

J Subst Abuse Treat 2021 01 9;120:108163. Epub 2020 Oct 9.

The Fenway Institute, Fenway Health, Boston, MA, USA; Department of Psychology, University of Massachusetts Boston, Boston, MA, USA.

Historically, federal and state policies have narrowly defined treatment models that have resulted in limited access to and engagement in counseling for individuals receiving medications for opioid use disorder (MOUD; e.g., methadone and buprenorphine). In response to the coronavirus pandemic, outpatient MOUD treatment providers rapidly transitioned from traditional, in-person care delivery models to revised COVID-19 protocols that prioritized telehealth counseling to protect the health of patients and staff and ensure continuity in MOUD care. These telehealth innovations appear to mitigate many of the longstanding barriers to counseling in the traditional system and have the potential to forever alter MOUD care delivery. Drawing on data from a Rhode Island-based clinic, we argue that MOUD counseling is achievable via telehealth and outline the need for, and anticipated benefits of, hybrid telehealth/in-person MOUD treatment models moving forward.
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http://dx.doi.org/10.1016/j.jsat.2020.108163DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7545305PMC
January 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

Negative Transgender-Related Media Messages Are Associated with Adverse Mental Health Outcomes in a Multistate Study of Transgender Adults.

LGBT Health 2021 01 10;8(1):32-41. Epub 2020 Nov 10.

The Fenway Institute, Fenway Health, Boston, Massachusetts, USA.

The purpose of this study was to examine the extent to which transgender people have observed negative transgender-related messages in the media and the relationship between negative media message exposure and the mental health of transgender people. In 2019, 545 transgender adults completed an online survey assessing demographics, negative transgender-related media messages, violence, and mental health. Separate multivariable logistic regression models examined the association of frequency of negative media exposure and clinically significant symptoms of depression, anxiety, post-traumatic stress disorder (PTSD), and global psychological distress. Mean age of the sample was 31.2 years (standard deviation [SD] = 11.2). Nearly half identified as nonbinary (42.2%), 82.0% were White, non-Hispanic, 56.9% had a college degree, and 67.0% were financially insecure. The majority reported experiencing childhood abuse (60.6%) and abuse in adulthood (58.0%). The mean frequency of exposure to negative transgender-related media was 6.41 (SD = 2.9) with 97.6% of the sample reporting exposure to negative media depictions of transgender people across a range of mediums. In separate multivariable models adjusted for age, gender identity, race, education, income, and childhood/adult abuse, more frequent exposure to negative depictions of transgender people in the media was significantly associated with clinically significant symptoms of depression (adjusted odds ratio [aOR] = 1.18; 95% confidence interval [CI] = 1.08-1.29;  = 0.0003); anxiety (aOR = 1.26; 95% CI = 1.14-1.40;  < 0.0001); PTSD (aOR = 1.25; 95% CI = 1.16-1.34;  < 0.0001); and global psychological distress (aOR = 1.28; 95% CI = 1.15-1.42;  < 0.0001). Exposure to negative media messages from multiple sources necessitates multilevel interventions to improve the mental health of transgender people and curb stigma at its source.
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http://dx.doi.org/10.1089/lgbt.2020.0279DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7826438PMC
January 2021

Substance Use, Mental Health Problems, and Physical and Sexual Violence Additively Increase HIV Risk Between Male Sex Workers and Their Male Clients in Northeastern United States.

J Acquir Immune Defic Syndr 2021 Mar;86(3):305-312

The Fenway Institute, Fenway Health, Boston, MA.

Background: Male sex workers (MSW) are disproportionately affected by HIV/AIDS, with an estimated HIV prevalence in the United States of 19.3%. Existing research suggests that MSW are also at risk of adverse psychosocial problems. Cross-sectional studies of MSW have suggested that co-occurring epidemics or a "syndemic" of psychosocial problems may increase vulnerability to HIV acquisition/transmission by elevated sexual risk. To the best of our knowledge, there are no published studies examining this relationship longitudinally among MSW. This study examined how a syndemic of 6 psychosocial problems result in additive risk for condomless anal sex (CAS) with male clients among a multicity, longitudinal cohort of MSW.

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

Methods: Between 2015 and 2017, 100 MSW from Boston, MA and Providence, RI completed behavioral/psychosocial surveys at baseline, 6 months, and 12months. Generalized estimating equation modeling was used to examine the prospective relationship of additive psychosocial problems and subsequent CAS with male clients, adjusting for age, site, race/ethnicity, MSW-type, and HIV serostatus.

Results: Mean age = 34.7 (SD = 11.8); 62% racial/ethnic minority; and 20% HIV+. The prevalence of 6 psychosocial syndemic problems was substantial at baseline and remained high at each time point (all within the past 6 months): 74% problematic depressive symptoms, 27% polydrug use (3+ drugs, not including stimulants), 57% stimulant (methamphetamine/cocaine/crack) use, 44% hazardous drinking, 15% experienced client-specific physical/sexual violence, and 57% childhood sexual abuse. Looking at the number of psychosocial problems experienced, 7% had zero, 27% had 1, 24% had 2, 27% had 3, and 15% had 4 or more. We identified a statistically significant positive "dose-response" relationship between the number of psychosocial problems and CAS with male clients over time, with the greatest odds of engaging in CAS with a male client over follow-up among those with 4 or more psychosocial problems (adjusted odds ratio = 5.18, 95% CI: 1.61 to 16.62).

Conclusions: Internet escorts and street-based MSW are likely to experience psychosocial problems and engaging in HIV sexual risk with male clients. The accumulation of psychosocial problems additively predicted CAS with male clients in a prospective cohort of MSW. The specification of psychosocial problems presents distinct treatment targets for HIV prevention among MSW in the United States.
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http://dx.doi.org/10.1097/QAI.0000000000002563DOI Listing
March 2021

Experiencing Intimate Partner Violence (IPV) Is Associated with Psychosocial Health Problems Among Gay, Bisexual, and Other Men Who Have Sex with Men (GBMSM) in Nigeria, Africa.

J Interpers Violence 2020 Oct 29:886260520966677. Epub 2020 Oct 29.

Brown University School of Public Health, RI, USA.

Previous research has shown high rates of intimate partner violence (IPV) among gay, bisexual, and other men who have sex with men (GBMSM). Experiencing IPV may predispose GBMSM to psychosocial health problems. A vast majority of the research on IPV among GBMSM have been conducted in North America and Europe. To date, no published studies that we are aware of have investigated the prevalence and correlates of IPV among GBMSM in West Africa. To fill this gap in research, the present study investigated the prevalence of IPV and its' association with psychosocial health problems in a large multicity sample of community-recruited GBMSM in Nigeria. Bivariate and multivariable logistic regression analyses were utilized to examine associations between sociodemographic characteristics, psychosocial health problems, sexual risk, and experiences of IPV ( = 389). The prevalence of experiencing emotional, physical, sexual, monitoring behaviors, and controlling behavior were 45%, 31%, 20%, 55%, and 22% respectively. Experiencing all types of IPV, except physical violence, was significantly associated with increased odds of having depressive symptoms (Adjusted OR [AOR] 1.79-2.63; 95% confidence interval [CI]: 1.08-4.60) and anxiety (AOR 1.63-2.63; 95% CI: 1.01-4.18). Experiencing emotional violence (standardized beta [] = 0.21; standard error [SE] SE = 0.44), physical violence ( = 0.14; SE = 0.48), and controlling behaviors ( = 0.11; SE = 0.54) was associated with increased odds of loneliness. Experiencing all types of IPV was associated with history of suicide thoughts (AOR 2.20-3.68; 95% CI: 1.28-6.32) and suicide attempt (AOR 2.36-3.42; 95% CI: 1.20-6.75). Additionally, we observed a dose-response relationship, whereby increasing number of IPV was associated with a higher likelihood of reporting psychosocial health problems. Lastly, after adjusting for other psychosocial health problems and demographic characteristics, there remained a significant association between experiencing IPV and reporting a history of suicide thoughts and suicide attempt. Consequently, it is imperative that health interventions aimed at improving psychosocial health of GBMSM explore experience and perpetration of IPV.
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http://dx.doi.org/10.1177/0886260520966677DOI Listing
October 2020

Experiences of minority stress among gay, bisexual, and other men who have sex with men (GBMSM) in Nigeria, Africa: The intersection of mental health, substance use, and HIV sexual risk behavior.

Glob Public Health 2020 Oct 27:1-15. Epub 2020 Oct 27.

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

Nigerian gay, bisexual, and other men who have sex with men (GBMSM) experience social marginalisation, discrimination and violence due to their sexual orientation and same-sex attraction, which may affect mental health, substance use, and HIV sexual risk behavior. The goal of the current study was to conduct formative qualitative research to gain better understanding of these issues among GBMSM in Lagos, Nigeria. Face-to-face, semi-structured, in-depth interviews were conducted with 30 GBMSM in Lagos, Nigeria. Data were analysed using a deductive content analysis approach. We found that Nigerian GBMSM experienced both general life stressors as well as proximal and distal sexual minority identity stressors, including rejection by family members, harassment, and physical violence perpetrated by the general public and police officers. Participants described dealing with mental health problems within the context of family rejection, experienced stigma due to sexual orientation, and feelings of social isolation. Substance use was described as occurring within the context of social settings. Lastly, some participants mentioned that they engaged in risky sexual behaviour while under the influence of alcohol and drugs. These findings call for comprehensive and innovative, GBMSM-affirming behavioural healthcare, substance cessation services, and innovative HIV prevention interventions specifically designed and tailored for Nigerian GBMSM.
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http://dx.doi.org/10.1080/17441692.2020.1834598DOI Listing
October 2020

Examining the Longitudinal Predictive Relationship Between HIV Treatment Outcomes and Pre-exposure Prophylaxis Use by Serodiscordant Male Couples.

J Acquir Immune Defic Syndr 2021 Jan;86(1):38-45

Department of Epidemiology, Brown University School of Public Health, Providence, RI.

Background: Men who have sex with men are disproportionately burdened by HIV/AIDS, and the advent of pre-exposure prophylaxis (PrEP) has provided an effective strategy to reduce the risk of HIV transmission. Research has shown that improving one partner's health-promoting behaviors increases the likelihood that their partner adopts healthier behaviors. We examined the longitudinal relationship between favorable HIV treatment outcomes with current PrEP use among HIV serodiscordant male partners.

Setting: Data are from Project Stronger Together, a randomized controlled trial that recruited serodiscordant male couples from Atlanta, GA; Boston, MA; and Chicago, IL.

Methods: Serodiscordant couples completed assessments at baseline, 6, 12, 18, and 24 months. We analyzed longitudinal data from 120 HIV serodiscordant male partners to assess the relationship between the HIV-negative partner's current PrEP use and their HIV-positive partner's current ART use, ART adherence, and viral load using generalized estimating equation models.

Results: Fewer than half of the HIV-negative partners were on PrEP at baseline and nearly two-thirds of their HIV-positive partners were virally suppressed. HIV-negative male partners who had partners with an undetectable viral load had greater odds of being a current PrEP user than HIV-negative partners with partners with a detectable viral load.

Conclusion: Our study highlights the need to develop dyad-level interventions to improve HIV medication use/adherence by HIV serodiscordant male couples. Our findings also suggest that dyad-level interventions may be able to leverage our understanding of how partners can influence each other's health-promoting behaviors to develop programs that improve health outcomes for both partners.
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http://dx.doi.org/10.1097/QAI.0000000000002522DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7736462PMC
January 2021

"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

"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

Appearance discrimination and binge eating among sexual minority men.

Appetite 2021 01 24;156:104819. Epub 2020 Aug 24.

San Diego State University, United States; San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology, United States. Electronic address:

Sexual minority men (SMM) face substantial disparities in rates of binge eating compared to heterosexual individuals, underscoring the need to study risk factors for the development of binge eating amongst SMM. One potential explanation for this disparity in binge eating is minority stress theory, which posits that minority groups face stressors, such as discrimination, due to their stigmatized position in society. Additionally, specific domains of discrimination may confer different levels of risk for binge eating. Therefore, the current study examined the association of various forms of discrimination, including appearance-based discrimination, and binge eating in a sample of SMM. A sample of 200 SMM (analytic sample of N = 187) from the greater Boston area completed self-report questionnaires assessing frequency of different forms of perceived discrimination (appearance, sexual orientation, race, etc.) and binge eating. A hierarchical binary logistic regression model was used to examine the association of different forms of discrimination with binge eating. 9% of the sample reported binge eating. Appearance-based discrimination was the most common form of discrimination (47%), and was significantly associated with binge eating, over and above all other forms of discrimination and sociodemographic variables, OR = 1.71, 95% CI = [1.24, 2.35], Wald χ (1) = 10.65, p = .001. Findings suggest that appearance-based discrimination may be related to binge eating in SMM. Clinicians may consider assessing appearance-based discrimination among SMM patients.
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http://dx.doi.org/10.1016/j.appet.2020.104819DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7669646PMC
January 2021

Feasibility of Short-Term PrEP Uptake for Men Who Have Sex With Men With Episodic Periods of Increased HIV Risk.

J Acquir Immune Defic Syndr 2020 08;84(5):508-513

Fenway Health, Boston, MA.

Background: Pre-exposure prophylaxis (PrEP) with emtricitabine/tenofovir disoproxil fumarate is efficacious in reducing HIV acquisition. For some gay, bisexual, and other men who have sex with men (MSM), daily ongoing PrEP may be unsuitable for use as a long-term prevention strategy because of episodic risk, cost issues, or concerns about the biological consequences of medication.

Setting: This study evaluated the feasibility of short-term, fixed-interval episodic PrEP (Epi-PrEP) for use among vacationing MSM. We describe the feasibility of implementing a clinic-based Epi-PrEP pilot program for 48 MSM who reported occasional condomless sex and anticipated a defined high-risk time.

Methods: This was a nonrandomized naturalistic study of an observational clinical intervention. The primary outcome assessed was adherence, as measured by self-report and plasma tenofovir levels.

Results: Of 54 MSM who enrolled in the study, 48 completed the 3-month visit. The majority (93.7%) had tenofovir concentrations consistent with daily use on returning from vacation. Almost 3/4 reported condomless sex during vacation, and about 1/3 reported recreational drug use. During the 3-month follow-up, 1 participant had become HIV-infected because of a lapse in continued access to the PrEP after study. Although adverse events were common, none were serious. More than 70% of participants indicated an interest in daily ongoing PrEP use.

Conclusions: Epi-PrEP was well tolerated by at risk MSM in this study, with high levels of medication adherence. Many participants felt the experience of initiating PrEP while on vacation could be a means for transition to long-term PrEP use.
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http://dx.doi.org/10.1097/QAI.0000000000002382DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489298PMC
August 2020

Validation of depressive symptoms, social support, and minority stress scales among gay, bisexual, and other men who have with men (GBMSM) in Nigeria, Africa: a mixed methods approach.

BMC Public Health 2020 Jun 29;20(1):1023. Epub 2020 Jun 29.

Department of Behavioral and Social Sciences, Brown University School of Public Health, 121 South Main St., Box G-S121-3, Providence, RI, 02912, USA.

Background: Gay, bisexual, and other men who have sex with men (GBMSM) in Nigeria experience social marginalization, discrimination and violence due to their sexual identity, which may negatively impact physical, mental, and sexual health outcomes. Studies on GBMSM in Africa utilize measurement scales developed largely for populations in the Global North. The validity and reliability of these instruments-to our knowledge-have never been thoroughly investigated among GBMSM in Nigeria. The aim of the current study was to determine the validity and reliability of the English versions of the Center for Epidemiologic Studies Depression Scale (CESD-R), Multidimensional Scale of Perceived Social Support (MSPSS), and LGBT Minority Stress Measure among a large multi-state sample of GBMSM Nigeria.

Methods: Between January and June 2019, we conducted cognitive interviews (N = 30) and quantitative assessments (N = 406) with GBMSM in Nigeria. The cognitive interviews assessed comprehension of scale items and elicited suggestions for scale modifications. The quantitative assessment was used to gather psychosocial health data and to evaluate psychometric properties and construct validity of the modified scales. We utilized confirmatory factor analysis to assess factor structure, correlation coefficients, and Cronbach's alpha to examine scale validity and internal consistency.

Results: Based on participant feedback from the cognitive interviews, we made slight modifications (i.e., culturally appropriate word substitutions) to all three scales. Results of quantitative analyses indicated good psychometric properties including high factor loadings, internal consistency and construct validity among the CESD-R, MSPSS, and LGBT Minority Stress Measure among GBMSM in Nigeria.

Conclusion: These results suggests that modifying research scales to be more culturally relevant likely do not jeopardize their validity and reliability. We found that modified scales measuring depressive symptoms, perceived social support, and minority stress among GBMSM in Nigeria remained valid. More research is needed to explore whether the psychometric properties remain if the scales are translated into broken English (Pidgin) and other traditional Nigerian languages (Yoruba, Igbo and Hausa).
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http://dx.doi.org/10.1186/s12889-020-09127-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7325044PMC
June 2020

Trajectories of initiation for the heroin-based drug whoonga - qualitative evidence from South Africa.

Int J Drug Policy 2020 08 12;82:102799. Epub 2020 Jun 12.

University of California, San Diego School of Medicine, 9500 Gilman Drive, La Jolla, CA 92093, United States; HIV Neurobehavioral Research Program, University of California, San Diego, 220 Dickinson Street, San Diego, CA 92103, United States. Electronic address:

Background: Whoonga is a smoked heroin-based street drug that first emerged in South Africa a decade ago. While previous scientific reports suggest that use is growing and youth are particularly vulnerable, trajectories of initiation are not well characterized.

Methods: In 2015, 30 men undergoing residential addiction treatment for this smoked heroin drug in KwaZulu-Natal, South Africa participated in semi-structured interviews about their experiences using the drug. Interview data were coded using qualitative content analysis.

Results: Participant trajectories to initiating smoked heroin were "vertical" in the context of marijuana use or "horizontal" in the context of other hard drug use. Participants reporting vertical trajectories began smoking heroin as youth at school or in other settings where people were smoking marijuana. Several participants with horizontal trajectories started smoking heroin to address symptoms of other drug or alcohol addiction. Social influences on initiation emerged as an overarching theme. Members of participants' social networks who were smoking or distributing heroin figured prominently in initiation narratives. Surprisingly, references to injection drug use were absent from initiation narratives. Participants reported people who smoke heroin differ from those who inject heroin by race.

Conclusion: Consistent with theories implicating social and structural influences on substance use initiation, people who started smoking heroin had social contacts who smoked heroin and frequented places where substance use was common. Smoked heroin initiation for several participants with horizontal trajectories may have been averted if they accessed evidence-based treatments for stimulant or alcohol use disorders. With increasing reports of heroin use across Africa, a coordinated approach to address this growing epidemic is needed. However, because smoked heroin and injection heroin use occur in distinct risk environments, interventions tailored to people who use smoked heroin will be needed to prevent smoked heroin use, prevent transition to injection use, and mitigate other social harms.
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http://dx.doi.org/10.1016/j.drugpo.2020.102799DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7493467PMC
August 2020

A Dyadic Perspective on Sexual Agreements Among Same-Sex Male Couples in the United States.

AIDS Behav 2020 Nov;24(11):3107-3123

Center for Sexuality and Health Disparities, University of Michigan, Ann Arbor, MI, USA.

Sexual agreements are an important HIV risk reduction strategy enacted by men in male-male partnerships. Greater levels of relationship quality have been associated with sexual agreement formation and adherence. However, current evidence supporting the associations between relationship quality and sexual agreements for male dyads is based primarily on the responses of just one partner. Understanding that relationship quality and decisions about sexual agreements are inherently influenced by both partners, the present analysis uses dyadic-level data to examine the sexual agreements among 199 HIV serodiscordant and seroconcordant male dyads (n = 398 individuals). Specifically, the analysis examines measures of love, trust, and conflict style as they relate to (1) the type of agreement established, (2) concordance in agreement reporting, (3) satisfaction with the agreement, and (4) broken agreements. A discrepancy in love between partners was associated with the type of agreement established, whether they reported the same agreement type, and whether one of the partners reported a broken agreement, but it was not associated with either partner's satisfaction with the agreement. A discrepancy in trust was associated with agreement concordance and agreement breaks, but it was not associated with the type of agreement established or satisfaction with the agreement. Lastly, a discrepancy in conflict style was associated with each of the agreement outcomes. Future research and intervention efforts should focus on understanding the behavioral and communication skills necessary for couples to make successful sexual agreements.
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http://dx.doi.org/10.1007/s10461-020-02865-7DOI Listing
November 2020

Potential Impact of Targeted HIV Pre-Exposure Prophylaxis Uptake Among Male Sex Workers.

Sci Rep 2020 03 27;10(1):5650. Epub 2020 Mar 27.

Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, United States.

Little is known about the potential population-level impact of HIV pre-exposure prophylaxis (PrEP) use among cisgender male sex workers (MSWs), a high-risk subset of cisgender men who have sex with men (MSM). Using an agent-based model, we simulated HIV transmission among cisgender MSM in Rhode Island to determine the impacts of PrEP implementation where cisgender MSWs were equally ("standard expansion") or five times as likely ("focused expansion") to initiate PrEP compared to other cisgender MSM. Without PrEP, the model predicted 920 new HIV infections over a decade, or an average incidence of 0.39 per 100 person-years. In a focused expansion scenario where 15% of at-risk cisgender MSM used PrEP, the total number of new HIV infections was reduced by 58.1% at a cost of $57,180 per quality-adjusted life-year (QALY) gained. Focused expansion of PrEP use among cisgender MSWs may be an efficient and cost-effective strategy for reducing HIV incidence in the broader population of cisgender MSM.
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http://dx.doi.org/10.1038/s41598-020-62694-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7101419PMC
March 2020

Prevalence and Risk Factors of Nonmedical Prescription Opioid Use Among Transgender Girls and Young Women.

JAMA Netw Open 2020 03 2;3(3):e201015. Epub 2020 Mar 2.

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

Importance: Nonmedical prescription opioid use is a pressing public health issue in the United States. Transgender youth, including adolescent girls and young women who were assigned male at birth and currently identify as women, female, transgender women, or another diverse gender identity along the transfeminine gender spectrum, are more likely than their cisgender peers to report illicit substance use and meet diagnostic criteria for substance use disorders. However, relatively little is known about the experiences of these populations in the current era of opioid addiction and misuse.

Objective: To report the prevalence of and risk factors associated with lifetime nonmedical prescription opioid use in a high-risk community sample of transgender adolescent girls and young women who are sexually active.

Design, Setting, And Participants: This cross-sectional study used 2012 to 2015 baseline data from Project LifeSkills, a randomized clinical trial of a behavioral intervention to reduce the risk of HIV acquisition and transmission among a diverse sample of transgender adolescent girls and young women recruited from Boston, Massachusetts, and Chicago, Illinois. A total of 297 transgender girls and women aged 16 to 29 years who were sexually active were included in this analysis. Data were analyzed from June 2019 to August 2019.

Exposures: Transgender woman identification.

Main Outcomes And Measures: Self-reported lifetime nonmedical prescription opioid use.

Results: Among 297 transgender adolescent girls and young women (mean [SD] age, 23.4 [3.5] years), 145 (48.8%) identified as non-Hispanic/Latinx black, 76 (25.6%) identified as non-Hispanic/Latinx white, 37 (12.5%) identified as Hispanic/Latinx, 7 (2.4%) identified as non-Hispanic/Latinx Asian, and 32 (10.8%) identified as multiracial or other race/ethnicity. Thirty-five participants (11.8%) reported lifetime nonmedical prescription opioid use. Young transgender women who smoked cigarettes monthly or less (adjusted odds ratio, 3.92; 95% CI, 1.10-13.89) and who smoked daily (adjusted odds ratio, 5.69; 95% CI, 1.87-17.33) had greater odds of nonmedical prescription opioid use compared with those who did not smoke. Additionally, participants who identified as a sexual orientation other than heterosexual, gay, lesbian, or bisexual had significantly greater odds of lifetime nonmedical prescription opioid use compared with those who identified as heterosexual (adjusted odds ratio, 3.69; 95% CI, 1.07-12.72).

Conclusions And Relevance: These findings suggest that transgender adolescent girls and young women have similar prevalence of lifetime nonmedical prescription opioid use compared with the US general population prevalence of 12.5%. These findings may serve as a call-to-action for public health surveillance studies and evidence-based interventions to be comprehensively tailored to examine and respond to specific trends of substance use, particularly opioid use disorder, among transgender populations.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.1015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7076341PMC
March 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