Amy K. Johnson

Syndemic theory and HIV-related risk among young transgender women: the role of multiple, co-occurring health problems and social marginalization.

OBJECTIVES We assessed whether multiple psychosocial factors are additive in their relationship to sexual risk behavior and self-reported HIV status (i.e., can be characterized as a syndemic) among young transgender women and the relationship of indicators of social marginalization to psychosocial factors. METHODS Participants (n = 151) were aged 15 to 24 years and lived in Chicago or Los Angeles. We collected data on psychosocial factors (low self-esteem, polysubstance use, victimization related to transgender identity, and intimate partner violence) and social marginalization indicators (history of commercial sex work, homelessness, and incarceration) through an interviewer-administered survey. RESULTS Syndemic factors were positively and additively related to sexual risk behavior and self-reported HIV infection. In addition, our syndemic index was significantly related to 2 indicators of social marginalization: a history of sex work and previous incarceration. CONCLUSIONS These findings provide evidence for a syndemic of co-occurring psychosocial and health problems in young transgender women, taking place in a context of social marginalization.

Improving adherence to antiretroviral therapy for youth living with HIV/AIDS: a pilot study using personalized, interactive, daily text message reminders.

Background For youth living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), nonadherence to antiretroviral therapy (ART) can lead to poor health outcomes and significantly decreased life expectancy. Objective To evaluate the feasability, acceptability, and preliminary efficacy of short message service (SMS) or text message reminders to improve adherence to ART for youth living with HIV/AIDS. Methods We conducted this prospective pilot study using a pre–post design from 2009 to 2010 at a community-based health center providing clinical services to youth living with HIV/AIDS. Eligibility criteria included HIV-positive serostatus, age 14–29 years, use of a personal cell phone, English-speaking, and being on ART with documented poor adherence. During the 24-week study period, participants received personalized daily SMS reminders and a follow-up message 1 hour later assessing whether they took the medication, and asking participants to respond via text message with the number 1 if they took the medication and 2 if they did not. Outcome measures were feasibility, acceptability, and adherence. Self-reported adherence was determined using the visual analog scale (VAS) and AIDS Clinical Trial Group (ACTG) questionnaire 4-day recall. Viral load and CD4 cell count were followed as biomarkers of adherence and disease progression at 0, 12, and 24 weeks. Results Participants (N = 25) were mean age 23 (range 14–29) years, 92% (n = 23) male, 60% (n = 15) black, and 84% (n = 21) infected through unprotected sex. Mean VAS scores significantly increased at 12 and 24 weeks in comparison with baseline (week 0: 74.7, week 12: 93.3, P < .001; week 24: 93.1, P < .001). ACTG questionnaire 4-day recall also improved (week 0: 2.33, week 12: 3.24, P = .002; week 24: 3.19, P = .005). There was no significant difference in CD4 cell count or viral load between baseline and 12- or 24-week follow-up, although there was a trend toward improvement of these biomarkers and a small to moderate standardized effect size (range of Cohen d: –0.51 to 0.22). Of 25 participants, 21 (84%) were retained, and 20 of the 21 (95%) participants who completed the study found the intervention helpful to avoid missing doses. Conclusions In this pilot study, personalized, interactive, daily SMS reminders were feasible and acceptable, and they significantly improved self-reported adherence. Larger controlled studies are needed to determine the impact of this intervention on ART adherence and other related health outcomes for youth living with HIV/AIDS.

Substance use as a mediator of the relationship between life stress and sexual risk among young transgender women.

This study examined whether life stress was associated with elevated sexual risk among young transgender women and whether this relationship was mediated by alcohol and substance use. The analysis was based on data collected from 116 transgender women aged 16 to 25 as part of a baseline assessment for an HIV prevention intervention. The median age was 20; the majority identified as African American (48%) or Hispanic (32%). Controlling for age, high life stress was associated with an increased odds of sexual risk (OR = 2.39; 95% CI 1.12-5.12). This association was attenuated when substance and alcohol use were added to the model (OR = 1.82; 0.80-4.13). A formal test of the mediation hypothesis indicated a statistically significant indirect effect (β = 0.08; 95% CI 0.02-0.20). Interventions aimed at reducing sexual risk behavior should address problems with substance use as well as more distal factors that impact risk, such homelessness, joblessness, and lack of access to medical care.

Exploring factors that underlie racial/ethnic disparities in HIV risk among young men who have sex with men.

Young men who have sex with men (YMSM) are among the highest risk groups for HIV, and the risk distribution varies by race/ethnicity. Prevalence rates are consistently higher for minority YMSM. Factors underlying these disparities are poorly understood. We examined disparities in HIV risk among a community-based sample of Black, Latino, and non-Hispanic Caucasian YMSM age 16–24. To address gaps in the literature, we examined factors between and within racial/ethnic groups across domains including: sexual and substance use behaviors, sexualized and other social contexts, psychological well-being, HIV attributes and prevention skills, and sexual minority stress.

Religiosity As a Protective Factor Against HIV Risk Among Young Transgender Women

PURPOSE Young transgender women (YTW) face many challenges to their well-being, including homelessness, joblessness, victimization, and alarming rates of HIV infection. Little has been written about factors that might help in preventing HIV in this population. Our objective was to examine the role of religion in the lives of YTW and its relationship to HIV risk. METHODS This study is derived from baseline data collected for an HIV prevention intervention. A convenience sample of YTW aged 16-25 years from Chicago were recruited consecutively and completed an audio computer-assisted self-interview. Logistic regression models were used to evaluate the relationship between sexual risk taking (sex work, multiple anal sex partners, unprotected receptive anal sex), alcohol use, formal religious practices (service attendance, reading/studying scripture), and God consciousness (prayer, thoughts about God). RESULTS A total of 92 YTW participated in the study, their mean age being 20.4 years; 58% were African American, 21% white, and 22% other. On multivariate logistic regression, alcohol use was significantly associated with sexual risk in both models, with adjusted odds ratio (OR) of 5.28 (95% confidence intervals [CI]: 1.96-14.26) in the Formal Practices model and 3.70 (95% CI: 1.53-8.95) in the God Consciousness model. Controlling for alcohol use, it was found that Formal Practices was significantly associated with sexual risk (OR = .29, 95% CI: .11-.77), but God Consciousness was not (OR = .60, 95% CI: .25-1.47). CONCLUSION Among YTW, formal religious practices may attenuate sexual risk-taking behaviors and therefore HIV risk. Further research is needed to explore the role of the religion in the lives of YTW as a protective asset.

Demographic, Psychosocial, and Contextual Factors Associated With Sexual Risk Behaviors Among Young Sexual Minority Women

Young sexual minority women are at risk for negative sexual health outcomes, including sexually transmitted infections and unintended pregnancies, yet little is known about these risks. We examined factors that may influence sexual risk from a psychosocial and contextual perspective. Analyses were conducted to examine within group relationships between sexual behaviors, negative outcomes, and related factors in a sample of young sexual minority women. Participants (N = 131) were young (mean = 19.8) and diverse in terms of race/ethnicity (57% non-White). Sex under the influence, having multiple partners, and having unprotected sex were common behaviors, and pregnancy (20%) and sexually transmitted infection (12%) were common outcomes. Risk behaviors were associated with age, alcohol abuse, and older partners. Results support the need for further research to understand how these factors contribute to risk in order to target risk reduction programs for this population.

“What Could Have Been Different”: A Qualitative Study of Syndemic Theory and HIV Prevention Among Young Men Who Have Sex With Men

Young men who have sex with men (MSM) experience multiple health disparities, including alcohol and drug use, partner violence, victimization due to sexual orientation, and HIV infection. Syndemic theorists explain the clustering of these disparities among adult MSM as a result of cultural marginalization. To date, research on a similar emerging syndemic among young MSM has been limited to quantitative studies. The authors seek to better understand these disparities, and how they may cluster together, via qualitative interviews with 21 ethnically diverse, HIV-infected young MSM aged 18 to 24 years. These youth report a lack of gay-specific HIV prevention education, absence of role models, and lack of productive future goal-related activities as factors related to their acquisition of HIV and downplay substance use as a factor. Although not necessarily the components traditionally cited by syndemic theorists, these findings support the notion that multiple factors of cultural marginalization cluster together in the lives of young MSM and underscore the importance of community-level interventions, such as sexual health education, access to mentors, and assistance with future goal setting and planning.

‘Yes, I Am More than Just That’: Gay/Bisexual Young Men Residing in the United States Discuss the Influence of Minority Stress on their Sexual Risk Behavior Prior to Hiv Infection

ABSTRACT. Rates of HIV infection in the United States are markedly over-represented among gay/bisexual young men (GBYM), especially those who are African American and Latino. The degree to which minority stress may explain racial disparities in HIV incidence is understudied in GBYM. This qualitative study examined racial/ethnic-minority and sexual-minority stress and their perceived influence on HIV infection in a sample of GBYM living with HIV. Findings indicated that racial/ethnic-minority stress more often emerged during sexual interactions, while sexual-minority stress was often family-based. Our discussion offers recommendations for primary HIV prevention efforts for GBYM.

Identifying variability in permanent supportive housing: A comparative effectiveness approach to measuring health outcomes

Supportive housing has become the dominant model in the United States to provide housing to the chronically homeless and to improve their housing stability and health. Most supportive housing programs follow a “housing first” paradigm modeled after the Pathways to Housing program in New York City. However, components of housing first supportive housing models were poorly defined, and supportive models have varied considerably in their dissemination and implementation to other parts of the country. Recently, research has been conducted to determine the fidelity by which specific housing programs adhere to the Pathways Housing First model. However, evidence regarding which combination of components leads to better health outcomes for particular subpopulations is lacking. This article presents results from qualitative interviews with supportive housing providers in the Chicago, Illinois, metropolitan area. Supportive housing varied according to housing configuration (scattered-site vs. project-based) and service provision model (low-intensity case management, intensive case management and behavioral health), resulting in 6 basic types. Supportive housing programs also differed in services they provided in addition to case management and the extent to which they followed harm-reduction versus abstinence policies. Results showed advantages and disadvantages of each of the 6 basic types. Comparative effectiveness research may help identify which program components lead to better health outcomes among different subpopulations of homeless. Future longitudinal research will use the identified typology and other factors to compare the housing stability and health outcomes of supportive housing residents in programs that differ along these dimensions.

Examining the themes of STD-related Internet searches to increase specificity of disease forecasting using Internet search terms

US surveillance of sexually transmitted diseases (STDs) is often delayed and incomplete which creates missed opportunities to identify and respond to trends in disease. Internet search engine data has the potential to be an efficient, economical and representative enhancement to the established surveillance system. Google Trends allows the download of de-identified search engine data, which has been used to demonstrate the positive and statistically significant association between STD-related search terms and STD rates. In this study, search engine user content was identified by surveying specific exposure groups of individuals (STD clinic patients and university students) aged 18–35. Participants were asked to list the terms they use to search for STD-related information. Google Correlate was used to validate search term content. On average STD clinic participant queries were longer compared to student queries. STD clinic participants were more likely to report using search terms that were related to symptomatology such as describing symptoms of STDs, while students were more likely to report searching for general information. These differences in search terms by subpopulation have implications for STD surveillance in populations at most risk for disease acquisition.