Search

OBJECTIVES Childhood sexual abuse (CSA) prevalence estimates range from 8-11% among older adults and may range from 16 to 22% among older adults living with HIV (OALH). CSA experiences can still impact the quality of life of older adults. To the best of our knowledge, however, there are no CSA-focused interventions tailored for OALH. Using a qualitative approach, this study characterized the desired components of a trauma-focused intervention for OALH who are CSA survivors. METHODS Twenty-four (24) adults aged 50 years of age or older who were living with HIV and had experienced CSA were recruited from a large HIV immunology center in South Carolina. Participants completed in-depth, qualitative, semi-structured interviews. We iteratively examined verbatim transcripts using thematic analysis. RESULTS Three main themes emerged: program format and modality, program content, and program coordinator. Most participants expressed a desire for a trauma-focused intervention program in which the CSA experience was addressed and they could talk to someone either individually, as a group, and/or both. CONCLUSION A trauma-focused intervention addressing CSA may be helpful for OALH who are CSA survivors. Future research should focus on designing and implementing age-appropriate interventions addressing the CSA experience, increasing resilience, and developing adaptive coping skills.

Social biases may influence providers' judgments related to pre-exposure prophylaxis (PrEP) and patients' consequent PrEP access. US primary and HIV care providers (n = 370) completed an experimental survey. Each provider reviewed one fictitious medical record of a patient seeking PrEP. Records varied by patient race (Black or White) and risk behavior (man who has sex with men [MSM], has sex with women [MSW], or injects drugs [MID]). Providers reported clinical judgments and completed measures of prejudice. Minimal evidence of racially biased judgments emerged. Providers expressing low-to-moderate sexual prejudice judged the MSM as more likely than the MSW to adhere to PrEP, which was associated with greater PrEP prescribing intention; sexual prejudice was negatively associated with anticipated MSM adherence. Providers judged the MID to be at higher risk, less likely to adhere, less safety-conscious, and less responsible than both the MSM and MSW; adverse adherence and responsibility judgments were associated with lower prescribing intention.Los sesgos sociales pueden influir sobre los juicios de proveedores de salud con respecto a la profilaxis pre-exposición (PrEP) y el consecuente acceso de los pacientes a PrEP. Proveedores de cuidados primarios y de VIH en los Estados Unidos (n = 370) respondieron una encuesta experimental. Cada proveedor leyó una historia médica de un paciente ficticio interesado en obtener PrEP. Las historias médicas variaron la raza (Negro o Blanco) y conducta de riesgo (hombre que tiene sexo con hombres [HSH], hombre que tiene sexo con mujeres [HSM], u hombre usuario de drogas inyectables [HDI]) del paciente. Los proveedores reportaron juicios clínicos y completaron medidas sobre prejuicio. La evidencia sobre sesgos raciales en los juicios clínicos fue mínima. Los proveedores que expresaron prejuicio sexual bajo a moderado, juzgaron que el paciente HSH tendría mayor adherencia a PrEP que el paciente HSM, lo cual se asoció con mayor intención de prescribir PrEP; el prejuicio sexual se asoció negativamente con la adherencia anticipada en HSH. El paciente HDI fue percibido como en mayor riesgo, con menor adherencia, menos preocupado por la seguridad, y menos responsable que los HSH y HSM; los juicios sobre baja adherencia y responsabilidad estuvieron asociados con menor intención de prescribir PrEP.

Expanding PrEP access necessitates training that supports healthcare providers’ progression along the PrEP implementation cascade, moving from PrEP awareness to prescription. We surveyed 359 USA providers about PrEP training content and format recommendations. We examined the association between cascade location and training recommendations. Most providers were aware of PrEP (100%), willing to prescribe PrEP (97.2%), had discussed PrEP with patients (92.2%), and had prescribed PrEP (79.9%). Latent class regression analysis revealed that cascade location was associated with training recommendations. Although all providers recommended PrEP-specific content (e.g., patient eligibility), providers who were located further along the cascade also recommended more comprehensive content, including sexual history-taking and sexual and gender minority competence training. Providers further along the cascade were also more likely to recommend interactive training formats (e.g., role-playing). These insights from providers furthest along the cascade indicate the importance of including comprehensive content and interactive formats in future PrEP training initiatives. Supplementary Information The online version contains supplementary material available at 10.1007/s10461-021-03375-w.

This article describes the incorporation of an evidence-based mental health intervention, the Youth Readiness Intervention (YRI), into a youth entrepreneurship training program in Sierra Leone. A collaborative team approach (CTA) was used as the implementation strategy to address the human resource shortage and related challenges associated with capacity and access to care.A cluster randomized quasi-experimental pilot trial (N=175) was conducted in one rural district of Sierra Leone. Pilot data assessed implementation feasibility and clinical effectiveness when using a CTA. A larger hybrid type-2 effectiveness-implementation cluster randomized trial is underway (N=1,151) in three rural districts. Findings on feasibility and fidelity, barriers and facilitators influencing the integration of the YRI into the entrepreneurship program, and clinical effectiveness of the YRI are of interest.Findings from the pilot study indicated that the YRI can be implemented within a youth entrepreneurship program and provide mental health benefits to youths at high risk of emotion dysregulation and interpersonal deficits. Pilot findings informed the ongoing, larger hybrid type-2 trial to understand barriers and facilitators of the CTA and clinical effectiveness of the YRI within youth employment programming.In fragile postconflict settings, innovative approaches are needed to address the mental health treatment gap. Findings from this study will support efforts by the government of Sierra Leone and its partners to address human resource challenges and increase access to evidence-based mental health services.

Trans and non-binary (TNB) people face mental health disparities, likely due to discrimination. This study aims to explore the types of discrimination that TNB people report and the corresponding coping strategies. A sample of 85 TNB adults between the ages of 18 and 46 years old completed two surveys a day for 30 days reporting discrimination, coping, and emotional state. The types of discriminatory events were grouped into four categories: rejection, active transphobia, microaggressions, and community-level transphobia. A total of 3240 discriminatory events were reported, with the most frequent types reported being misgendering and other microaggressions. Results from linear regressions found individuals who experienced rejection were less likely to use support-based coping strategies, while individuals who experienced multiple events were more likely to report marijuana use. These findings should encourage researchers and practitioners to pay attention to discrimination when intervening on mental health with people who identify as TNB.

The adverse impact of exposure to war-related traumatic events on mental health is well documented. Few studies, however, have focused on the impact of exposure to war-related traumatic events on HIV sexual risk behavior in post-conflict countries such as Liberia. We investigated whether exposure to war-related traumatic events was linked to HIV sexual risk behavior, and identified potential mediators of this relationship, including stressful life events, problematic alcohol use, and intimate partner violence (IPV) among women and men in Liberia. Data were collected from a sample of 395 participants in Monrovia, Liberia. Results from the serial multiple mediator model did not support direct or indirect effects between war-related traumatic events and HIV sexual risk behavior among women. For men, we found both direct and indirect effects between war-related traumatic events and HIV sexual risk behavior. Findings from this research highlight the need for trauma-informed HIV prevention strategies in Liberia.

BACKGROUND We sought to compare self-reported alcohol consumption using Timeline Followback (TLFB) to biomarker-based evidence of significant alcohol use (phosphatidylethanol [PEth] > 20 ng/ml). Using data from patients with HIV (PWH) entering a clinical trial, we asked whether TLFB could predict PEth > 20 ng/ml and assessed the magnitude of association between TLFB and PEth level. METHODS We defined unhealthy alcohol use as any alcohol use in the presence of liver disease, at-risk drinking, or alcohol use disorder. Self-reported alcohol use obtained from TLFB interview was assessed as mean number of drinks/day and number of heavy drinking days over the past 21 days. Dried blood spot samples for PEth were collected at the interview. We used logistic regression to predict PEth > 20 ng/ml and Spearman correlation to quantify the association with PEth, both as a function of TLFB. RESULTS Among 282 individuals (99% men) in the analytic sample, approximately two-thirds (69%) of individuals had PEth > 20 ng/ml. The proportion with PEth > 20 ng/ml increased with increasing levels of self-reported alcohol use; of the 190 patients with either at-risk drinking or alcohol use disorder based on self-report, 82% had PEth > 20 ng/ml. Discrimination was better with number of drinks per day than heavy drinking days (AUC: 0.80 [95% CI: 0.74 to 0.85] vs. 0.74 [95% CI: 0.68 to 0.80]). The number of drinks per day and PEth were significantly and positively correlated across all levels of alcohol use (Spearman's R ranged from 0.29 to 0.56, all p values

There is a need for evidence-based contextualized mental health interventions for persons living with HIV/AIDS. In the current study, the primary researcher conducted open trials with African American women living with HIV/AIDS (AAWLWHA) to examine the acceptability and feasibility of Project UPLIFT, a mindfulness-based cognitive therapy intervention that has demonstrated effectiveness in persons living with epilepsy. Women were recruited for a tele-delivered phone intervention group separated by gender identity, as well as participated in pre- and post-test assessments. Additionally, data on acceptability was collected. Both cis- and transgender women were highly satisfied with the intervention and demonstrated improvement in depressive and stress symptoms. The intervention seemed to be particularly feasible for cisgender women, though more qualitative mental health research may be warranted with transgender women. The current research has implications for the utility of mindfulness-based interventions such as UPLIFT, with AAWLWHA.

Background At-risk levels of alcohol use threaten the health of patients with HIV (PWH), yet evidence-based strategies to decrease alcohol use and improve HIV-related outcomes in this population are lacking. We examined the effectiveness of integrated stepped alcohol treatment (ISAT) on alcohol use and HIV outcomes among PWH and at-risk alcohol use. Methods In this multi-site, randomized trial conducted between January 28, 2013 through July 14, 2017, we enrolled PWH and at-risk alcohol use [defined as alcohol consumption of ≥ 14 drinks per week or ≥ 4 drinks per occasion in men ≤ 65 years old or ≥ 7 drinks per week or ≥ 3 drinks per occasion in women or men > 65 years old]. ISAT (n = 46) involved: Step 1- Brief Negotiated Interview with telephone booster, Step 2- Motivational Enhancement Therapy, and Step 3- Addiction Physician Management. Treatment as usual (TAU) (n = 47) involved receipt of a health handout plus routine care. Analyses were conducted based on intention to treat principles. Results Despite a multi-pronged approach, we only recruited 37% of the target population (n = 93/254). Among ISAT participants, 50% advanced to Step 2, among whom 57% advanced to Step 3. Participants randomized to ISAT and TAU had no observed difference in drinks per week over the past 30 days at week 24 (primary outcome) [least square means (Ls mean) (95% CI) = 8.8 vs. 10.6; adjusted mean difference (AMD) (95% CI) = − 0.4 (− 3.9, 3.0)]. Conclusion An insufficient number of patients were interested in participating in the trial. Efforts to enhance motivation of PWH with at-risk alcohol use to engage in alcohol-related research and build upon ISAT are needed. Trial registration Clinicaltrials.gov: NCT01410123, First posted August 4, 2011

Background Following 14 years of civil war in Liberia, war-exposure, gender-based violence, and extreme poverty have been identified as key challenges to the mental and sexual health of young pregnant women, and the health of their unborn children. Despite ongoing efforts to rebuild the country’s healthcare infrastructure, empirical research and interventions focused on addressing the consequences of war on the mental and sexual health of young pregnant women in Liberia are severely limited. To address these concerns, we developed Project POWER (Progressing Our Well-being, Emotions, and Relationships) (POWER), a mindfulness-infused cognitive-behavioral intervention for young adult pregnant women. This study sought to: 1) assess the feasibility and acceptability of POWER; and (2) determine the preliminary efficacy of POWER for improving mental and sexual health outcomes among Liberian war-exposed pregnant young adult women. Methods Eighty-seven women ages 18-25 years were recruited from three catchment areas in Monrovia, Liberia. Participants participated in one of two ten-session programs delivered over 5-weeks: POWER or a control group (a health education program). Feasibility and acceptability of POWER were examined using program log (e.g., the number of participants screened and enrolled, facilitator satisfaction, etc.) data from an exit interview. Results Preliminary efficacy of POWER’s effects on mental and sexual health outcomes was assessed using a series of four one-way repeated measures ANOVA with time and group as predictors. Analyses provided preliminary support for the feasibility and acceptability of POWER. Preliminary efficacy of POWER showed significant reductions in depression symptoms, PTSD symptoms, prenatal distress, and transactional sex over time. Conclusions Findings suggest that POWER may be a feasible and acceptable intervention to promote mental and sexual health for young adult pregnant women in Liberia. Future research is needed to determine the efficacy of POWER on a larger scale in Liberia.

People with HIV (PWH) frequently engage in unhealthy alcohol use, which can adversely affect antiretroviral adherence and HIV disease progression. Brief interventions based on Motivational Interviewing (MI), including the Brief Negotiated Interview (BNI), can help to reduce drinking. This study examines MI processes observed during a single 15-20 min BNI session delivered by social workers to PWH with unhealthy alcohol use (N = 59) in the context of a stepped care intervention to reduce alcohol consumption. BNI sessions were coded for technical and relational processes encouraged in MI, such as autonomy support, instructive language, and self-exploration. Multiple regression analyses explored the relationship between: (1) Participants' pre-intervention drinking behaviors (weekly drinks and heavy drinking days) and these MI processes, and (2) MI processes and intervention outcomes. Results indicated that PWH who reported more weekly drinks at baseline engaged in less self-exploration, while social workers delivering the BNI used less instructive language for those who reported more heavy drinking days. PWH who engaged in more self-exploration and received more autonomy support had fewer heavy drinking days 6 months after the intervention. These findings suggest the value of providing more opportunities within BNIs to encourage self-exploration, as it may help to enhance intervention efficacy.

The timeline followback (TLFB) takes more resources to collect than the Alcohol Use Disorder Identification Test (AUDIT-C). We assessed agreement of TLFB and AUDIT-C with the biomarker phosphatidylethanol (PEth) and compared changes in TLFB and PEth among persons with HIV (PWH) using secondary data from randomized trials. We calculated operating characteristics and agreement between TLFB (> 1 and > 2 average drinks/day), AUDIT-C ≥ 4 and PEth ≥ 20 among 275 men with HIV. Median age was 57 years, 80% were African-American; and 17% white. Sixty-eight percent had PEth ≥ 20, 46% reported > 2 average drinks/day on TLFB, 61% reported > 1 average drinks/day on TLFB, and 72% had an AUDIT-C ≥ 4. Relative to PEth, sensitivity for AUDIT-C ≥ 4 was 84% (kappa = 0.36), and for TLFB > 1 average drink/day was 76% (kappa = 0.44). Change in alcohol use appeared greater using TLFB measures than PEth. Strategies to robustly assess alcohol use in PWH may require both self-report and biomarkers.

In the United States, approximately 45% of persons living with HIV (PLHIV) are ≥ 50 years of age. Many older PLHIV have multi-morbidities that complicate HIV infection and/or interfere with, or are exacerbated by, antiretroviral treatment. Physical health symptoms and psychiatric disorders, particularly depression, can worsen life quality in older PLHIV. This study assessed associations among physical symptoms, indicators of HIV-related health status (i.e., time since diagnosis; ever diagnosed with AIDS; having attained viral suppression), depressive symptoms, and health-related quality of life (HRQoL) in older PLHIV. Regression analyses examined data from 296 PLHIV ≥ 50 years of age living in Cincinnati, OH, Columbus, OH, and New York City. Depressive symptoms and physical symptoms, particularly those related to appearance and sexual functioning, most strongly predicted HRQoL. Indicators of HIV health status did not significantly predict HRQoL. Depressive symptoms were a particularly robust predictor of HRQoL, even when accounting for physical health symptoms. Findings suggest that symptom management is critical to HRQoL in older PLHIV, and symptoms related to physical appearance and sexual functioning should not be overlooked in this growing population.

African-American HIV-seropositive women are at elevated risk for depressive symptoms compared to their seropositive counterparts. Depressive symptoms have been linked to HIV/AIDS-related health predictors and outcomes such as medication and care adherence, and viral load. Project UPLIFT, a mindfulness-based cognitive therapy intervention originally designed for persons with epilepsy has been shown effective to reduce depressive and anxiety symptoms. Focus groups were conducted to assess the appropriateness and acceptability of UPLIFT for African-American HIV-seropositive women and to obtain feedback on needed modifications. The focus groups, including cisgender and transgender African-American HIV-seropositive women, revealed, while well received, modifications should include lowering the reading level of content and altering specific mindfulness-based exercises to make them relevant and acceptable to the target population. This qualitative work demonstrates UPLIFT could be a promising avenue to improve the mental health of African-American HIV-seropositive women, a group for which mindfulness interventions had not been previously considered. SIGNIFICANCE: Mindfulness-based interventions have been found effective in reducing depression, anxiety, and chronic pain. Further, it has been used for groups living with chronic illness, particularly HIV/AIDS. It has helped to improve mental and behavioral health, as well as increase CD4 count and reduce viral load for some samples of people living with HIV/AIDS. African-American women living with HIV/AIDS are especially vulnerable to poor mental and behavioral health given their experience of mental illness and hesitancy to engage mental healthcare. Though used for other groups of people living with HIV/AIDS, mindfulness-based cognitive therapy has not previously been considered for this population. This study explored the acceptability and feasibility of an MBCT intervention for this group. The data suggests that this intervention could be potentially useful in improving the mental health of this population, and includes suggestions for making the intervention culturally relevant.

This qualitative study (N = 20) examined the online and mobile dating app use of sexual minority males living in non-metropolitan areas. Many participants reported negative experiences while using ...

Efforts to identify and address social inequities in HIV pre-exposure prophylaxis (PrEP) access are urgently needed. We investigated early-adopting PrEP prescribers' beliefs about how stigma contributes to PrEP access disparities in health care and explored potential intervention strategies within the context of PrEP service delivery. US-based PrEP prescribers were recruited through professional networks and participant referrals. Qualitative interviews were conducted, transcribed, and thematically analyzed. Participants (n = 18) were primarily male (72%); white (39%) or Asian (33%); and heterosexual (56%). Most practiced in the Northeastern (67%) or Southern (22%) United States; were physicians (94%); and specialized in HIV/infectious disease (89%). Participants described multiple forms of structural and interpersonal stigma impeding PrEP access. The requirement that PrEP be prescribed was a perceived deterrent for populations with medical mistrust and/or low health literacy. Practice norms such as discussing PrEP only in response to patient requests were seen as favoring more privileged groups. When probed about personally held biases, age-related stereotypes were the most readily acknowledged, including assumptions about older adults being sexually inactive and uncomfortable discussing sex. Participants criticized providers who chose not to prescribe PrEP within their clinical practice, particularly those whose decision reflected personal values related to condomless sex or discomfort communicating about sex with their patients. Suggested solutions included standardizing PrEP service delivery across patients and increasing cultural competence training. These early insights from a select sample of early-adopting providers illuminate mechanisms through which stigma could compromise PrEP access for key populations and corresponding points of intervention within the health care system.

Introduction: Men who have sex with men (MSM) in rural areas have limited access to HIV prevention and education resources. Given the growing usage of mobile dating apps among the wider MSM population, this research sought to explore their use among MSM in rural areas and their potential for delivering HIV prevention information. Methods: Participants were recruited from different areas of the rural Southern USA. This mixed-methods study consisted of an online survey (n=85) and follow-up qualitative phone interviews with 20 survey respondents. The survey assessed dating app use, sexual behaviors, and pre-exposure prophylaxis (PrEP) awareness, usage, and attitudes among MSM in the rural, Southern USA. Interviews explored perceptions of dating apps and their potential value as a source of health and HIV prevention information. Results: Among survey respondents, 74% had used a dating app, with Grindr being the most frequently used app. Of individuals who were in a relationship, 41% had met their current partner online. Using a dating app was associated with having a greater number of sexual partners. Three-quarters of participants had heard of PrEP, but only 7% had ever received a prescription for it and less than one-third reported that it would be easy to get PrEP if they wanted it. Dating app users were more likely than non-app users to have more positive attitudes toward taking PrEP and interest in taking PrEP. In qualitative interviews, respondents expressed support for integrating HIV prevention information into dating apps. Conclusion: Dating app usage is high among rural MSM. Individuals who use these apps have more sexual partners and also are more interested in PrEP for HIV prevention, suggesting that this is an ideal group to target for PrEP education and interventions. This could be especially beneficial for MSM in rural areas, as most have difficulty accessing PrEP and PrEP education.

Background Youth Functioning and Organizational Success for West African Regional Development (Youth FORWARD) was launched as an implementation science collaboration focused on scaling out evidence-based mental health interventions for youth exposed to war and other adversities through novel delivery platforms. This implementation science case study examines the use of a collaborative team approach (CTA) as a scale-out strategy to foster the integration of an evidence-based group mental health intervention, the Youth Readiness Intervention, into youth employment programs tied to regional economic development in Sierra Leone. Methods A case study methodology is used to explore the feasibility and acceptability of integrating an evidence-based intervention, the Youth Readiness Intervention (YRI), into youth entrepreneurship programs (ENTR) in Sierra Leone, facilitated by the CTA. The authors analyzed field notes logged during program implementation, 8 weeks of supervision notes, 20 interviews with agency leaders and front-line staff delivering the YRI within this alternate delivery platform. Quantitative dissemination and implementation interviews administered to youth, facilitators, and agency leaders were analyzed using descriptive statistics and mixed linear models. A linked Hybrid Type II effectiveness-implementation cluster randomized trial is evaluating the clinical effectiveness of the YRI within this delivery platform. Results Extant data indicate the strong feasibility and acceptability of integrating the YRI into the ENTR program. Facilitators of integration of the YRI into the ENTR include mission alignment of the organizations with the delivery of psychosocial interventions, shared commitment to serving vulnerable youth, support from local District Youth Councils, and high interest from the youth served. Barriers include perceived competition between frontline organizations seeking funding for psychosocial interventions, and challenges in flexibility between donors and implementation partners operating in a fragile/post-conflict setting. The CTA was a feasible and acceptable strategy to support fidelity and quality improvement while scaling out the YRI. Conclusions Youth entrepreneurship and livelihood programs offer a promising mechanism for expanding the reach of evidence-based interventions to youth in fragile and post-conflict settings. Quality improvement and sustainment of evidence-based interventions are novel concepts in such settings. The CTA strategy institutionalizes the integration of an evidence-based intervention into youth entrepreneurship programs. Trial registration NCT03603613 (phase 1 pilot, registered May 18, 2018) and NCT03542500 (phase 2 scale-out study, registered May 18, 2018).

We sought to test the efficacy of extended-release naltrexone (XR-NTX) on HIV-related and drinking outcomes. From April 2011-February 2015, we conducted a 4-site randomized double-blind placebo controlled clinical trial involving 51 HIV-positive patients with heavy drinking and

Human trafficking exerts psychological effects on survivors that persist after intervention, and even after community reintegration. Effects include anxiety, depression, alienation, disorientation, aggression, suicidal ideation, attention deficit, and posttraumatic stress disorder (PTSD). Community supports and coping mechanisms may mitigate these effects. The report presented here is part of a long-term program of research to develop and test evidence-informed mental health and human capacity-building intervention programs for women and girls who are victims of trafficking. Structural equation modeling was used to assess a conditional process model (moderated mediation) of the effect of social support, coping, and community reintegration on PTSD among n = 144 girls and women. Participants received psychosocial intervention at a residential care facility for trafficking survivors. Results indicate model fit was excellent. Results indicate community reintegration indirectly influenced PTSD through its effect on perceived social support. Survivors who reported more difficulty reintegrating back into the community perceived less social support than those that reported easier community reintegration, and trafficking survivors who perceived less social support indicated more PTSD. Survivors with more PTSD symptoms tended to report using more dysfunctional coping mechanisms.

HIV diagnosis presents a critical opportunity to reduce secondary transmission, improve engagement in care, and enhance overall well-being. To develop relevant interventions, research is needed on the psychosocial experiences of newly diagnosed individuals. This study examined avoidant coping, self-efficacy for HIV disclosure decisions, and depression among 92 newly diagnosed men who have sex with men (MSM) who reported recent sexual risk behavior. It was hypothesized that avoidant coping would mediate the relationship between self-efficacy and depression. Cross-sectional surveys were collected from participants three months after HIV diagnosis. To test for mediation, multiple linear regressions were conducted while controlling for HIV disclosure to sexual partners. Self-efficacy for HIV disclosure decisions showed a negative linear relationship to depression symptoms, and 99% of this relationship was mediated by avoidant coping. The index of mediation of self-efficacy on depression indicated a small-to-medium effect. Higher self-efficacy was related to less avoidant coping, and less avoidant coping was related to decreased depression symptoms, all else held constant. These findings highlight the role of avoidant coping in explaining the relationship between self-efficacy for HIV disclosure decisions and depression.

Background: One-third of women who experience intimate partner violence (IPV) are identified as having alcohol use problems. Yet, little research has examined factors that may increase the risk of ...

Summary Background We examined the effectiveness of integrated stepped alcohol treatment (ISAT) on alcohol use and HIV outcomes among patients living with HIV and alcohol use disorder. Methods In this multisite, randomised controlled trial, conducted in five Veterans Affairs-based HIV clinics in the USA (Atlanta, GA; Brooklyn-Manhattan, NY; Dallas and Houston, TX; and Washington, DC), we recruited people living with HIV and an alcohol use disorder who were not otherwise receiving formal alcohol treatment. Patients were eligible if they were aged 18 years or older, HIV positive, English speaking, and met criteria for alcohol use disorder by the Diagnostic and Statistical Manual for Mental Disorders-IV criteria for alcohol abuse or dependence. Key exclusion criteria included if the patient was acutely suicidal or had a psychiatric condition that affected their ability to participate in counselling interventions, or if they had any medical conditions that would preclude completing the study or cause harm during the course of the study. Using a web-based clinical trial management system, we randomly assigned participants (1:1) to receive ISAT or treatment as usual; patients, investigators, and clinicians were unmasked to allocation. ISAT involved three steps: step 1, addiction physician management, comprising eight sessions; step 2, addiction physician management plus motivational enhancement therapy, comprising four sessions; and step 3, specialty referral. Participants were stepped up at weeks 4 and 12 if they exceeded a priori drinking criteria. Treatment as usual involved referral to substance use treatment services. The primary outcome was number of drinks per week over the past 30 days at week 24 by use of the timeline followback method, assessed in the intention-to-treat population. Adverse events were tracked throughout the study period in all randomly assigned participants. This trial is registered at ClinicalTrials.gov, number NCT01410123. Findings Between Jan 28, 2013, and July 14, 2017, 128 of 351 patients assessed for eligibility were eligible and randomly assigned to receive ISAT (n=63) or treatment as usual (n=65). Mean age was 54 years (range 23–70), 125 (98%) of 128 participants were men, and 101 (79%) were black. 25 (20%) were lost to follow-up. In the ISAT group, of 57 participants who did not die or withdraw, 30 (52%) advanced to step 2, and 17 (57%) of 30 advanced to step 3. 32 (51%) of 63 participants assigned to ISAT versus 17 (26%) of 65 assigned to treatment as usual received at least one alcohol treatment medication (p=0·004). Participants in both groups decreased their alcohol consumption, but at week 24 we did not detect a difference in number of drinks per week between the groups (least squares mean 10·4 drinks per week [SD 16·5] in the ISAT group vs 15·6 drinks per week [SD 17·6] in the treatment as usual group; adjusted mean difference −4·2, 95% CI −9·4 to 0·9; p=0·11). One adverse event occurred that was possibly related to treatment occurred in the ISAT group (headache). Interpretation ISAT increases the receipt of alcohol treatment medications and counselling without changes in drinking at week 24. Strategies to implement and enhance ISAT are needed. Future efforts should focus on promoting ISAT with attention to enhancing patient engagement and retention in alcohol-related care. Funding US National Institute on Alcohol Abuse and Alcoholism.

Background There is no known safe level of alcohol use among patients with HIV and liver disease. We examined the effectiveness of integrated stepped alcohol treatment (ISAT) on alcohol use, HIV, and liver outcomes among patients with HIV and liver disease. Methods In this multi-site, randomized trial conducted between January 28, 2013 through July 15, 2016, we enrolled 95 patients with HIV and liver disease [defined as having active hepatitis C infection or FIB-4 score > 1.45]. ISAT (n = 49) involved: Step 1- Brief Negotiated Interview with telephone booster, Step 2- Motivational Enhancement Therapy, and Step 3- Addiction Physician Management. Treatment as usual (TAU) (n = 46) involved receipt of a health handout plus routine care. Analyses were conducted based on intention to treat. Results Among ISAT participants, 55% advanced to Step 2, among whom 70% advanced to Step 3. Participants randomized to ISAT and TAU increased abstinence (primary outcome) over time. Abstinence rates were non-significantly higher by self-report (38% vs. 23%, adjusted odds ratio [AOR] [95% CI] = 2.6 [0.8, 9.0]) and phosphatidylethanol (43% vs. 32%, AOR [95% CI] = 1.8 [0.5, 6.3] among those randomized to ISAT vs. TAU at week 24. VACS Index scores (AMD [95% CI] = 1.1 [−3.2, 5.5]) and the proportion with an undetectable HIV viral load (AOR [95% CI] = 0.3 [0.1, 1.3]) did not differ by group at week 24 (p values >0.05). ISAT had non-significantly lower FIB-4 scores (adjusted mean difference [AMD] [95% CI] = −0.2 [−0.9, 0.5]), ALT (AMD [95% CI] = −7 [−20, 7]) and AST (AMD [95% CI] = −4 [−15, 7]) at week 24 compared to TAU. Conclusion ISAT is feasible and potentially effective at enhancing delivery of evidence-based alcohol treatment to promote alcohol abstinence and improve liver biomarkers among patients with HIV and liver disease.

This study investigated how HIV-related shame is associated with health-related quality of life (HRQoL) in older people living with HIV (PLHIV). Structural equation modeling tested whether HIV-related shame was associated with three dimensions of HRQoL (physical, emotional, and social well-being) and whether there were significant indirect associations of HIV-related shame with the three HRQoL dimensions via depression and loneliness in a sample of 299 PLHIV ≥50 years old. Results showed that depression and loneliness were key mechanisms, with depression at least partially accounting for the association between HIV-related shame and both emotional and physical well-being, respectively, and loneliness accounting for the association between HIV-related shame and social well-being. HIV-related shame appears to be an important correlate of HRQoL in older PLHIV and may provide a promising leveraging point by which to improve HRQoL in older PLHIV.

Introduction Despite healthcare providers’ growing awareness of pre‐exposure prophylaxis (PrEP), prescription rates remain low. PrEP is an efficacious HIV prevention strategy recommended for use with condoms but still protective in their absence. Concern about the impact of PrEP on condom use and other risk behaviour is, nonetheless, among the barriers to prescription commonly reported. To understand the implications of this concern for PrEP access, we examined how medical students’ willingness to prescribe PrEP varied by patients’ condom use and partnering practices. We also assessed the perceived acceptability of various reasons for condom discontinuation with PrEP. Methods An online survey was distributed to 854 medical students in the Northeastern US in 2015. Participants (n = 111) were surveyed about their willingness to prescribe PrEP for each of six male patients who systematically differed in their reported condom use (sustained use, sustained nonuse, or discontinuation with PrEP) and partnering practices (single male partner with untreated HIV or multiple male partners of unknown HIV status). Participants also reported perceived acceptability of four reasons for condom discontinuation: pleasure, sexual functioning, intimacy, and conception. Results Willingness to prescribe PrEP was inconsistent with patient risk: When the patient used condoms and planned to sustain condom use, most participants were willing to prescribe PrEP – 93% if the patient had a single partner and 86% if the patient had multiple partners. Fewer were willing to prescribe if the patient did not use condoms and planned to sustain nonuse (53% and 45%, respectively) or used condoms but planned to discontinue use (27% and 28%). Significantly fewer participants were willing to prescribe for a patient with multiple partners versus a single partner when the patient reported sustained condom use or sustained condom nonuse. The number of participants who were willing to prescribe was similarly low for a patient with multiple partners versus a single partner when the patient reported that he planned to discontinue condom use. More participants accepted a patient discontinuing condoms for conception (69%) than for intimacy (23%), pleasure (14%), or sexual functioning (13%). Conclusion Medical students’ clinical judgments were misaligned with patient risk and suggest misconceptions or personal values may undermine provision of optimal HIV prevention services.

Although intimate partner violence (IPV) is prevalent among women living with HIV and negatively impacts their health, few studies have examined the ability of AIDS service organisations (ASOs) to address IPV. This study used a qualitative approach to identify facilitators of and barriers to addressing IPV in female clients of ASOs in the United States. In-depth interviews were conducted between March and August 2011 with 20 ASO staff members and 19 female clients who reported a current or past history of IPV. Interviews were audio recorded, transcribed and analysed using the constant comparative method. These data identify barriers to addressing IPV at the organisation, provider and client levels, and include suggestions from both clients and providers about improving access to care. Client and provider suggestions differed in some areas. While providers emphasised structural changes such as increased training on IPV provided by their organisation, clients highlighted the importance of trusting personal relationships with staff to increase client disclosure of IPV experiences. Given the differing opinions of clients and staff, ASOs should consider involving women with histories of IPV in the process of programme and policy development. ASOs have the unique opportunity to provide comprehensive and holistic care by addressing IPV. The extent to which ASOs are able to recognise and address IPV and strategies for increasing this ability warrant greater attention from funders, ASO administrators and researchers. Language: en

HIV disclosure to sexual partners facilitates joint decision-making and risk reduction strategies for safer sex behaviors, but disclosure may be impacted by depression symptoms. Disclosure is also associated with disclosure self-efficacy, which in turn may also be influenced by depressive symptoms. This study examined the relationship between depression and HIV disclosure to partners following diagnosis among men who have sex with men (MSM), mediated by disclosure self-efficacy. Newly HIV-diagnosed MSM (n = 92) who reported sexual activity after diagnosis completed an assessment soon after diagnosis which measured depressive symptoms, and another assessment within 3 months of diagnosis that measured disclosure self-efficacy and disclosure. Over one-third of the sample reported elevated depressive symptoms soon after diagnosis and equal proportions (one-third each) disclosed to none, some, or all partners in the 3 months after diagnosis. Depressive symptoms were negatively associated with disclosure self-efficacy and disclosure to partners, while disclosure self-efficacy was positively associated with disclosure. Disclosure self-efficacy partially mediated the relationship between depression and disclosure, accounting for 33% of the total effect. These findings highlight the importance of addressing depression that follows diagnosis to enhance subsequent disclosure to sexual partners.

Improving the economic well-being of the girls and women is a key to reducing re-trafficking and in providing stability that survivors can use to rebuild their lives. The study looks at how various sociodemographic traits affected the financial capability of n = 144 women and girls who received intervention at a residential care facility in Ghana, West Africa. Three domain of financial capability are assessed in this, i.e., financial risk, financial planning, and financial saving. A scaled likelihood ratio test (chi-square difference test) was used to evaluate the significance of each direct covariate effect(%). Each of the overall goodness-of-fit indices suggested that the initial CFA model fit the data well, χ2(19, N = 144) = 31.45, p = 0.04, RMSEA = 0.067 (90% CI: 0.017-0.108), TLI = 0.923, CFI = 0.948. Older women reported lower levels of financial savings than younger women. We found that women with secondary school education or higher reported significantly higher financial risk than women with less education. Women with children reported lower levels of financial saving than women without children. Married women indicated significantly more financial saving than single women. There was a significant negative effect of time spent in trafficking conditions on financial saving, indicating the highest average level of financial savings at intervention and decreased thereafter. Programs and policies in resource-scarce contexts that aim to assist trafficking survivors must go beyond providing psychosocial counseling and focus also on economic development opportunities.

Objective Understanding how populations at particular risk for posttraumatic stress disorder (PTSD) and its deleterious outcomes cope with individual PTSD symptoms is critical to developing interventions that promote resilience, support recovery, and ultimately empower traumatized populations. Therefore, the purpose of this study was to identify specific strategies women use to cope with individual PTSD symptoms among a population at particular risk for experiencing trauma and its negative sequelae-African American victims of intimate partner violence (IPV) who use substances. Method This 30-day study included 107 African American women who reported experiencing current IPV and using a substance. During their follow-up interviews, women participated in a structured interview to retrospectively report on the strategies they typically used to cope with various PTSD symptoms during the 30-day period. Results Results of content analysis revealed that women used 19 different strategies to cope with symptoms (e.g., social support, substance use, electronic media, religious or spiritual coping), which varied as a function of the PTSD symptom experienced. Aggregating symptoms to the cluster level obscured the variability in strategies used to cope with individual symptoms. Conclusions Findings are discussed in the context of the larger literature on coping and PTSD, specifically regarding (a) coping strategies that may be adaptive or maladaptive and (b) directions for future research that attend to experiences of individual PTSD symptoms. (PsycINFO Database Record

Despite the demonstrated effectiveness of HIV pre-exposure prophylaxis (PrEP) and evidence that most PrEP users do not engage in risk compensation (i.e., increased risk behavior due to a perceived decrease in HIV susceptibility), some healthcare providers report patient risk compensation to be a deterrent to prescribing PrEP. Overcoming this barrier is essential to supporting PrEP access and uptake among people at risk for HIV. To inform such efforts, this qualitative study explored PrEP-related risk compensation attitudes among providers with firsthand experience prescribing PrEP. US-based PrEP providers (n = 18), most of whom were HIV specialists, were recruited through direct outreach and referral from colleagues and other participants. Individual 90-min semistructured interviews were conducted by phone or in person from September 2014 through February 2015, transcribed, and thematically analyzed. Three attitudinal themes emerged: (1) providers' role is to support patients in making informed decisions, (2) risk behavior while taking PrEP does not fully offset PrEP's protective benefit (i.e., PrEP confers net protection, even with added behavioral risk), and (3) PrEP-related risk compensation is unduly stigmatized within and beyond the healthcare community. Participants were critical of other healthcare providers' negative judgment of patients and reluctance to prescribe PrEP due to anticipated risk compensation. Several providers also acknowledged an evolution in their thinking from initial ambivalence toward greater acceptance of PrEP and PrEP-related behavior change. PrEP providers' insights about risk compensation may help to address unsubstantiated concerns about PrEP-related risk compensation and challenge the acceptability of withholding PrEP on these grounds.

Female sex workers are subjected to intense physical, sexual, and mental abuses that are well documented in the medical and public health literature. However, less well-studied are the mental coping mechanisms that are employed by women in this population to survive. The Stockholm Syndrome has been discussed in the news media as a potential phenomenon in this vulnerable population, but has not been formally studied. From a previous retrospective qualitative analysis reviewing interviews with women in sex work throughout India, we found that the four main criteria for Stockholm Syndrome (perceived threat to survival; showing of kindness from a captor; isolation from other perspectives; perceived inability to escape) are present in narrative accounts from this population. Thus, we propose that Stockholm Syndrome should be considered as a contributing phenomenon with regard to the psychological challenges faced by female sex workers, and can likely help guide interventions accordingly.

The HIV/AIDS epidemic was first recognized in the United States in 1981. For the past 30 plus years, there have been a wide array of social, scientific, and political shifts in the understanding, prevention, and treatment of HIV. The HIV epidemic has historically focused on prevalence, prevention, and treatment in large metropolitan or urban areas of the United States. While urban areas saw the greatest increase in HIV cases from 1982 to 1984, the 25 counties with the greatest increase in HIV cases from 1988 to 1990 were consisted of rural areas. The rise of HIV in rural areas came with challenges, many of which persist today. This chapter discusses the historical background of the HIV epidemic, with special emphasis on prevention, treatment, and future directions to address HIV in rural communities of the United States.

Studies of sexual stigma management techniques expected to decrease HIV risk among Black men who have sex with men (MSM) have yielded some counterintuitive findings. For example, some research suggests that identification with and participation in the gay community may be related to higher levels of sexual risk behavior among Black MSM. Moreover, some of this research tends to assume that Black and White MSM experience the gay community in identical ways. Borrowing from key tenets of intersectionality theory, we examine whether there are substantive differences in the ways in which Black and White MSM experience the gay community. In particular, we use the Urban Men's Health Study to quantitatively test Black–White differences in perceptions of racial hierarchy and racism within and positive affiliation with the gay community. Our findings suggest that Black MSM may encounter racism, and may experience engagement with the gay community as less positive than their White counterparts. These data contextualize existing research, and suggest that racism may shape the extent to which affiliation with the gay community serves as a protective factor against HIV for Black MSM.

Background Many efforts have been undertaken to improve access to healthcare services in low-income settings; nevertheless, underutilisation persists. Women9s lack of empowerment may be a central reason for underutilisation, but empirical literature establishing this relationship is sparse. Methods We conducted a cross-sectional study using data from the 2007 Liberia Demographic and Health Survey. Our sample included all non-pregnant women who were currently married or living with a partner (N=3925 unweighted). We used multivariate logistic regression to assess the associations between constructs derived from the Theory of Gender and Power (TGP) and healthcare utilisation. Results Two-thirds of women (65.6%) had been to a healthcare facility for herself or her children in the past 12 months. Constructs from the three major theoretical structures were associated with healthcare utilisation. Women with no education, compared with women with some education, were less likely to have been to a healthcare facility (OR=0.76; 95% CI 0.62 to 0.93) as were women who had experienced sexual abuse (OR=0.65; 95% CI 0.45 to 0.95) and women who were married (OR=0.69, 95% CI 0.54 to 0.88). Women in higher wealth quintiles, compared with women in the next lower wealth quintile, and women with more decision-making power had greater odds of having been to a healthcare facility (OR=1.22; 95% CI 1.10 to 1.36 and OR=1.10; 95% CI 1.01 to 1.20; respectively). Conclusions Strong associations exist between healthcare utilisation and empowerment among women in Liberia, and gender imbalances are prevalent. This fundamental issue likely needs to be addressed before large-scale improvement in health service utilisation can be expected.

Objective The current study investigates the relationship between romantic attachment style and depressive symptoms between both members of pregnant adolescent and young adult couples.

Women who experience intimate partner violence (IPV) may be at elevated risk for poor sexual health outcomes, including sexually transmitted infections (STIs). This association, however, has not been consistently demonstrated in low-income or post-conflict countries. Furthermore, the role that attitudes towards IPV play in sexual-health outcomes and behaviour has rarely been examined. We examined associations between IPV experiences, accepting attitudes towards physical IPV, and sexual-health and behavioural outcomes among 592 young women in post-conflict Liberia. Participants' experiences with either moderate or severe physical violence or sexual violence were common. Additionally, accepting attitudes towards physical IPV were positively associated with reporting STI symptoms, IPV experiences and the ability to negotiate safe sex. Findings suggest that for sexual-health-promotion and risk-reduction-intervention efforts to achieve full impact, interventions must address the contextual influence of violenc...

CITATION: Watson, R., et al. 2016. Proceedings of the 13th annual conference of INEBRIA. Addiction Science & Clinical Practice, 11:13, doi:10.1186/s13722-016-0062-9.

Substance use has a significant impact on post-conflict populations; however, little is known about this critical issue in Liberia. This study examined the current risk factors for and consequences of substance use in Monrovia, Liberia. In-depth interviews were conducted with 20 substance users and 21 key informants. Findings support that Liberia’s civil war played a role in increasing substance use, but also that additional risk factors continue to generate substance use today. This study provides insights into the roles of civil war and additional risk factors for substance use in Liberia. Recommendations for substance use-related policies and programs are provided.

Sexual stereotypes may adversely affect the health of Black men who have sex with men (MSM). Greater understanding of the nature and nuances of these stereotypes is needed. This online, survey-based study used an inductive, intersectional approach to characterize the sexual stereotypes ascribed to Black MSM by the U.S. general public, their distinctiveness from those ascribed to Black men and MSM in general, and their relative prototypicality as compared to dominant subgroups. Members of the public, recruited in 2014–2015, were randomly assigned to survey conditions that varied systematically by race (Black, White, or unspecified) and sexual orientation (gay, heterosexual, or unspecified) of a designated social group. Participants (n = 285) reported stereotypes of their assigned group that they perceived to exist in U.S. culture in an open-response format. Cross-condition comparisons revealed that, overall, Black gay male stereotypes were non-prototypical of Black men or gay men. Rather, stereotypes of Black men were more similar to Black heterosexual men and stereotypes of gay men were more similar to White gay men. Nonetheless, 11 of the 15 most frequently reported Black gay male stereotypes overlapped with stereotypes of Black men (e.g., large penis), gay men (e.g., deviant), or both (e.g., promiscuous). Four stereotypes were unique relative to both Black men and gay men: down low, diseased, loud, and dirty. Findings suggest that Black MSM face multiple derogatory sexual stereotypes, several of which are group-specific. These stereotypes are consistent with cultural (mis)representations of Black MSM and suggest a need for more accurate portrayals of existing sexual diversity within this group.

Optimizing access to HIV pre-exposure prophylaxis (PrEP), an evidence-based HIV prevention resource, requires expanding healthcare providers' adoption of PrEP into clinical practice. This qualitative study explored PrEP providers' firsthand experiences relative to six commonly-cited barriers to prescription-financial coverage, implementation logistics, eligibility determination, adherence concerns, side effects, and anticipated behavior change (risk compensation)-as well as their recommendations for training PrEP-inexperienced providers. U.S.-based PrEP providers were recruited via direct outreach and referral from colleagues and other participants (2014-2015). One-on-one interviews were conducted in person or by phone, transcribed, and analyzed. The sample (n = 18) primarily practiced in the Northeastern (67%) or Southern (22%) U.S. Nearly all (94%) were medical doctors (MDs), most of whom self-identified as infectious disease specialists. Prior experience prescribing PrEP ranged from 2 to 325 patients. Overall, providers reported favorable experiences with PrEP implementation and indicated that commonly anticipated problems were minimal or manageable. PrEP was covered via insurance or other programs for most patients; however, pre-authorization requirements, laboratory/service provision costs, and high deductibles sometimes presented challenges. Various models of PrEP care and coordination with other providers were utilized, with several providers highlighting the value of clinical staff support. Eligibility was determined through joint decision-making with patients; CDC guidelines were commonly referenced but not considered absolute. Patient adherence was variable, with particularly strong adherence noted among patients who had actively sought PrEP (self-referred). Providers observed minimal adverse effects or increases in risk behavior. However, they identified several barriers with respect to accessing and engaging PrEP candidates. Providers offered a wide range of suggestions regarding content, strategy, and logistics surrounding PrEP training, highlighting sexual history-taking and sexual minority competence as areas to prioritize. These insights from early-adopting PrEP providers may facilitate adoption of PrEP into clinical practice by PrEP-inexperienced providers, thereby improving access for individuals at risk for HIV.

Strategic framing of public messages about HIV pre-exposure prophylaxis (PrEP) may influence public support for policies and programs affecting access. This survey study examined how public attitudes toward PrEP differed based on the social group PrEP was described as benefiting ("beneficiary") and the moderating effect of prejudice. Members of the general public (n = 154) recruited online were randomly assigned to three beneficiary conditions: general population, gay men, or Black gay men. All participants received identical PrEP background information before completing measures of PrEP attitudes (specifying beneficiary), racism, and heterosexism. Despite anticipating greater PrEP adherence among gay men and Black gay men and perceiving PrEP as especially beneficial to the latter, participants expressed lower support for policies/programs making PrEP affordable for these groups vs. the general population. This disparity in support was stronger among participants reporting greater prejudice. Inclusive framing of PrEP in public discourse may prevent prejudice from undermining implementation efforts.