Frances Aunon

A Qualitative Exploration of Sexual Risk and HIV Testing Behaviors Among Men Who Have Sex with Men in Beirut, Lebanon

Men who have sex with men (MSM) may account for most new HIV infections in Lebanon, yet little is known about the factors that influence sexual risk behavior and HIV testing in this population. Qualitative interviews were conducted with 31 MSM living in Beirut, and content analysis was used to identify emergent themes. Mean age of the participants was 28.4 years, and all identified as either gay (77%) or bisexual (23%). Half reported not using condoms consistently and one quarter had not been HIV-tested. Many described not using condoms with a regular partner in the context of a meaningful relationship, mutual HIV testing, and a desire to not use condoms, suggesting that trust, commitment and intimacy play a role in condom use decisions. Condoms were more likely to be used with casual partners, partners believed to be HIV-positive, and with partners met online where men found it easier to candidly discuss HIV risk. Fear of infection motivated many to get HIV tested and use condoms, but such affect also led some to avoid HIV testing in fear of disease and social stigma if found to be infected. Respondents who were very comfortable with their sexual orientation and who had disclosed their sexuality to family and parents tended to be more likely to use condoms consistently and be tested for HIV. These findings indicate that similar factors influence the condom use and HIV testing of MSM in Beirut as those observed in studies elsewhere of MSM; hence, prevention efforts in Lebanon can likely benefit from lessons learned and interventions developed in other regions, particularly for younger, gay-identified men. Further research is needed to determine how prevention efforts may need to be tailored to address the needs of men who are less integrated into or do not identify with the gay community.

Sexual stigma, psychological well-being and social engagement among men who have sex with men in Beirut, Lebanon.

This qualitative study sought to explore sexual identity development among men who have sex with men in Beirut, Lebanon; the stigma experienced by these men; and how their psychological well-being and social engagement are shaped by how they cope with this stigma. Semi-structured interviews were conducted with 31 men who have sex with men and content analysis was used to identify emergent themes. While many men reported feeling very comfortable with their sexual orientation and had disclosed their sexual orientation to family, most men struggled at least somewhat with their sexuality, often because of perceived stigma from others and internal religious conflict about the immorality of homosexuality. Most participants described experiencing verbal harassment or ridicule or being treated as different or lesser than in social relationships with friends or family. Mechanisms for coping with stigma included social avoidance (trying to pass as heterosexual and limiting interaction with men who have sex with men to the internet) or withdrawal from relationships in an attempt to limit exposure to stigma. Findings suggest that effective coping with both internal and external sexual stigma is central to the psychological well-being and social engagement of men who have sex with men in Beirut, much as has been found in Western gay communities.

Forms of Safety and Their Impact on Health: An Exploration of HIV/AIDS-Related Risk and Resilience Among Trans Women in Lebanon.

Using minority stress theory, the authors investigated risk behaviors of transgender women (trans women) in Lebanon. Using semistructured interviews, the authors explored six areas: relationships with family and friends; openness about gender and sexuality; experiences with stigma; sexual behavior; attitudes and behaviors regarding HIV testing; and perceived HIV-related norms among transgender peers. Participants voiced the importance of different forms of safety: social/emotional, physical, sexual, and financial. Strategies for obtaining safety were negotiated differently depending on social, behavioral, and structural factors in the environment. In this article, we provide study findings from the perspectives of trans women, their exposure to stigma, and the necessary navigation of environments characterized by transphobia.

Development and pilot testing of an intervention to promote care engagement and adherence among HIV-positive Kenyan MSM.

Objectives:In many African settings, MSM are a stigmatized group whose access to and engagement in HIV care may be challenging. Our aim was to design a targeted, culturally appropriate intervention to promote care engagement and antiretroviral therapy (ART) adherence for MSM in coastal Kenya, and describe intervention safety, feasibility, and acceptability based upon a small pilot study. Design:Based on qualitative work including in-depth interviews with HIV-positive MSM and focus groups with providers, we developed a tailored intervention and conducted a pilot test to refine intervention materials and procedures. Methods:The Shikamana intervention combines modified Next-Step Counseling by trained providers, support from a trained peer navigator, and tailored use of SMS messaging, phone calls, and discrete pill carriers. Providers, including counselors and clinicians, work together with peer navigators as a case management team. Results:Forty HIV-positive MSM aged 19–51 participated in intervention development and testing. Six counselors, three clinical officers, and four MSM peers were trained in intervention procedures. Of 10 ART-naïve participants who enrolled in the pilot, eight completed follow-up with no adverse events reported. One participant was lost to follow-up after 2 months and another failed to initiate ART despite ongoing counseling. No adverse events were reported. Staff feedback and exit interviews rated the intervention as feasible and acceptable. Conclusion:This adherence support intervention tailored for Kenyan MSM was well tolerated, feasible, and acceptable in the pilot phase. A randomized controlled trial of a scaled-up programme to estimate intervention efficacy is ongoing.

Effectiveness of antidepressants and predictors of treatment response for depressed HIV patients in Uganda

Antidepressant medication is well established for the treatment of depression but little is known about its effectiveness for HIV populations in sub-Saharan Africa. This study examined the effectiveness of antidepressant treatment and predictors of treatment response among depressed HIV patients in Uganda. Data were obtained from two open-label trials in which 184 HIV patients were diagnosed with depression and started on antidepressants. Data at treatment baseline and month 6 were compared to assess treatment response, and baseline predictors of response were assessed. A total of 154 completed month 6, of whom 122 (79%) had responded to treatment and were no longer depressed (Patient Health Questionnaire-9, score < 5). Bivariate analysis found that education, CD4 count, general health functioning, physical health, pain, quality of life and social support variables were associated with antidepressant treatment response; however, only secondary education and social support independently predicted treatment response in logistic multiple regression analysis. Baseline depression severity was not associated with treatment response. In conclusion, antidepressants are effective in treating both moderate and more severe depression among persons living with HIV in Uganda, and education [OR (95% CI) = 4.33 (1.33–14.11)] and social support [OR (95% CI) = 1.54 (1.03–2.30)] were most predictive of treatment response.

Impact of antidepressant therapy on cognitive aspects of work, condom use, and psychosocial well-being among HIV clients in Uganda.

Objective: Depression has been found to impede several health outcomes among people living with HIV, but little research has examined whether depression treatment mitigates this influence. We assessed the impact of antidepressant therapy on measures of work, condom use, and psychosocial well-being among depressed HIV clients in Uganda. Methods: Paired t-tests and McNemar tests were used to assess change in survey data collected from participants at initiation of antidepressant therapy (baseline) and 6 months later. Results: Ninety-five participants completed the 6-month assessment, of whom 82 (86%) responded to treatment (defined as Patient Health Questionnaire-9 score < 5). Among study completers, work functioning improved significantly, as did measures of self-efficacy related to condom use and work (as well as general self-efficacy), and internalized HIV stigma declined; however, actual engagement in work activity and consistent condom use did not show significant change. Similar findings were observed among treatment responders. Conclusions: Antidepressant treatment benefits functional capacity, psychological well-being, and cognitive intermediary factors that may be essential for behavioral change related to work and condom use, but supplementary therapeutic strategies may be needed to impact more direct behavioral change.

Church-Based HIV Screening in Racial/Ethnic Minority Communities of California, 2011-2012

Community-based human immunodeficiency virus (HIV) testing at religious congregations has been proposed as a potentially effective way to increase screening among disproportionately affected populations, such as those self-identifying as African American and Latino. Although congregations may provide reach into these communities, the extent to which church-based HIV testing alleviates access barriers, identifies new cases, and reaches people at increased risk for HIV is not well documented. We examined the results of an HIV testing program that was conducted as part of a larger intervention aimed at reducing HIV stigma at five churches in Los Angeles County, California, in 2011-2012. HIV screening identified one positive result in 323 tests but reached a substantial proportion of people who had not been tested before, including many who lacked health insurance. Although this approach may not be an efficient way to identify cases of previously unknown HIV infection, it could help achieve universal testing goals.

Suicide risk factors among trans feminine individuals in Lebanon.

ABSTRACT Transgender women are disproportionately affected by high rates of depression and suicide attempts. It is therefore important to identify factors that influence suicidal risk, particularly in the Middle East, where little research has examined the mental health of transgender women. We examined risk factors associated with suicide attempts among 54 trans feminine individuals in Beirut, Lebanon. Data were collected using interviewer-administered questionnaires and were analyzed using bivariate statistics. Twenty-five (46%) participants reported having ever attempted suicide. Among them, only one participant had received some kind of counseling in response to the attempted suicide. Low general social support, low social integration, and low support from peers were significantly associated with a history of attempted suicide, as were being more open about transgender identity in public and any hormone use (past or current). These findings suggest that progression in gender transition can have unintended consequences related to mental health and suicide risk, while social support systems can mitigate the impact of mental health problems. Some of these findings mirror other contexts around the globe and can inform mental health services for trans feminine individuals in Lebanon, the greater Middle East region, and other international settings.

HIV Viral Suppression Trends Over Time Among HIV-Infected Patients Receiving Care in the United States, 1997 to 2015: A Cohort Study

Approximately 1.2 million adults are living with HIV in the United States, with a disproportionate burden among men who have sex with men and among African Americans (1). Since 1996, the availability of potent antiretroviral therapy (ART) has led to large decreases in HIV-related mortality and morbidity. Antiretroviral therapy has transformed HIV from a fatal disease into a manageable chronic illness for people living with HIV (PLWH) who are aware of their infection and can access and adhere to ART. Furthermore, ART regimens have become increasingly better tolerated and easier to take (2). Achieving and maintaining HIV viral suppression with ART can optimize health outcomes among PLWH and limit transmission to others (3, 4). Monitoring viral suppression is thus an important aspect of HIV care. Identifying predictors of nonsuppression and groups at increased risk for it can enhance intervention efforts. Reports from individual clinics suggest high levels of viral suppression (5), but current large-scale estimates from across the United States are limited. One of the best assessments was from the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD), which found peak viral suppression of 72%; however, key potential predictors, such as adherence and substance use, were not examined (6). Furthermore, this analysis only included data through 2008 and did not examine potential improvements in viral suppression due to recent changes in ART regimens, such as increased use of integrase strand transfer inhibitors (ISTIs). These drugs may have superior tolerability, reduced pill burden, and improved virologic and immune outcomes (715). Up-to-date evaluations are needed to assess improvements in HIV care, specifically viral suppression, over the past decade. The Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) is a cohort collaboration that integrates data from a large and diverse population of PLWH across the United States (16). CNICS captures a broad range of information associated with the rapidly changing course of HIV disease management. Our objective was to examine changes in viral suppression over time and identify associated factors. We were particularly interested in the association of viral suppression with changing demographic and clinical characteristics, such as substance use patterns, medication adherence, and ISTI use. Methods Data Source CNICS is a dynamic cohort of more than 32000 PLWH who have had 2 or more HIV clinical care visits at 8 sites across the United States (Appendix Figure 1). Each CNICS clinic is at a Centers for AIDS Research site. The CNICS data repository integrates comprehensive clinical data, including laboratory test results; ART and other medications; diagnoses; demographic data; and historical information, including prior ART use, collected at initial clinic visits via standardized intake processes (16). In addition, in recent years, sites have initiated the CNICS clinical assessment of patient-reported measures and outcomes, including illicit drug use, alcohol use, adherence, and depression (1720). During routine clinical care visits, PLWH use touchscreen tablets equipped with Web-based survey software to complete the CNICS clinical assessments (17, 21). Those who appear intoxicated; have cognitive impairment; or do not speak English, Spanish, or Amharic are not asked to complete the assessment. Appendix Figure 1. Map of CNICS sites. CNICS = Centers for AIDS Research Network of Integrated Clinical Systems. Institutional review boards at each site approved CNICS protocols. Study Participants The overall study sample included all CNICS participants aged 18 years or older who had a viral load (VL) measure as part of clinical care between 1997 and 2015. We also examined key subgroups, including those who were receiving ART. We included a subgroup of PLWH receiving ART in or after 2010 to minimize the effect of changes in treatment initiation guidelines. Additional subgroup sensitivity analyses were done among PLWH who had completed the CNICS clinical assessment of patient-reported measures, such as adherence and illicit drug use, and among those known to be ART-naive at initiation of CNICS care. Outcomes The primary outcome was viral suppression versus detection, which we defined as a VL of no more than 400 versus greater than 400 copies/mL to exclude clinically insignificant VL blips (22) and account for changing thresholds of detection over time. In addition, we examined a secondary outcome of VL (in copies/mL) at each time point as a continuous variable, which we log-transformed (in base10) due to skew. We then back-transformed VL coefficients by raising them to a power of 10. We calculated relative VL values, which we defined as the ratio of VL for PLWH with and without each characteristic of interest (such as ISTI use). Predictors We examined age, race/ethnicity, sex, HIV transmission risk factors, and CD4 cell count at ART initiation. Self-reported adherence to ART (23, 24), illicit drug use (including and excluding marijuana) (2529), and depression (30, 31) were collected as part of the CNICS clinical assessment (Appendix Table 1), which was integrated into clinical care between 2005 and 2011 at 7 CNICS sites. Appendix Table 1. Categories and Instruments Used for Key Covariates Statistical Analysis We used 2 tests for categorical variables and t tests for continuous variables to assess differences in demographic and clinical characteristics among persons with and without viral suppression based on VL at the end of follow-up. To understand VL trends in unadjusted ecological analyses (1997 to 2015), we determined the percentage of VL tests showing no more than 400 copies/mL each year for all patients receiving care that year (overall). We then examined VL trends among PLWH categorized by various factors, including age, sex, race/ethnicity, and HIV transmission risk factor. We examined time to viral suppression for the majority (>50%) of VL tests by year of ART initiation. People living with HIV typically had multiple measures in all years since CNICS enrollment. Because we were concerned that those who were lost to follow-up may have been less likely to have viral suppression, we repeated trend analyses limiting tests to 1 random VL result per calendar year per person and accounting for possible differential loss to follow-up using inverse probability of censoring weights based on prior VL values and demographic characteristics (age, sex, and race/ethnicity) to rebalance the sample on the basis of these parameters (32). To operationalize this approach, separate logistic models (with age, sex, and race as covariates) were fit to each time point to estimate the weights. This limited potential selection bias due to loss to follow-up that differed on the basis of characteristics of participants who were lost to follow-up. Our primary analysis was a joint longitudinal and survival model that examined associations between demographic and clinical characteristics and having a detectable VL among persons receiving ART from 1997 to 2015 while accounting for loss to follow-up (33). In this model, we specified the longitudinal process as a mixed logistic model with detectable VL as the outcome. We specified the time-to-event process as loss to follow-up (due to death or leaving the cohort) using a Weibull distribution. This approach was selected because of known limitations with less complex models (34). In particular, there was concern that the loss-to-follow-up process was related to the detectable VL process, and so the models for these 2 processes needed to be estimated jointly. Using this model allowed us to account for potential informative dropout due to loss to follow-up that was related to both the covariates included in the model and the detectable VL measures. We repeated the analyses and limited them to patients known to be ART-naive at enrollment. We also conducted sensitivity analyses that added adherence, illicit drug use (opiates or heroin, cocaine or crack, and methamphetamine or crystal methamphetamine), and depression among the subset who completed the CNICS clinical assessment and included current substance use categorized by class (opiates or heroin, cocaine or crack, methamphetamine or crystal methamphetamine, marijuana, and hazardous alcohol use) with adherence. To minimize the effect of changes in treatment initiation guidelines, we conducted a subgroup analysis for 2010 to 2015, during which time the guidelines changed little after having been expanded to include initiation of treatment independent of CD4 cell count. Additional sensitivity analyses were conducted that included CD4 cell count at ART initiation, added a quadratic term for calendar time (year of cohort entry, centered around 2010), excluded site, and used a different VL cut point (50 copies/mL). Finally, we repeated the analyses using linear mixed models with VL (log10) as a continuous outcome because these models inherently handle unbalanced numbers and times of observations between patients and clustering by participant (35). All models were adjusted for age, sex, race/ethnicity, site, ISTI use, calendar time, and years of follow-up. Statistical models were fit using Stata, version 14 (StataCorp), with the GSEM package used to fit the joint longitudinal and survival models. Role of the Funding Source CNICS is funded by grants from the National Institutes of Health. The funders had no role in the design, conduct, or analysis or the decision to publish this manuscript. Results We included 31930 PLWH from 8 CNICS sites (Appendix Figure 2) who had at least 1 HIV VL measurement after 1 January 1997 (mean number of measurements per person, 17 [SD, 16]), of whom 47% were alive and receiving care at the end of the study period. Eighty-two percent were men, 55% were nonwhite, and the mean number of HIV care visits was 22. Table 1 shows demographic and clinical chara

The Role of Urban Congregations in Addressing HIV

With their extensive social reach and influence across diverse communities, faith-based organizations have an exceptional opportunity to help address human immunodeficiency virus (HIV) worldwide. But in these efforts, many congregations face constraints, including limited size and resources, as well as competing social needs and ministries. Until recently, the roles that faith-based organizations might play have not been clearly defined. In a carefully designed series of studies conducted over eight years, RAND researchers sought to better understand the capacity of urban congregations for HIV prevention and care, specifically in the areas of stigma reduction and HIV testing. The research was conducted collaboratively with community-based partners, including faith and public health leaders. It had three main phases: (1) research to understand the roles that congregations have played throughout the various stages of the HIV epidemic; (2) development of a multi-component, church-based program to address HIV stigma and promote HIV testing in African American and Latino churches; and (3) an evaluation to assess how the program worked in real-world settings.