Judy Y. Tan

A Randomized Controlled Trial of Cognitive Behavioral Therapy for Adherence and Depression (CBT-AD) in HIV-infected Individuals

OBJECTIVE To evaluate cognitive-behavioral therapy to enhance medication adherence and reduce depression (CBT-AD) in individuals with HIV. DESIGN A two arm, randomized, controlled, cross-over trial comparing CBT-AD to enhanced treatment as usual only (ETAU). ETAU, which both groups received, included a single-session intervention for adherence and a letter to the patients provider documenting her or his continued depression. The intervention group also received 10 to 12 sessions of CBT-AD. MAIN OUTCOME MEASURES Adherence to antiretroviral therapy as assessed by Medication Event Monitoring Systems (MEMs) and depression as assessed by blinded structured evaluation. RESULTS At the acute outcome assessment (3-months), those who received CBT-AD evidenced significantly greater improvements in medication adherence and depression relative to the comparison group. Those who were originally assigned to the comparison group who chose to cross over to CBT-AD showed similar improvements in both depression and adherence outcomes. Treatment gains for those in the intervention group were generally maintained at 6- and 12-month follow-up assessments. By the end of the follow-up period, those originally assigned CBT-AD demonstrated improvements in plasma HIV RNA concentrations, though these differences did not emerge before the cross-over, and hence there were not between-groups differences. CONCLUSIONS CBT-AD is a potentially efficacious approach for individuals with HIV struggling with depression and adherence. Replication and extension in larger efficacy trials are needed.

A meta-analysis of the efficacy of HIV/AIDS prevention interventions in Asia, 1995–2009

The HIV/AIDS epidemic continues to grow in pockets across Asia, despite early successes at curtailing its spread in countries like Thailand. Recent evidence documents dramatic increases in incidence among risk groups and, alarmingly, the general population. This meta-analysis summarizes the sexual risk-reduction interventions for the prevention of HIV-infection that have been evaluated in Asia. Sexual risk-reduction outcomes (condom use, number of sexual partners, incident sexually transmitted infections [STI], including HIV) from 46 behavioral intervention studies with a comparison condition and available by August 2010 were included. Overall, behavioral interventions in Asia consistently reduced sexual risk outcomes. Condom use improved when interventions sampled more women, included motivational content, or did not include STI testing and treatment. Incident HIV/STI efficacy improved most when interventions sampled more women, were conducted more recently, or when they included STI counseling and testing. Sexual frequency efficacy improved more in interventions that were conducted in countries with lower human development capacities, when younger individuals were sampled, or when condom skills training was included. Behavioral interventions for reducing sexual risk in Asia are efficacious; yet, the magnitude of the effects co-varies with specific intervention and structural components. The impact of structural factors on HIV intervention efficacy must be considered when implementing and evaluating behavioral interventions. Implications and recommendations for HIV/AIDS interventions are discussed.

Sexual positioning and race-based attraction by preferences for social dominance among gay Asian/Pacific Islander men in the United States.

For gay men in the United States, race/ethnicity has been demonstrated to factor importantly into sexual preferences, and race-based beliefs regarding certain racial groups are prevalent within the gay male community. For gay men of color, such beliefs may differentially influence their sexual preferences. Yet, little is known about the social-psychological factors underlying differences in sexual preferences among gay men of color. The present study examined how personal preferences for social hierarchy and dominance may explain variations in sexual positioning preferences, and how this relationship may be further qualified by their race-based sexual attraction among gay Asian/Pacific Islander (API) men. A total of 141 API gay men were recruited to participate in an online survey. Measures assessed participants’ sexual positioning preferences, race-based sexual attraction, and preferences for social hierarchy or social dominance orientation (SDO). Self-identified tops scored higher on SDO than bottoms or versatiles. Participants attracted to non-API men scored higher on SDO compared to participants attracted to API men and participants who reported no race-based attraction. Finally, a significant two-way interaction indicated that tops attracted to non-API men scored the highest on SDO, and bottoms with no race-based attraction in men scored the lowest. Race/ethnicity is a prominent factor in sexual attraction and sexual positioning preferences among gay men, and one’s proclivity for social hierarchy and dominance explains differences in sexual preferences among API gay men. By demonstrating how API gay men negotiate sexual preferences, present findings help elucidate existing race-based sexual dynamics within gay male culture.

Social-structural indices and between-nation differences in HIV prevalence.

Summary Research emphasises the role that social structures play in shaping national HIV prevalence. This study examined how social, economic, and political contexts that may represent the confluence of individual capabilities and environmental affordances or constraints are associated with national HIV prevalence. Based on social-ecological perspectives, we examined social-structural dimensions in relation to national HIV prevalence. The study identified six publicly available nation-level social, political, and economic indices and examined their associations with national 2009 HIV prevalence across 225 nations. National indices, (a) education expenditures, (b) unemployment rate, (c) homicide rate, (d) freedom of religion, and (e) womens social rights, altogether explained 43% of the variability in national HIV prevalence. Education expenditures, homicide rate, and freedom of religion were significant predictors of national HIV prevalence in the multivariate analysis. The present study identified nation-level factors that capture social, economic, and political contexts to explain between-nation differences in HIV prevalence. Findings extend current literature on the social-structural foundation of HIV-risk and the relationship between human rights and health. National safeguards that afford individuals the power to promote general quality of life and protection from structural violence may be most important to lowering overall rates of HIV transmission.

Filial ethics and judgments of filial behaviour in Taiwan and the United States

Parent-child relationships are fundamental human relationships in which specific norms govern proper parent-child interactions. Such norms, or filial ethics, have been observed in different cultures, including in the United States and Taiwan, but important differences may exist in how filial practices are viewed across cultures. From a traditional view of power as domination over others, if filial relationships are viewed to reflect power differentials between parents and children, actors who follow filial ethics should be viewed as less powerful than actors who do not follow filial ethics for maintaining or enhancing positive parent-child relationships. Alternatively, power can be conceptualized as the ability to meet ones needs (e.g., for communal care and trust), and actors who follow filial ethics should be viewed as more powerful and trustworthy than actors who do not follow filial ethics because they have the ability to maintain or enhance positive parent-child relationships. Based on a power-trust model, we compared American and Taiwanese perceptions of actors in an experiment using vignettes describing filial behaviours. We conducted a path analysis with a sample of 112 American and 74 Taiwanese participants to test the proposed relations. Results showed that both Taiwanese and Americans rated actors more favourably (i.e., as more powerful and trustworthy) when actors behaved according to filial ethics than when they did not. Some cross-cultural differences were also observed: Taiwanese attributed trust-traits to actors who performed filial practices to a larger degree than did Americans. We discuss implications for the implicit nature of filial relationships and conceptualization of power cross-culturally.

A social-ecological perspective on power and HIV/AIDS with a sample of men who have sex with men of colour

This paper applies a social-ecological theory of power to posit that individual HIV-related vulnerability stems from how power is leveraged across situations over time. The current study identified six power domains and explored how the interchangeability of power shapes HIV-related vulnerability among men who have sex with men of colour. Data were collected as part of a mixed-methods study on the social networks and experiences of racial/ethnic and sexual minority status. A total of 35 Asian/Pacific Islander, Black and Latino men who have sex with men were recruited and individual in-depth interviews were conducted. Results showed that men who have sex with men of colour actively traded upon various domains to alter their relative power within a given situation. Results suggest that power interchangeability, or the degree to which power from one domain can be leveraged to gain power in another, may shape HIV-related vulnerability. Findings offer a dynamic understanding of the nature of HIV risk as derived from everyday power exchanges and provide theoretical foundation for future work on individual resilience against HIV-related risks over time.

The Role of the Primary Romantic Relationship in HIV Care Engagement Outcomes Among Young HIV-Positive Black Men Who Have Sex with Men

The primary romantic relationship plays a fundamental role in health maintenance, but little is known about its role in HIV care engagement among young Black men who have sex with men (MSM) living with HIV. We examined how HIV care engagement outcomes (i.e., having a primary healthcare provider, receiving HIV treatment, taking antiretroviral medication, and medication adherence) vary by partnership status (single vs. concordant-positive vs. discordant) in a sample of young Black MSM living with HIV. Results showed mixed findings. Partnership status was significantly associated with HIV care engagement, even after adjusting for individual, social, and structural factors. While partnered men were consistently more likely than their single counterparts to have a regular healthcare provider, to receive recent treatment, and to have ever taken antiretroviral medication, they were less likely to report currently receiving antiretroviral therapy. Moreover, men with a discordant partner reported better adherence compared to men with a concordant or no partner. The association between partnership status and HIV care engagement outcomes was not consistent across the stages of the HIV Care Continuum, highlighting the complexity in how and why young Black men living with HIV engage in HIV healthcare. Given the social context of HIV disease management, more research is needed to explicate underlying mechanisms involved in HIV care and treatment that differ by relational factors for young Black MSM living with HIV.

High Stakes for the Health of Sexual and Gender Minority Patients of Color

As clinicians, educators, and researchers, our ability to provide the best possible care to our patients who are sexual and gender minority (SGM) people of color is increasingly challenged. Relative to the general population, SGM patients often have worse health outcomes, and among SGM patients, racial and ethnic minorities are particularly vulnerable. Healthcare policies proposed by the current administration, along with an increasingly hostile and dangerous social climate, have the potential to seriously harm SGM patients of color. In this paper, we discuss these key policy issues impacting the health of SGM patients of color. We then suggest questions for clinicians to consider to help them decide which advocacy activities are right for them, recommending self-examination, skills development, and political action. We end by outlining concrete, actionable steps to advocate for SGM patients of color in patient care, healthcare organizations, medical education, research, and public policy.

A Conceptual Model of Dyadic Coordination in HIV Care Engagement Among Couples of Black Men Who Have Sex with Men: A Qualitative Dyadic Analysis

Among Black men who have sex with men (MSM), HIV incidence is disproportionately high and HIV care engagement is disproportionately low. There may be important opportunities to leverage the primary relationship to improve engagement in HIV care and treatment among Black MSM couples. Using dyadic qualitative analysis of semi-structured, one-on-one interviews, we explored dyadic aspects of HIV care engagement among 14 Black MSM couples in which at least one partner was HIV-positive and identified as a Black cisgender man. Findings showed that men varied in how involved they were in their HIV-positive partner’s care and treatment, and in how they reciprocated their partner’s involvement. Patterns of dyadic HIV care engagement supported a conceptual model of dyadic coordination that describes Black MSM relationships in terms of two conceptual dimensions of dyadic HIV care engagement, and guides future intervention designs with Black MSM couples.

HIV/AIDS in Asian and Pacific Islanders in the United States

Although research consistently documents high levels of HIV risk behavior among Asian and Pacific Islanders (APIs) in the United States, there has been minimal prioritization of public health resources and funding for this population. In this chapter we review the state of HIV/AIDS epidemiology and prevention science for APIs as an emerging risk group. The chapter is organized into four sections: (i) epidemiological trends in HIV/AIDS among APIs, (ii) social factors associated with HIV risk among APIs, (iii) HIV prevention interventions for APIs, and (iv) the role of community based organizations and social movements in responding to HIV/AIDS in APIs. We consider and critique how APIs have been overlooked and excluded in research and prevention, and offer suggestions for future research, intervention, and community mobilization strategies to respond to the growing HIV/AIDS epidemic among APIs.